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Robert K Nam,
Sender Herschorn,
D Andrew Loblaw,
Ying Liu,
Laurence H Klotz,
Lesley K Carr,
Ronald T Kodama,
Aleksandra Stanimirovic,
Vasundara Venkateswaran, Refik Saskin,
Calvin H L Law,
David R Urbach,
Steven A Narod
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ABSTRACT: Urinary incontinence can be a significant complication of radical prostatectomy. It can be treated with post-prostatectomy surgical procedures. The long-term rate of patients who undergo these surgeries, including artificial urinary sphincter or urethral sling insertion, is not well described. We examined the long-term rate of post-prostatectomy incontinence surgery and factors influencing it.
We performed a population based study of 25,346 men who underwent radical prostatectomy for prostate cancer in Ontario, Canada between 1993 and 2006. We used hospital and cancer registry administrative data to identify patients from this cohort who were later treated with surgery for urinary incontinence.
Of the 25,346 patients 703 (2.8%) underwent artificial urinary sphincter insertion and 282 (1.1%) underwent urethral sling placement a median of 2.9 years after prostatectomy. The probability of an artificial urinary sphincter/sling procedure increased with time from prostatectomy. Cumulative 5, 10 and 15-year Kaplan-Meier rates of an artificial urinary sphincter/sling procedure were 2.6% (95% CI 2.4-2.8), 3.8% (95% CI 3.6-4.1) and 4.8% (95% CI 4.4-5.3), respectively. Factors predicting surgery for incontinence were patient age at radical prostatectomy (HR 1.24 per decade, 95% CI 1.11-1.38, p = 0.0002), radiotherapy after surgery (HR 1.61, 95% CI 1.36-1.90, p <0.0001) and surgeon volume (49 or greater prostatectomies per year) (HR 0.59, 95% CI 0.46-0.77, p <0.0001).
Of patients who undergo radical prostatectomy 5% are expected to be treated with surgery for urinary incontinence during a 15-year period. Increasing patient age, radiation treatment and low surgeon volume are associated with significantly higher risk.
The Journal of urology 06/2012; 188(2):502-6. · 4.02 Impact Factor
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ABSTRACT: PURPOSE: The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding. METHODS: In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away. RESULTS: There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06). CONCLUSIONS: Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services.
The American journal of emergency medicine 05/2012; · 1.54 Impact Factor
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ABSTRACT: To determine the sociodemographic factors associated with cervical cancer screening and follow-up of abnormal results.
Population cohort study.
Ontario.
Women between the ages of 18 and 70 years who were eligible for Papanicolaou testing.
Rates of cervical cancer screening and follow-up of abnormal and inadequate Pap test results, and associated sociodemographic factors such as age, neighbourhood income level, and health region. Multivariate logistic regression was used to identify independent factors associated with screening and follow-up.
Of the 3.7 million women eligible for screening, 69% had had Pap tests in the past 3 years. These rates varied by age, income, and region (P < .001). Women residing in the lowest-income neighbourhoods were half as likely to be screened (odds ratio 0.56, 95% CI 0.55 to 0.56). Only 44% of those whose Pap test results revealed atypical squamous cells of uncertain significance or low-grade squamous intraepithelial lesions had repeat Pap tests or colposcopy within 6 months, and this varied by age, income, and region (P < .001). Among women with unsatisfactory Pap test results, only 35% were retested within 4 months, and this varied by age (P < .001).
Despite universal health coverage, cervical cancer screening rates are suboptimal among low-income women at greatest risk. Follow-up among women with inadequate or abnormal test results is often poor. Novel models of cervical cancer screening are needed to address these inadequacies.
Canadian family physician Medecin de famille canadien 01/2012; 58(1):e22-31. · 1.19 Impact Factor
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ABSTRACT: Although there is interest in measuring the quality of cancer care, there has been limited effort to evaluate quality for specific subpopulations such as women or to examine differences in performance among women associated with sociodemographic characteristics. The objective of this study was to identify a comprehensive set of quality indicators for evaluation of the quality of cancer care received by women using administrative data.
A conceptual measurement framework developed by the study investigators was used to guide literature review to identify existing quality indicators. The list of potential indicators from the literature was first reviewed by the study investigators with respect to importance and feasibility to determine a set of indicators to present to an expert panel who used a modified Delphi process to select indicators for inclusion using predetermined explicit criteria.
The Project for an Ontario Women's Health Evidence-Based Report Card.
A multidisciplinary expert panel consisting of clinicians, researchers and administrators with expertise in cancer, quality of care and/or health services research.
Set of quality indicators evaluable from administrative data.
The initial literature search identified 427 indicators, of which 46 were rated as important and feasible by the study investigators. Following two rounds of ratings and an in-person meeting, the expert panel recommended 31 indicators for inclusion in the final set spanning the following areas: general indicators (three indicators), cancer screening (six), colorectal cancer (four), lung cancer (three), breast cancer (five), gynecologic cancers (five), and end-of-life care (five).
A comprehensive set of 31 indicators was identified to evaluate the quality of cancer care received by women that also allows assessment of gender and socioeconomic disparities in cancer care.
International Journal for Quality in Health Care 07/2011; 23(5):554-64. · 1.96 Impact Factor
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ABSTRACT: To describe trends in the aggressiveness of end-of-life (EOL) cancer care in a universal health care system in Ontario, Canada, between 1993 and 2004, and to compare with findings reported in the United States.
A population-based, retrospective, cohort study that used administrative data linked to registry data. Aggressiveness of EOL care was defined as the occurrence of at least one of the following indicators: last dose of chemotherapy received within 14 days of death; more than one emergency department (ED) visit within 30 days of death; more than one hospitalization within 30 days of death; or at least one intensive care unit (ICU) admission within 30 days of death.
Among 227,161 patients, 22.4% experienced at least one incident of potentially aggressive EOL cancer care. Multivariable analyses showed that with each successive year, patients were significantly more likely to encounter some aggressive intervention (odds ratio, 1.01; 95% CI, 1.01 to 1.02). Multiple emergency department (ED) visits, ICU admissions, and chemotherapy use increased significantly over time, whereas multiple hospital admissions declined (P < .05). Patients were more likely to receive aggressive EOL care if they were men, were younger, lived in rural regions, had a higher level of comorbidity, or had breast, lung, or hematologic malignancies. Chemotherapy and ICU utilization were lower in Ontario than in the United States.
Aggressiveness of cancer care near the EOL is increasing over time in Ontario, Canada, although overall rates were lower than in the United States. Health system characteristics and patient or physician cultural factors may play a role in the observed differences.
Journal of Clinical Oncology 03/2011; 29(12):1587-91. · 18.37 Impact Factor
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ABSTRACT: Most quality indicators for colonoscopy measure processes; little is known about their relationship to patient outcomes. We investigated whether characteristics of endoscopists, determined from administrative data, are associated with development of postcolonoscopy colorectal cancer (PCCRC).
We identified individuals diagnosed with colorectal cancer in Ontario from 2000 to 2005 using the Ontario Cancer Registry. We determined performance of colonoscopy using Ontario Health Insurance Plan data. Patients who had complete colonoscopies 7 to 36 months before diagnosis were defined as having a PCCRC. Patients who had complete colonoscopies within 6 months of diagnosis had detected cancers. We determined if endoscopist factors (volume, polypectomy and completion rate, specialization, and setting) were associated with PCCRC using logistic regression, controlling for potential covariates.
In the study, 14,064 patients had a colonoscopy examination within 36 months of diagnosis; 584 (6.8%) with distal and 676 (12.4%) with proximal tumors had PCCRC. The endoscopist's specialty (nongastroenterologist/nongeneral surgeon) and setting (non-hospital-based colonoscopy) were associated with PCCRC. Those who underwent colonoscopy by an endoscopist with a high completion rate were less likely to have a PCCRC (distal: odds ratio [OR], 0.73; 95% confidence interval [CI], 0.54-0.97; P = .03; proximal: OR, 0.72; 95% CI, 0.53-0.97; P = .002). Patients with proximal cancers undergoing colonoscopy by endoscopists who performed polypectomies at high rates had a lower risk of PCCRC (OR, 0.61; 95% CI, 0.42-0.89; P < .0001). Endoscopist volume was not associated with PCCRC.
Endoscopist characteristics derived from administrative data are associated with development of PCCRC and have potential use as quality indicators.
Gastroenterology 01/2011; 140(1):65-72. · 11.68 Impact Factor
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ABSTRACT: Endoscopists are advised to measure and report their rates of colonoscopy-associated perforation and bleeding. However, evidence from population-based studies is lacking on the time period over which monitoring is needed to detect these adverse events.
To determine the time course of perforation or bleeding requiring hospital admission within 30 days after outpatient colonoscopy.
Population-based cohort study.
Ontario, Canada.
Men and women, 50 to 75 years old who underwent an outpatient colonoscopy during the period from April 1, 2002 to March 31, 2003.
Hospitalization for colonoscopy-related perforation or bleeding within 30 days after the procedure.
We identified 67,632 patients who had an outpatient colonoscopy, of whom 37 were admitted for hospitalization with perforation and 83 with bleeding within 30 days after the procedure. For those with a perforation, 34 of 37 (92%) were admitted within 2 days and all within 5 days. For those with bleeding, 30 of 83 (36%) were admitted within 2 days and 80 of 83 (96%) within 14 days.
Lack of information on medication use.
After outpatient colonoscopy, use of a 14-day time period for reporting would capture all perforations and the majority (96%) of bleeds requiring hospital admission.
Gastrointestinal endoscopy 12/2010; 73(3):520-3. · 6.71 Impact Factor
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ABSTRACT: Referral to a nephrologist before initiation of chronic dialysis occurs less frequently for blacks than whites, but the reasons for this disparity are incompletely understood. Here, we examined the contribution of racial composition by zip code on access and quality of nephrology care before initiation of renal replacement therapy (RRT). We retrospectively studied a cohort study of 92,000 white and black adults who initiated RRT in the United States between June 1, 2005, and October 5, 2006. The percentage of patients without pre-ESRD nephrology care ranged from 30% among those who lived in zip codes with <5% black residents to 41% among those who lived in areas with >50% black residents. In adjusted analyses, as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-ESRD nephrology care increased. Among patients who received nephrology care, the quality of care (timing of care and proportion of patients who received a pre-emptive renal transplant, who initiated therapy with peritoneal dialysis, or who had a permanent hemodialysis access) did not differ by the racial composition of their residential area. In conclusion, racial composition of residential areas associates with access to nephrology care but not with quality of the nephrology care received.
Journal of the American Society of Nephrology 07/2010; 21(7):1192-9. · 9.66 Impact Factor
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ABSTRACT: Although colonoscopy use has increased in the United States and Canada since the early 1990s, it is unclear whether this has been associated with benefit at the population level. Our objective was to evaluate the association between regional colonoscopy rates and death from colorectal cancer (CRC).
We conducted a natural experiment involving a 14-year follow-up of a cohort of all men and women 50-90 years of age living in Ontario on 1 January 1993 exposed to different intensities of colonoscopy use. Each member of the study cohort was assigned to a region each year, on the basis of his/her residence. Each individual was followed up through 31 December 2006; age- and sex-standardized CRC incidence rates were calculated and all CRC deaths were identified. Each year, for each region, the rate of colonoscopies performed on persons 50-90 years of age, per 1,000 population 50-90 years of age, living in the region, was calculated. Multivariable cox proportional hazards models were used to evaluate the association between colonoscopy rate and death from CRC, adjusting for age, sex, comorbidity, income, and location of residence (urban/rural).
The study cohort comprised 2,412,077 persons 50-90 years of age. The mean age was 64 years, and 53.7% were women. Colonoscopy rates increased in all regions during 1993-2006. The increased rate of complete colonoscopy was inversely associated with death from CRC. For every 1% increase in complete colonoscopy rate, the hazard of death decreased by 3%.
Increased colonoscopy use was associated with mortality reduction from CRC at the population level.
The American Journal of Gastroenterology 03/2010; 105(7):1627-32. · 7.28 Impact Factor
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Robert K Nam, Refik Saskin,
Yuna Lee,
Ying Liu,
Calvin Law,
Laurence H Klotz,
D Andrew Loblaw,
John Trachtenberg,
Aleksandra Stanimirovic,
Andrew E Simor,
Arun Seth,
David R Urbach,
Steven A Narod
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ABSTRACT: Transrectal ultrasound guided prostate biopsy is widely used to confirm the diagnosis of prostate cancer. The technique has been associated with significant morbidity in a small proportion of patients.
We conducted a population based study of 75,190 men who underwent a transrectal ultrasound guided biopsy in Ontario, Canada, between 1996 and 2005. We used hospital and cancer registry administrative databases to estimate the rates of hospital admission and mortality due to urological complications associated with the procedure.
Of the 75,190 men who underwent transrectal ultrasound biopsy 33,508 (44.6%) were diagnosed with prostate cancer and 41,682 (55.4%) did not have prostate cancer. The hospital admission rate for urological complications within 30 days of the procedure for men without cancer was 1.9% (781/41,482). The 30-day hospital admission rate increased from 1.0% in 1996 to 4.1% in 2005 (p for trend <0.0001). The majority of hospital admissions (72%) were for infection related reasons. The probability of being admitted to hospital within 30 days of having the procedure increased 4-fold between 1996 and 2005 (OR 3.7, 95% CI 2.0-7.0, p <0.0001). The overall 30-day mortality rate was 0.09% but did not change during the study period.
The hospital admission rates for complications following transrectal ultrasound guided prostate biopsy have increased dramatically during the last 10 years primarily due to an increasing rate of infection related complications.
The Journal of urology 03/2010; 183(3):963-8. · 4.02 Impact Factor
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ABSTRACT: The incidence of colorectal cancer (CRC) is reduced for at least 10 years after a negative colonoscopy, compared with the general population. However, CRCs do occur in individuals after a negative colonoscopy. We investigated whether the colonoscopy volume and specialty of the endoscopists who perform the exam are associated with CRC after a negative complete colonoscopy.
A cohort of Ontario residents, 50-80 years old, who had a negative complete colonoscopy between January 1, 1992, and December 31, 1997, was identified by using linked administrative databases. Cohort members had no history of CRC or inflammatory bowel disease or a recent colonic resection. Each individual was followed through December 31, 2006, and those with a new diagnosis of CRC were identified. Multivariable analysis was used to evaluate the association of patient, endoscopist, and procedure setting characteristics with incident CRC.
A cohort of 110,402 individuals with a negative complete colonoscopy was identified; the majority (86%) had their procedures performed in hospitals. During the 15-year follow-up period, 1596 (14.5%) developed CRC. There was no association between endoscopist colonoscopy volume and incident CRC. Among persons who had their colonoscopies at a hospital, those who had their procedures performed by a non-gastroenterologist were at significantly increased risk for developing subsequent CRC.
Endoscopist specialty is an important determinant of the effectiveness of colonoscopy in usual clinical practice. After a negative colonoscopy, those who have had their procedures performed by a gastroenterologist are less likely to develop CRC.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 10/2009; 8(3):275-9. · 5.64 Impact Factor
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ABSTRACT: To evaluate factors associated with survival after lymphadenectomy for endometrial cancer and to address their effect relating to systemic therapy.
This was a retrospective, population-based cohort study of 316 women with endometrial cancer who underwent surgery including lymphadenectomy in Ontario, Canada, from 1996-2000. Data obtained from administrative databases included comorbidities, socioeconomic status, grade, myometrial invasion, cervical involvement, lymphovascular-space invasion, nodal status, and adjuvant pelvic radiotherapy. Primary outcome was 5-year overall survival. Factors associated with survival were identified in a multivariable Cox proportional hazards model.
Mean age was 62.2 years (+/-11.6 years). Thirty-eight women (12%) had positive pelvic nodes. Seventy-five (23.7%) received adjuvant pelvic radiotherapy. Age older than 60, grade 3 tumor, deep myometrial invasion (greater than 50%), and cervical stromal involvement were associated with a higher risk of death compared with reference categories. There were no survival differences according to comorbidities, socioeconomic status, or lymphovascular-space invasion. Five-year overall survival was 53.1% for node-negative patients with two or three uterine risk factors and 75.0% for node-positive patients with none or only one uterine risk factor. Pelvic-node status was not an independent determinant of survival (positive nodes: hazard ratio 1.39, 95% confidence interval 0.89-2.18).
High-risk uterine factors including grade 3 tumor, deep myometrial invasion, and cervical stromal involvement are more significant determinants of survival in endometrial cancer than pelvic-node status. Uterine risk factors should be considered, regardless of nodal status, when offering systemic therapy to maximize survival outcomes.
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Obstetrics and Gynecology 10/2009; 114(4):736-43. · 4.73 Impact Factor
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ABSTRACT: To determine the stated practices of clinicians in weaning critically ill adults from invasive ventilation.
We conducted a cross-sectional, self-administered postal survey of Critical Care physicians and respiratory therapists (RTs) in leadership roles at Canadian teaching hospitals. We identified respondents using electronic mail and telephone correspondence. We used rigorous survey methodology to develop, test, and administer the questionnaire.
One hundred ten of 162 (67.9%) clinicians returned the survey with 99 respondents (55 physicians and 44 RTs) completing it either in-part or in-full. Approximately 95% of respondents acknowledged ever performing spontaneous breathing trials (SBTs) in clinical practice. Of these, 95.6% and 32% of respondents reported conducting daily and twice-daily screening to identify SBT candidates, at least sometimes. The three most common techniques to conduct SBTs included; pressure support (PS) with positive end-expiratory pressure (70.8%), continuous positive airway pressure (35.7%), and use of a T-piece (25.0%). PS ventilation was the weaning strategy used most frequently before SBTs. Most respondents (57.1%) considered continuous infusion of sedative-hypnotics to be a relative contraindication to tracheal extubation. However, concurrent administration of low dose vasopressors, inotropes, and analgesic boluses, or continuous analgesic infusions were considered acceptable amongst 60.8%, 73.2%, 78.4% and 58.8% of respondents, respectively. We did not observe regional variation in whether clinicians ever perform SBTs, the ventilatory modes used prior to an SBT nor in the use of PS and SBTs during the weaning process.
Pressure support and SBTs are common features of weaning in Canadian teaching hospitals. Compared to the published literature, our survey suggests that weaning practices have evolved over time and that practice variation may be greater on an international level compared to a national level.
Canadian Anaesthetists? Society Journal 09/2009; 56(8):567-76. · 2.31 Impact Factor
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ABSTRACT: Improvements in imaging technology over time have led to its increasingly widespread use in health care, even when the imaging may not be indicated. This study evaluates patterns of preoperative ultrasound, CT and MRI use among uterine cancer patients in Ontario.
This population-based study identified women diagnosed with uterine malignancy from 1995-2005 in the Ontario Cancer Registry. Record linkages were made to other healthcare databases to characterize residence, socioeconomic status, comorbidities, and timing of investigations surrounding diagnosis.
We identified 12,522 women who received surgery for uterine adenocarcinoma or sarcoma, of which 9145 (73%) had a preoperative ultrasound, and 1148 (9.2%) had a preoperative CT and/or MRI. Over 10 years, the rate of CT use increased 4.5-fold while MRI use increased 10.6-fold. There were no significant differences in CT/MRI use among patients with increased comorbidities, urban residence or socioeconomic status. Higher rates of CT/MRI use were associated with non-endometrioid high-risk histology (33.5% vs 14.6%, p<0.0001). Median time from ultrasound to surgery was 11.6 weeks. Time from diagnosis to surgery was 2 weeks longer if a preoperative CT/MRI was done. Half of these tests were ordered by non-gynecologists.
The rate of preoperative CT and MRI use in patients with uterine cancer has increased twice as much as the reported rate in cancer patients overall. Given the questionable utility of preoperative CT/MRI in this disease, guidelines should be developed for use of these imaging tests in uterine cancer, especially when use is associated with a delay in surgery.
Gynecologic Oncology 09/2009; 115(2):226-30. · 3.89 Impact Factor
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ABSTRACT: To conduct a population-based study of incidence and screening rates for secondary breast and colorectal cancers after endometrial cancer and to assess implications for follow-up.
This was a retrospective population-based study from administrative databases. The inception cohort included all women diagnosed with endometrial cancer in Ontario, Canada from 1996 to 2000, without a previous history of breast or colorectal cancer. We ascertained 5-year recurrence and overall survival rates and practitioner type during follow-up. Primary outcomes were age-standardized incidence and screening rates of breast and colorectal cancer during follow-up compared with the general female population.
There were 3,473 women in the cohort. The 5-year recurrence rate was 15.0% and overall survival was 79.3%. Family physicians were most often involved in follow-up care. Age-standardized incidence rates of breast and colorectal cancer were 0.5% and 0.7%, respectively, compared with 0.5% (P=.76) and 0.2% (P<.001) in the general population. Age-standardized screening rates for these cancers were 64.0% and 30.0%, respectively, compared with 31.0% (P<.008) and 15.0% (P<.001) in the general population. Women aged older than 70 years and those with the lowest income were least likely to have secondary cancer screening.
Women with endometrial cancer have a comparable risk of breast cancer but higher risk of colorectal cancer compared with the general population. Follow-up after endometrial cancer should include counseling and uptake of secondary cancer prevention strategies, which will contribute to maximizing long-term survivorship for these women.
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Obstetrics and Gynecology 05/2009; 113(4):790-5. · 4.73 Impact Factor
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ABSTRACT: With the increasing use of colonoscopy there is growing concern about the quality of these procedures.
To evaluate the rates of complete colonic evaluation after an incomplete colonoscopy and their associated factors.
Men and women > or =50 years old living in Ontario on January 1, 1997 who did not have a prior history of colorectal cancer, inflammatory bowel disease, or colonic resection comprised the inception cohort. Receipt of an incomplete colonoscopy between January 1, 1997 and December 31, 2002 was determined. Individuals were followed over 1 year and the time from incomplete colonoscopy to complete colonic evaluation was estimated using Kaplan-Meier analysis. A generalized estimating equations model was used to evaluate the association between patient, physician, and setting factors and complete colonic evaluation.
Twenty thousand one hundred sixty-six individuals had an incomplete colonoscopy, of whom 29.4% underwent complete colonic evaluation within 1 year after the procedure. Women > or =80 years were less likely to undergo complete colonic evaluation (odds ratio: 0.89; 95% confidence interval: 0.79-0.99), as were those who had their colonoscopy in a private office or clinic (odds ratio: 0.77; 95% confidence interval: 0.67-0.89).
Only 29.4% of individuals with an incomplete colonoscopy underwent complete colonic evaluation within 1 year after the procedure. Women > or =80 years and those who had their colonoscopy in a private office or clinic were less likely to undergo complete colonic evaluation. The quality of care provided to older women and colonoscopy practice in office settings may be suboptimal.
Medical care 01/2009; 47(1):48-52. · 3.24 Impact Factor
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ABSTRACT: Preoperative diagnosis of breast cancer is a standard of care. We conducted a population-based study to determine the factors associated with the use of percutaneous needle biopsy to diagnose breast cancer in Ontario.
We identified a total of 3644 women who underwent breast tissue sampling (percutaneous needle biopsy or surgical excision) that yielded a diagnosis of cancer between Apr. 1, 2002, and Dec. 31, 2002, and for whom we were able to obtain complete data. We performed univariate and multivariate analyses to examine the association between a number of variables and the use of percutaneous biopsy or surgery for diagnosis and the performance of biopsy with or without image guidance. The variables were age, local health integration network (LHIN), income quintile, urban or rural residence, access to a primary care provider, prior mammogram, prior regular screening mammography, screen-initiated biopsy, and surgeon and radiologist specialization in breast disease.
A total of 2374 women (65%) underwent percutaneous biopsy to diagnose breast cancer. The use of percutaneous biopsy varied from 22% to 81% among LHINs. On multivariate analysis, no patient variables were associated with the use of percutaneous biopsy for diagnosis. Only the LHIN and surgeon and radiologist specialization were predictive of whether a woman received a percutaneous biopsy. These 2 variables, along with income quintile and screen-initiated biopsy, were associated with the use of image-guided biopsy as the method of choice.
Geographic variation in the use of percutaneous biopsy, particularly image-guided biopsy, for the diagnosis of breast cancer exists across Ontario. The frequency of such biopsies may be a useful quality indicator. Strategies to improve uptake of organized evidence-based care may increase the use of percutaneous biopsy.
Canadian journal of surgery. Journal canadien de chirurgie 01/2009; 51(6):453-63. · 1.05 Impact Factor
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ABSTRACT: Colonoscopy is advocated for screening and prevention of colorectal cancer (CRC), but randomized trials supporting the benefit of this practice are not available.
To evaluate the association between colonoscopy and CRC deaths.
Population-based, case-control study.
Ontario, Canada.
Persons age 52 to 90 years who received a CRC diagnosis from January 1996 to December 2001 and died of CRC by December 2003. Five controls matched by age, sex, geographic location, and socioeconomic status were randomly selected for each case patient.
Administrative claims data were used to detect exposure to any colonoscopy and complete colonoscopy (to the cecum) from January 1992 to an index date 6 months before diagnosis in each case patient and the same assigned date in matched controls. Exposures in case patients and controls were compared by using conditional logistic regression to control for comorbid conditions. Secondary analyses were done to see whether associations differed by site of primary CRC, age, or sex.
10 292 case patients and 51 460 controls were identified; 719 case patients (7.0%) and 5031 controls (9.8%) had undergone colonoscopy. Compared with controls, case patients were less likely to have undergone any attempted colonoscopy (adjusted conditional odds ratio [OR], 0.69 [95% CI, 0.63 to 0.74; P < 0.001]) or complete colonoscopy (adjusted conditional OR, 0.63 [CI, 0.57 to 0.69; P < 0.001]). Complete colonoscopy was strongly associated with fewer deaths from left-sided CRC (adjusted conditional OR, 0.33 [CI, 0.28 to 0.39]) but not from right-sided CRC (adjusted conditional OR, 0.99 [CI, 0.86 to 1.14]). Limitation: Screening could not be differentiated from diagnostic procedures.
In usual practice, colonoscopy is associated with fewer deaths from CRC. This association is primarily limited to deaths from cancer developing in the left side of the colon.
Annals of internal medicine 12/2008; 150(1):1-8. · 16.73 Impact Factor
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ABSTRACT: The most widely quoted complication rates for colonoscopy are from case series performed by expert endoscopists. Our objectives were to evaluate the rates of bleeding, perforation, and death associated with outpatient colonoscopy and their risk factors in a population-based study.
We identified all individuals 50 to 75 years old who underwent an outpatient colonoscopy during April 1, 2002, to March 31, 2003, in British Columbia, Alberta, Ontario, and Nova Scotia, Canada. Using administrative data, we identified all individuals who were admitted to hospital with bleeding or perforation within 30 days following the colonoscopy in each province. We calculated the pooled rates of bleeding and perforation from the 4 provinces. In Ontario, we abstracted the hospital charts of all deaths that occurred within 30 days following the procedure. We used generalized estimating equations models to evaluate factors associated with bleeding and perforation.
We identified 97,091 persons who had an outpatient colonoscopy. The pooled rates of colonoscopy-related bleeding and perforation were 1.64/1000 and 0.85/1000, respectively. The death rate was 0.074/1000 or approximately 1/14,000. Older age, male sex, having a polypectomy, and having the colonoscopy performed by a low-volume endoscopist were associated with increased odds of bleeding or perforation.
Although colonoscopy has established benefits for the detection of colorectal cancer and adenomatous polyps, the procedure is associated with risks of serious complications, including death. Older age, male sex, having a polypectomy, and having the procedure done by a low-volume endoscopist were independently associated with colonoscopy-related bleeding and perforation.
Gastroenterology 09/2008; 135(6):1899-1906, 1906.e1. · 11.68 Impact Factor
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ABSTRACT: Little is known about the risk of proximal and distal colorectal cancer (CRC) following flexible sigmoidoscopy (FS) in usual clinical practice. Our objective was to estimate the annual incidence of CRC within 7 yr following FS and to identify factors associated with incident CRC in those with a negative FS.
In this population-based retrospective cohort study, we included men and women 50-80 yr of age who had a negative or positive FS during 1996-1998 in Ontario. We followed each individual through December 31, 2005 and calculated the age- and sex-standardized incidence rates (SIRs) and 95% confidence intervals (CIs) for distal and proximal CRC. We compared the relative rate (RR) and 95% CIs of incident CRC between the negative and positive FS cohorts and the remaining Ontario population. Cox models were used to evaluate factors associated with incident cancers.
The RR for distal CRC was significantly lower among those with a negative FS than in the Ontario population during each year of follow-up except the first year. For example, at 7 yr, the SIR for distal CRC following negative FS was 0.74 cancers/1,000 persons (95% CI 0.46-1.13) compared with 1.07/1,000 (95% CI 1.02-1.11) in the Ontario population (RR = 0.69, 95% CI 0.40-0.99). The RR for proximal CRC, except for year 2, did not differ between the negative FS cohort and the Ontario population during follow-up. In the positive FS cohort, the RR for distal CRC was significantly higher in the first year of follow-up compared with the Ontario population, but not thereafter. The results were similar for the RR for proximal CRC in the positive FS cohort. Only age was significantly associated with incident CRC following negative FS.
Following negative FS, the incidence of distal but not proximal CRC was reduced for up to 7 yr. Following a positive FS, the incidence of distal and proximal cancer after the first year of follow-up did not differ from the Ontario population. The benefit of FS was confined to the distal colon, emphasizing the potential limitation of FS in practice.
The American Journal of Gastroenterology 09/2008; 103(8):2075-82. · 7.28 Impact Factor
