Sumit R Majumdar

University of Alberta, Edmonton, Alberta, Canada

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Publications (308)1841.98 Total impact

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    ABSTRACT: To examine the prevalence of multimorbidity (≥2 chronic conditions) in severely obese patients and its associations with weight loss and health status over 2 years. In a prospective cohort including 500 severely obese adults, self-reported prevalence of 20 chronic conditions was calculated at baseline and 2 years. Multivariable logistic regression models were fitted to test the covariate-adjusted associations between ≥5% weight reduction and reduction in multimorbidity and the association between health status (visual analogue scale [VAS]) and reduction in multimorbidity over 2 years. After 2 years, mean weight change was -12.9 ±18.7 kg, 53% had ≥5% weight reduction, mean change in VAS was 11.5 ± 21.2, and 53.5% had ≥10% increase in VAS. Multimorbidity was reported in 95.4% and 92.8% patients at baseline and 2 years, respectively. Weight loss (≥5%) over 2 years was associated with reduction in multimorbidity (adjusted OR = 1.7, 95% CI 1.1-2.7). Reduction in multimorbidity was associated with clinically important improvements (≥10% increase in VAS) in health status (adjusted OR = 2.5, 95% CI 1.6, 4.0). Multimorbidity is common in severely obese patients. Having ≥5% weight reduction over 2 years was associated with a reduction in multimorbidity, which was also associated with improvements in health status. © 2015 The Obesity Society.
    Obesity 02/2015; · 4.39 Impact Factor
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    ABSTRACT: Frailty is a multidimensional syndrome characterized by loss of physiologic reserve that gives rise to vulnerability to poor outcomes. We aimed to examine the association between frailty and long-term health-related quality-of-life among survivors of critical illness. Prospective multicenter observational cohort study. ICUs in six hospitals from across Alberta, Canada. Four hundred twenty-one critically ill patients who were 50 years or older. None. Frailty was operationalized by a score of more than 4 on the Clinical Frailty Scale. Health-related quality-of-life was measured by the EuroQol Health Questionnaire and Short-Form 12 Physical and Mental Component Scores at 6 and 12 months. Multiple logistic and linear regression with generalized estimating equations was used to explore the association between frailty and health-related quality-of-life. In total, frailty was diagnosed in 33% (95% CI, 28-38). Frail patients were older, had more comorbidities, and higher illness severity. EuroQol-visual analogue scale scores were lower for frail compared with not frail patients at 6 months (52.2 ± 22.5 vs 64.6 ± 19.4; p < 0.001) and 12 months (54.4 ± 23.1 vs 68.0 ± 17.8; p < 0.001). Frail patients reported greater problems with mobility (71% vs 45%; odds ratio, 3.1 [1.6-6.1]; p = 0.001), self-care (49% vs 15%; odds ratio, 5.8 [2.9-11.7]; p < 0.001), usual activities (80% vs 52%; odds ratio, 3.9 [1.8-8.2]; p < 0.001), pain/discomfort (68% vs 47%; odds ratio, 2.0 [1.1-3.8]; p = 0.03), and anxiety/depression (51% vs 27%; odds ratio, 2.8 [1.5-5.3]; p = 0.001) compared with not frail patients. Frail patients described lower health-related quality-of-life on both physical component score (34.7 ± 7.8 vs 37.8 ± 6.7; p = 0.012) and mental component score (33.8 ± 7.0 vs 38.6 ± 7.7; p < 0.001) at 12 months. Frail survivors of critical illness experienced greater impairment in health-related quality-of-life, functional dependence, and disability compared with those not frail. The systematic assessment of frailty may assist in better informing patients and families on the complexities of survivorship and recovery.
    Critical care medicine. 01/2015;
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    ABSTRACT: Context: Intuitively, rapid bone mineral density (BMD) loss should predict fracture risk independently of current BMD, but studies have not confirmed this. We hypothesized that measurement error when characterizing rates of BMD loss might explain this paradox. Objective: To examine the importance of measurement error in predicting BMD loss. Design and Setting: Retrospective registry study using BMD results for Manitoba, Canada. Patients: Untreated women age 50 years and older with three femoral neck BMD tests. Main Outcome Measures: Correlation in annualized rates of BMD change for interval 1 (first to second scan) versus interval 2 (second to third scan) with confirmatory model-based simulations that varied measurement error and testing intervals. Results: Five hundred forty two women with a mean age of 62 years had BMD measurements separated by a mean of 3.5 years for interval 1 and 3.4 years for interval 2. Mean femoral neck BMD loss was stable (-0.5% per year for interval 1, -0.6% per year for interval 2) with a weak negative correlation between intervals (r = -0.11, P = .01). There were no significant correlations for BMD change at the total hip (r = 0.01, P = .74) or total spine (r = -0.01, P = .77). Simulations showed low explained variation for BMD change between intervals 1 and 2 (<20%). To explain 50% of the variation of BMD change between intervals 1 and 2 required a BMD measurement error ≤0.008 g/cm(2) or a BMD testing interval ≥5 years. Conclusions: The low correlation between past and future BMD loss helps explain why the rate of BMD loss is unlikely to be helpful for refining fracture risk.
    Journal of Clinical Endocrinology &amp Metabolism 01/2015; 100(2):jc20143777. · 6.31 Impact Factor
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    ABSTRACT: Background Adding pharmacists to primary care teams significantly improved blood pressure control and reduced predicted 10–year cardiovascular risk in patients with Type 2 diabetes. This pre-specified sub-study evaluated the economic implications of this cardiovascular risk reduction strategy.Methods One-year outcomes and healthcare utilization data from the trial were used to determine cost-effectiveness from the public payer perspective. Costs were expressed in 2014 Canadian dollars and effectiveness was based on annualized risk of cardiovascular events derived from the UKPDS Risk Engine.ResultsThe 123 evaluable trial patients included in this analysis had a mean age of 62 (± 11) years, 38% were men, and mean diabetes duration was 6 (± 7) years. Pharmacists provided 3.0 (± 1.9) hours of additional service to each intervention patient, which cost $226 (± $1143) per patient. The overall one-year per-patient costs for healthcare utilization were $190 lower in the intervention group compared with usual care [95% confidence interval (CI): $1040, $668). Intervention patients had a significant 0.3% greater reduction in the annualized risk of a cardiovascular event (95% CI: 0.08%, 0.6%) compared with usual care. In the cost-effectiveness analysis, the intervention dominated usual care in 66% of 10 000 bootstrap replications. At a societal willingness-to-pay of $4000 per 1% reduction in annual cardiovascular risk, the probability that the intervention was cost-effective compared with usual care reached 95%. A sensitivity analysis using multiple imputation to replace missing data produced similar results.Conclusions Within a randomized trial, adding pharmacists to primary care teams was a cost-effective strategy for reducing cardiovascular risk in patients with Type 2 diabetes. In most circumstances, this intervention may also be cost saving.This article is protected by copyright. All rights reserved.
    Diabetic Medicine 01/2015; · 3.24 Impact Factor
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    ABSTRACT: Our purpose was to measure the effect of non-benefit drug use on observed associations between exposure and outcome, thereby documenting an empirical example of the potential magnitude of biases introduced when exposure status is misclassified from a restrictive drug coverage policy. New users of antidiabetic agents were identified with a 1-year washout period between January 1, 1995, and December 31, 2005, in Saskatchewan, Canada, and were followed until December 31, 2008. Within this population-based cohort, persons were classified as users of benefit or non-benefit thiazolidinediones (TZDs) according to their first prescription record between January 1, 2006, and December 31, 2006 (non-benefit prescription records were not captured before 2006). An intention-to-treat approach was used to categorize TZD exposure over time. We evaluated the potential bias introduced by drug exposure misclassification by evaluating bootstrapped differences in hazard ratio (HR) estimates of all-cause hospitalization or death between users and nonusers of TZDs obtained from analyses that contained complete drug use (non-benefit and benefit drug use) versus benefit drug use only (non-benefit drug use was misclassified as unexposed). All analyses were replicated within the same cohort of new users of antidiabetic agents for clopidogrel and β-blocker (bisoprolol or carvedilol) users versus nonusers because these agents were also subject to exposure misclassification from non-benefit drug use during the period of the study. Among 27,333 new users of antidiabetic agents, we identified 5759 TZD users (28% non-benefit) and 21,574 nonusers of TZDs. The crude HR for hospitalization or death among TZD users versus nonusers was higher in a database that contained benefit-only prescriptions than in a database that contained all prescriptions (HR = 1.11 [95% CI, 1.05-1.18] vs HR = 0.99 [95% CI, 0.94-1.04]). However, the differences in HRs after adjustment for demographic characteristics, health care utilization, comorbidities, and medications suggested minimal bias was introduced when TZD exposure was misclassified in the benefit-only database (adjusted HR [aHR] = 1.04 [95% CI. 0.98-1.10] vs aHR = 0.99 [95% CI, 0.94-1.04]; bootstrapped aHR difference = +0.05 [95% CI, 0.02-0.08]). Minimal differences in aHRs were also observed within analyses of clopidogrel (1551 users [24% non-benefit]; bootstrapped aHR difference = +0.01 [95% CI, -0.04 to 0.06]) and β-blocker users (351 users [42% non-benefit]; bootstrapped aHR difference = +0.06 [95% CI, -0.09 to 0.20]) versus nonusers. Although patient characteristics and outcomes differed between users of non-benefit and benefit drugs, misclassification of drug exposure did not meaningfully bias estimates of all-cause mortality and hospitalization after covariate adjustment in our study. Copyright © 2015 Elsevier HS Journals, Inc. All rights reserved.
    Clinical therapeutics. 01/2015;
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    ABSTRACT: Hospitals reduce staffing levels and services on weekends. This raises the question of whether weekend discharges may be inadequately prepared and thus at higher risk for adverse events postdischarge. To compare death or nonelective readmission rates 30 days after weekend versus weekday discharge. Retrospective cohort. All teaching hospitals in Alberta, Canada. General internal medicine (GIM) discharges (only 1 per patient). Analyses were adjusted for demographics, comorbidity, and length of stay based on a previously validated index. Of 7991 patients (mean age, 62.1 years; 51.9% male; mean Charlson 2.56; 57.5% LACE ≥10) discharged from 7 teaching hospitals, 1146 (14.3%) were discharged on a weekend. Although they had substantially shorter lengths of stay (5.64 days, 95% confidence interval [CI]: 5.35-5.93 vs 7.86 days, 95% CI: 7.71-8.00, adjusted P value < 0.0001) and were less likely to be discharged with homecare support (10.9% vs 19.3%) or to long-term care facilities (3.1% vs 7.8%), patients discharged on weekends exhibited similar rates of death or readmission at 30 days compared to those discharged on weekdays (10.6% vs 13.2%, adjusted odds ratio [aOR]: 0.94, 95% CI: 0.77-1.16), even among the 4591 patients deemed to be at high risk for postdischarge events based on LACE (length of hospital stay, acuity of admission, comorbidity burden quantified using the Charlson Comorbidity Index, and emergency department visits in the 6 months prior to admission) score ≥10 (16.8% vs 16.5% for weekday discharges, aOR: 1.09 [95% CI: 0.85-1.41]). GIM patients discharged from teaching hospitals on weekends have shorter lengths of stay and exhibit similar postdischarge outcomes as patients discharged on weekdays. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine. © 2014 Society of Hospital Medicine.
    Journal of Hospital Medicine 12/2014; · 2.08 Impact Factor
  • T T Dang, S R Majumdar, T J Marrie, D T Eurich
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    ABSTRACT: Community-acquired pneumonia (CAP) is one of the most common reasons for physician visits and hospitalizations in North America. Rates of CAP increase with age and CAP is associated with significant morbidity and mortality, especially in the elderly. Though there is much written about the epidemiology and risk factors of incident (first episode) pneumonia, much less is known about recurrent pneumonia. Rates of recurrent pneumonia within 3-5-years of an episode of CAP are 9-12 % with a median time to recurrence of 123-317 days and mortality ranging from 4 to 10 %. Age ≥65-years-old and impaired functional status are the only patient characteristics that are independently associated with increased risk of recurrence. In terms of modifiable risk factors, only the use of proton-pump inhibitors and systemic and inhaled corticosteroids have consistently been associated with increased risk of recurrent pneumonia, while angiotensin-converting enzyme (ACE) inhibitors may exert a protective effect. Many chronic medical conditions typically associated with increased incident pneumonia-such as chronic obstructive pulmonary disease (COPD), neurological disease (resulting in dysphagia or silent aspiration), and heart failure-were not associated with increased risk of recurrent pneumonia. However, those who are immune-suppressed (e.g., immunoglobulin deficiencies) may be at increased risk of recurrent pneumonia. In summary, among those who survive an episode of pneumonia, recurrence is not uncommon, particularly in the elderly. Following recovery from an episode of pneumonia, patients should be evaluated for risk factors that would predispose to a second episode including seeking evidence of immunosuppression in younger patients and medication optimization, particularly in the elderly.
    Drugs & Aging 12/2014; · 2.50 Impact Factor
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    ABSTRACT: To evaluate the effectiveness and safety of dipeptidyl peptidase-4 (DPP-4) inhibitors versus intermediate-acting insulin for adults with type 2 diabetes mellitus (T2DM) and poor glycaemic control despite treatment with two oral agents. Studies were multicentre and multinational. Ten studies including 2967 patients with T2DM. Studies that examined DPP-4 inhibitors compared with each other, intermediate-acting insulin, no treatment or placebo in patients with T2DM. Primary outcome was glycosylated haemoglobin (HbA1c). Secondary outcomes were healthcare utilisation, body weight, fractures, quality of life, microvascular complications, macrovascular complications, all-cause mortality, harms, cost and cost-effectiveness. 10 randomised clinical trials with 2967 patients were included after screening 5831 titles and abstracts, and 180 full-text articles. DPP-4 inhibitors significantly reduced HbA1c versus placebo in network meta-analysis (NMA; mean difference (MD) -0.62%, 95% CI -0.93% to -0.33%) and meta-analysis (MD -0.61%, 95% CI -0.81% to -0.41%), respectively. Significant differences in HbA1c were not observed for neutral protamine Hagedorn (NPH) insulin versus placebo and DPP-4 inhibitors versus NPH insulin in NMA. In meta-analysis, no significant differences were observed between DPP-4 inhibitors and placebo for severe hypoglycaemia, weight gain, cardiovascular disease, overall harms, treatment-related harms and mortality, although patients receiving DPP-4 inhibitors experienced less infections (relative risk 0.72, 95% CI 0.57 to 0.91). DPP-4 inhibitors were superior to placebo in reducing HbA1c levels in adults with T2DM taking at least two oral agents. Compared with placebo, no safety signals were detected with DPP-4 inhibitors and there was a reduced risk of infection. There was no significant difference in HbA1c observed between NPH and placebo or NPH and DPP-4 inhibitors. PROSPERO # CRD42013003624. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
    BMJ Open 12/2014; 4(12):e005752. · 2.06 Impact Factor
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    ABSTRACT: Survivors of ischemic stroke/transient ischemic attack (TIA) are at high risk for other vascular events. We evaluated the impact of 2 types of case management (hard touch with pharmacist or soft touch with nurse) added to usual care on global vascular risk. This is a prespecified secondary analysis of a 6-month trial conducted in outpatients with recent stroke/TIA who received usual care and were randomized to additional monthly visits with either nurse case managers (who counseled patients, monitored risk factors, and communicated results to primary care physicians) or pharmacist case managers (who were also able to independently prescribe according to treatment algorithms). The Framingham Risk Score [FRS]) and the Cardiovascular Disease Life Expectancy Model (CDLEM) were used to estimate 10-year risk of any vascular event at baseline, 6 months (trial conclusion), and 12 months (6 months after last trial visit). Mean age of the 275 evaluable patients was 67.6 years. Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months: median 4.8% (Interquartile range (IQR) 0.3%-11.3%) for the pharmacist arm versus 5.1% (IQR 1.9%-12.5%) for the nurse arm on the FRS (P = .44 between arms) and median 10.0% (0.1%-31.6%) versus 12.5% (2.1%-30.5%) on the CDLEM (P = .37). These reductions persisted at 12 months: median 6.4% (1.2%-11.6%) versus 5.5% (2.0%-12.0%) for the FRS (P = .83) and median 8.4% (0.1%-28.3%) versus 13.1% (1.6%-31.6%) on the CDLEM (P = .20). Case management by nonphysician providers is associated with improved global vascular risk in patients with recent stroke/TIA. Reductions achieved during the active phase of the trial persisted after trial conclusion. Copyright © 2014 Mosby, Inc. All rights reserved.
    American Heart Journal 12/2014; 168(6):924-30. · 4.56 Impact Factor
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    ABSTRACT: The impact of multimorbidity on patients with community-acquired pneumonia has not been well characterised. Thus, our aim was to explore the relationship between multimorbidity and adverse events within 90 days of discharge. Data were prospectively collected for a population-based cohort of all adults discharged from any of the seven emergency departments (ED) or six hospitals in Edmonton (Alberta, Canada) with community-acquired pneumonia. Multivariable Cox regression models were used to examine the independent association between multimorbidity (defined as two or more chronic conditions) and subsequent 90-day mortality, hospitalisation, or ED visits after treatment of pneumonia. The cohort included 5565 patients, mean age was 57 years (SD 20), 54% were male, and 59% were treated as outpatients; 1602 (29%) patients had multimorbidity. Within 90 days, 255 (5%) patients died, 1205 (22%) were hospitalised, 1280 (23%) died or were hospitalised, and 2049 (37%) were admitted to the ED. The presence of multimorbidity was independently associated with an increased risk of death or hospitalisation within 90 days (37% vs. 17% for those without multimorbidity, adjusted hazard ratio: 1.43, 95% confidence interval: 1.26 to 1.62) as well as ED visits (45% vs. 34%, adjusted hazard ratio: 1.40, 95% confidence interval: 1.26 to 1.56). Multimorbidity was present in one-third of all patients with pneumonia in our study, and it was independently associated with death, hospitalisation, or return to ED within 90 days of discharge. Our findings suggest that multimorbidity is strongly related to prognosis and should be considered when making site-of-care decisions in the ED or deciding upon readiness for discharge. Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
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    ABSTRACT: The use of the interactive communication loop has been recommended as an effective method to enhance patient understanding and recall of information.
    Nursing Research 11/2014; 63(6):408-17. · 1.50 Impact Factor
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    ABSTRACT: Although underused, written asthma action plans (AAPs) are associated with reduced numbers of emergency department (ED) visits and hospitalizations. To describe the frequency of use and contents of any AAPs reported by patients presenting with exacerbations to three urban Canadian EDs. Prospective data were collected through ED interview and chart review. Descriptive analyses used proportions and medians with interquartile range; multivariable logistic regression was used for the adjusted analyses. Among 176 enrolled patients, the median age was 27 years (interquartile range 23 to 39 years) and 97 (55%) were female. Few (n=42 [24%]) reported having AAPs at ED presentation and only six were written. Most (n=35 [75%]) patients with any AAP took action before the ED visit; none used a valid anti-inflammatory strategy. The first step of 27 plans was to increase asthma medication; no patients appropriately increased inhaled corticosteroids (ICS). In multivariable analyses, only the use of either ICS or ICS⁄long-acting β-agonist combination agents (31% had AAPs versus 12% did not have AAPs (adjusted OR 3.0 [95% CI 1.14 to 8.07]) and asthma education (47% had AAPs versus 21% did not have AAPs, adjusted OR 3.2 [95% CI 1.13 to 9.19]) were independently associated with AAP possession. Possession of AAPs among patients presenting to the ED with acute asthma was low, and only one in 10 AAPs were written. Patients who reported having any AAP used ineffective strategies to abort or mitigate the severity of an ED visit. Increasing frequency of written AAPs and improving their contents holds immediate promise in improving outcomes related to asthma.
    Canadian respiratory journal: journal of the Canadian Thoracic Society 11/2014; 21(6):351-356. · 1.66 Impact Factor
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    ABSTRACT: Direct-to-consumer advertising (DTCA) remains a controversial issue, with concerns that it leads to unnecessary and inappropriate prescribing. Whether DTCA shifts prescribing from first-line (guideline-recommended) therapy to second-line drugs has not been studied.
    Journal of General Internal Medicine 10/2014; · 3.42 Impact Factor
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    ABSTRACT: Background:Acute asthma is a common emergency department (ED) presentation. In a prospective multicenter cohort study we determined the frequency and factors associated with asthma relapse following discharge from the ED. Methods:Adults aged 18-55 years who were treated for acute asthma and discharged from 20 Canadian EDs underwent a structured ED interview and follow-up telephone interview four weeks later. Standardized anti-inflammatory treatment was offered at discharge. Multivariable analyses were performed. Results:Of 807 enrolled patients, 58% were female and the median age was 30 years. Relapse occurred in 144 patients (18%) within four weeks of ED discharge. Factors independently associated with relapse occurrence were: female sex (22% vs 12% males, adjusted odds ratio [aOR] = 1.9, 95% confidence interval [CI]: 1.2, 3.0), symptom duration of > 24 hours prior to ED visit (19% vs 13% short duration, aOR = 1.7, 95% CI: 1.3, 2.3), ever using oral corticosteroids (21% vs 12% for never use, aOR = 1.5, 95% CI: 1.1, 2.0), current use of an inhaled corticosteroids[ICS]/long-acting β-agonist combination product (25% vs 15% for ICS monotherapy, aOR = 1.9, 95% CI: 1.1, 3.2), and owning a spacer device (24% vs 15% not owning one aOR = 1.6, 95% CI: 1.3, 1.9). Conclusions:Despite receiving guideline-concordant anti-inflammatory treatments at ED discharge, almost one-in-five patients relapsed within four weeks. Female sex, prolonged symptoms, treatment-related factors and markers of prior asthma severity were significantly associated with relapse. These results may help clinicians target more aggressive interventions for patients at high risk of relapse.
    Chest 10/2014; · 7.13 Impact Factor
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    ABSTRACT: Background Guidelines and experts describe 5% to 10% reductions in body weight as `clinically important¿; however, it is not clear if 5% to 10% weight reductions correspond to clinically important improvements in health-related quality of life (HRQL). Our objective was to calculate the amount of weight loss required to attain established minimal clinically important differences (MCIDs) in HRQL, measured using three validated instruments.Methods Data from the Alberta Population-based Prospective Evaluation of Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study, a population-based, prospective Canadian cohort including 150 wait-listed, 200 medically managed and 150 surgically treated patients were examined. Two-year changes in weight and HRQL measures (Short-Form (SF)-12 physical (PCS; MCID¿=¿5) and mental (MCS; MCID¿=¿5) component summary score, EQ-5D Index (MCID¿=¿0.03) and Visual Analog Scale (VAS; MCID¿=¿10), Impact of Weight on Quality of Life (IWQOL)-Lite total score (MCID¿=¿12)) were calculated. Separate multivariable linear regression models were constructed within medically and surgically treated patients to determine if weight changes achieved HRQL MCIDs. Pooled analysis in all 500 patients was performed to estimate the weight reductions required to achieve the pre-defined MCID for each HRQL instrument.ResultsMean age was 43.7 (SD 9.6) years, 88% were women, 92% were white, and mean initial body mass index was 47.9 (SD 8.1) kg/m2. In surgically treated patients (two-year weight loss¿=¿16%), HRQL MCIDs were reached for all instruments except the SF-12 MCS. In medically managed patients (two-year weight loss¿=¿3%), MCIDs were attained in the EQ-index but not the other instruments. In all patients, percent weight reductions to achieve MCIDs were: 23% (95% confidence interval (CI): 17.5, 32.5) for PCS, 25% (17.5, 40.2) for MCS, 9% (6.2, 15.0) for EQ-Index, 23% (17.3, 36.1) for EQ-VAS, and 17% (14.1, 20.4) for IWQOL-Lite total score.Conclusions Weight reductions to achieve MCIDs for most HRQL instruments are markedly higher than the conventional threshold of 5% to 10%. Surgical, but not medical treatment, consistently led to clinically important improvements in HRQL over twoyears.Trial NCT00850356.
    BMC Medicine 10/2014; 12(1):175. · 7.28 Impact Factor
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    ABSTRACT: Depressive symptoms are common, and when coexisting with diabetes, worsen outcomes and increase health care costs. We evaluated a nurse case-manager-based collaborative primary care team model to improve depressive symptoms in diabetic patients.
    Diabetes Care 10/2014; · 8.57 Impact Factor
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    ABSTRACT: We investigated sex- and age-specific associations between income and fractures at the hip, humerus, spine, and forearm in adults aged ≥50 years. Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women.
    Osteoporosis International 10/2014; · 4.17 Impact Factor
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    ABSTRACT: To examine the safety, effectiveness, and cost effectiveness of long acting insulin for type 1 diabetes.
    BMJ British medical journal 10/2014; 349. · 16.30 Impact Factor
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    ABSTRACT: Objective To examine the measurement properties of the 16 screening questions (16-SQ) of inadequate health literacy (HL) and their briefer version (3-SQ), and identify the best screen for inadequate HL in non-white populations. Methods Sample included 378 individuals with type-2 diabetes. We computed sensitivity, specificity, positive and negative likelihood ratios, and C-indices, using the s-TOFHLA as a reference measure. We also conducted exploratory factor analysis, and used structural equation modeling (SEM) for confirmatory purposes. Results Mean age was 56.1 years, 69% were female, and 83% were African-American. 10% had limited HL (s-TOHFLA scores <23). Six questions (6-SQ) were identified and included in the final item-reduced factor analysis, which showed good fit in confirmatory SEM (chi-square = 9.5; P = 0.305; RMSEA = 0.023). Weighted summative score of the 6-SQ and the item “difficulty understanding written information” performed better than the 3-SQ in identifying patients with inadequate HL (C-indices 0.67 vs. 0.75). Conclusion The weighted summative score of the 6-SQ and the item “difficulty understanding written information” performed better than the other items or combinations of these items in identifying individuals with inadequate HL. Practice Implications The proposed weighting of scores could be applied in studies using these screening questions for better classification of inadequate HL.
    Patient Education and Counseling 10/2014; · 2.60 Impact Factor
  • Canadian Journal of Diabetes 10/2014; 38(5, Supplement):S55. · 0.46 Impact Factor

Publication Stats

8k Citations
1,841.98 Total Impact Points


  • 2001–2015
    • University of Alberta
      • • Department of Medicine
      • • School of Public Health
      • • Division of General Internal Medicine
      Edmonton, Alberta, Canada
  • 2013
    • University of Manitoba
      • Department of Pediatrics and Child Health
      Winnipeg, Manitoba, Canada
    • McGill University Health Centre
      Montréal, Quebec, Canada
    • TEC Edmonton
      Edmonton, Alberta, Canada
    • Northern Alberta Institute of Technology
      Edmonton, Alberta, Canada
  • 2012
    • St. Michael's Hospital
      Toronto, Ontario, Canada
    • The University of Calgary
      • Faculty of Medicine
      Calgary, Alberta, Canada
  • 2011
    • McGill University
      • Division of General Internal Medicine
      Montréal, Quebec, Canada
  • 2003–2011
    • Harvard Medical School
      • Department of Population Medicine
      Boston, MA, United States
  • 2010
    • Stanford University
      Palo Alto, California, United States
    • McMaster University
      • Department of Medicine
      Hamilton, Ontario, Canada
    • Golden Jubilee National Hospital
      Clydebank, Scotland, United Kingdom
  • 2009
    • University of British Columbia - Vancouver
      • Centre for Health Services and Policy Research
      Vancouver, British Columbia, Canada
  • 2003–2007
    • Institute of Health Economics
      Edmonton, Alberta, Canada
  • 2006
    • The University of Manchester
      Manchester, England, United Kingdom
  • 2005
    • The University of Western Ontario
      • Department of Medicine
      London, Ontario, Canada
  • 2002
    • University Health Network
      • Department of Medicine
      Toronto, Ontario, Canada