ABSTRACT Objective: The aim of this study was to compare time on treatment among individuals initiating buprenorphine/naloxone and methadone and understand how retention varies according to age, sex, and urban/rural residence. Methods: We conducted a population-based retrospective cohort study among individuals aged 18 years and older, residing in Southern Ontario, Canada, who initiated buprenorphine/naloxone or methadone between October 2016 and December 2018 (N=15,724). We compared time on treatment across demographic and geographic subgroups. Our primary outcome was time to treatment discontinuation, defined as missing at least 14 consecutive days of opioid agonist therapy (OAT). Results: We identified 15,724 eligible individuals, among whom 7209 (45.8%) initiated buprenorphine/naloxone and 8515 (54.2%) initiated methadone. The median time to treatment discontinuation was significantly shorter among those initiating buprenorphine/naloxone rather than methadone (114 d, interquartile range:15–665 d vs. 263 d interquartile range: 32–1015 d, respectively, P <0.0001). Time on treatment increased with age in both OAT groups, with the exception of those aged 65 and older, where retention declined. Among methadone recipients, time on treatment was longer among rural relative to urban residents (372 vs. 255 d; P =0.0073), with no variation by sex. Conversely, females treated with buprenorphine/naloxone had significantly longer treatment retention than men (125 vs. 108 d; P =0.0372), with no variation by urban or rural residence. Conclusions: Treatment retention is lower among individuals treated with buprenorphine/naloxone relative to methadone. Moreover, retention varies between and within OAT groups by demographic variables and place of residence. Further research which aims to explain these differences is needed to optimize OAT treatment. Objectifs de l'étude: Comparer la durée du traitement chez les personnes qui commencent à prendre de la buprénorphine/naloxone et de la méthadone et comprendre comment la rétention varie en fonction de l'âge, du sexe et du lieu de résidence (urbain ou rural). Méthodes: Nous avons mené une étude de cohorte rétrospective basée sur la population parmi les personnes âgées de 18 ans et plus, résidant dans le sud de l’Ontario, au Canada, qui ont commencé à prendre de la buprénorphine/naloxone ou de la méthadone entre octobre 2016 et décembre 2018 (N=15 724). Nous avons comparé la durée du traitement entre les sous-groupes démographiques et géographiques. Notre résultat principal était le temps écoulé jusqu'à l’arrêt du traitement, défini comme l’absence d’au moins 14 jours consécutifs de traitement par agoniste opioïde (TAO). Résultats: Nous avons identifié 15 724 personnes éligibles, parmi lesquelles 7 209 (45,8%) ont commencé à prendre de la buprénorphine/naloxone et 8 515 (54,2%) de la méthadone. Le temps médian avant l’arrêt du traitement était significativement plus court chez les personnes ayant commencé la buprénorphine/naloxone plutôt que la méthadone (114 jours, intervalle interquartile [IQR] 15-665 jours contre 263 jours IQR 32-1 015 jours, respectivement, P <0.0001). La durée du traitement a augmenté avec l'âge dans les deux groupes de TAO, à l’exception des personnes âgées de 65 ans et plus, chez qui la rétention a diminué. Parmi les patients traités à la méthadone, la durée du traitement était plus longue dans les zones rurales que dans les zones urbaines (372 jours contre 255 jours; P =0.0073), sans variation selon le sexe. Inversement, les femmes traitées à la buprénorphine/naloxone avaient une durée de traitement significativement plus longue que les hommes (125 jours contre 108 jours ; P =0.0372), sans variation selon le lieu de résidence (urbain ou rural). Conclusion: La rétention du traitement est plus faible chez les personnes traitées à la buprénorphine/naloxone qu’avec la méthadone. De plus, la rétention varie entre et au sein des groupes TAO en fonction des variables démographiques et du lieu de résidence. Des recherches supplémentaires visant à expliquer ces différences sont nécessaires pour optimiser le traitement par TAO.
Although fluoroquinolones are sometimes associated with mild, transient elevations in aminotransferase levels, serious acute liver injury is uncommon. Regulatory warnings have identified moxifloxacin as presenting a particular risk of hepatotoxicity. Thus, we examined the risk of idiosyncratic acute liver injury associated with the use of moxifloxacin relative to other selected antibiotic agents.
Methods:
We conducted a population-based, nested, case–control study using health care data from Ontario for the period April 2002 to March 2011. We identified cases as outpatients aged 66 years or older with no history of liver disease, and who were admitted to hospital for acute liver injury within 30 days of receiving a prescription for 1 of 5 broad-spectrum antibiotic agents: moxifloxacin, levofloxacin, ciprofloxacin, cefuroxime axetil or clarithromycin. For each case, we selected up to 10 age- and sex-matched controls from among patients who had received a study antibiotic, but who were not admitted to hospital for acute liver injury. We calculated odds ratios (ORs) to determine the association between admission to hospital and previous exposure to an antibiotic agent, using clarithromycin as the reference.
Results:
A total of 144 patients were admitted to hospital for acute liver injury within 30 days of receiving a prescription for one of the identified drugs. Of these patients, 88 (61.1%) died while in hospital. After multivariable adjustment, use of either moxifloxacin (adjusted OR 2.20, 95% confidence interval [CI] 1.21–3.98) or levofloxacin (adjusted OR 1.85, 95% CI 1.01–3.39) was associated with an increase in risk of acute liver injury relative to the use of clarithromycin. We saw no such risk associated with the use of either ciprofloxacin or cefuroxime axetil.
Interpretation:
Among older outpatients with no evidence of liver disease, moxifloxacin and levofloxacin were associated with an increased risk of acute liver injury relative to clarithromycin.
Introduction The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release. Methods We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015—March 2016; fiscal year [FY] 2015) and in the most recent year available (January—December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication. Results In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%). Conclusion Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing.
We welcome Professor Randsborg's suggestions that in addition to surgical volume, environmental factors such as institutional structures and patient demographics also impact on patient outcomes following total knee arthroplasty (TKA). However, we would argue that the true surgical volume is the
To describe the contributions of prescribed and non-prescribed opioids to opioid related deaths.
Design
Population based cohort study.
Setting
Ontario, Canada, from 1 January 2013 to 31 December 2016.
Participants
All Ontarians who died of an opioid related cause.
Exposure
Active opioid prescriptions, defined as those with a duration overlapping the date of death, and recent opioid prescriptions, defined as those dispensed in the 30 and 180 days preceding death. Postmortem toxicology results from the Drug and Drug/Alcohol Related Death database were used to characterise deaths on the basis of presence of prescribed and non-prescribed (that is, diverted or illicit) opioids, overall and stratified by year and age.
Results
2833 opioid related deaths occurred. An active opioid prescription on the date of death was relatively common but declined slightly throughout the study period (38.2% (241/631) in 2013 and 32.5% (278/855) in 2016; P for trend=0.03). Older people and women were relatively more likely to have an active opioid prescription at time of death. In 2016, 46% (169/364) of people aged 45-64 had an active opioid prescription compared with only 12% (8/69) among those aged 24 or younger (P for trend<0.001). Similarly, 46% (124/272) of women had an active opioid prescription at time of death compared with 26.4% (154/583) of men (P<0.001). Among people with active opioid prescriptions at time of death, 37.8% (375/993) also had evidence of a non-prescribed opioid on postmortem toxicology. By 2016, the non-prescribed opioid most commonly identified after death was fentanyl (41%; 47 of 115 cases). Among people without an active opioid prescription at time of death, fentanyl was detected in 20% (78/390) of deaths in 2013, increasing to 47.5% (274/577) by 2016 (P<0.001).
Conclusions
Prescribed, diverted, and illicit opioids all play an important role in opioid related deaths. Although more than half of all opioid related deaths still involved prescription drugs (either dispensed or diverted) in 2016, the increased rate of deaths involving fentanyl between 2015 and 2016 is concerning and suggests the need for a multifactorial approach to this problem that considers both the prescribed and illicit opioid environments.
Aims: This article describes the development of a collaborative, multi-disciplinary approach to acute stroke care within a semi-rural district general hospital (DGH). The approach uses existing staff, equipment and resources from within the emergency department, the coronary care unit, the ambulance service, and the radiology department. Content and discussion: The programme is currently achieving a stroke thrombolysis rate of 11%, 1% above the Department of Health's target, and over 13 times higher than the national average. Patient outcomes compare favourably with that achieved by much larger specialist stroke centres. Over 50% of patientsshow a positive benefit by the seventh day post-stroke. Conclusions: The development of large hyperacute centres as envisaged in the national stroke strategy's ‘hub and spoke’ model may help combat the significant mortality and morbidity associated with stroke in the UK. However, the success of this model suggests that all hospitals, regardless of their size or location, should be able to offer state-of-the-art hyperacute stroke care.
Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment.
Methods:
We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits.
Results:
Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21).
Interpretation:
Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.
Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs).Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists.We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030.Over time, we observed greater feminization of the workforce and increasing age of workforce members.We identified a large regional variation in rheumatology supply.Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care.Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed. RésuméLa main-d' oeuvre en rhumatologie est de plus en plus confrontée au manque de médecins et au fardeau croissant des maladies rhumatismales et musculosquelettiques (MRM).La rhumatologie constitue l' une des spécialités non chirurgicales vers lesquelles on aiguille le plus fréquemment des patients, et les délais d' attente pour consulter un surspécialiste y sont les plus longs.Nous avons utilisé une méthode axée sur la population pour décrire les changements dans la main-d' oeuvre en rhumatologie, le volume de patients ainsi que la variation géographique de l' offre et de l' accès aux rhumatologues, en Ontario, au Canada, entre 2000 et 2019; avec une projection des changements de l' offre d'ici à 2030.Au fil du temps, nous avons observé une plus grande féminisation de l' effectif et une augmentation de l'âge de la main-d' oeuvre.Nous avons observé une grande variation régionale dans l' offre en rhumatologie.Moins de nouveaux patients sont vus chaque année, ce qui contribue probablement à l' augmentation des temps d' attente et à une réduction de l' accès aux soins.Il est nécessaire de mettre au point des stratégies et des politiques pour accroître la masse critique et pour améliorer la distribution régionale de l' offre de main-d' oeuvre, et ce, afin de fournir efficacement des soins de rhumatologie et afin de soutenir la prestation de soins de santé aux patients atteints de MRM.
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