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Background: The use of peritoneal dialysis (PD) has been declining over the past decade in Canada, and high technique failure rates have been implicated. Studies have examined clinical risk factors for PD technique failure, but few studies have addressed sociodemographic factors driving technique failure. There are no studies examining the effect of physician factors on technique failure., Methods: We conducted a retrospective cohort study using Ontario healthcare databases from 1 April 1995 to 31 March 2005 to examine the effects of patient sociodemographic and physician characteristics on PD technique failure. The primary outcome was time to technique failure. Secondary outcomes included the proportion of patients experiencing technique failure during the first year and the proportion of patients experiencing death during the study period. A competing risks analysis was applied to the Cox proportional hazards model to determine the predictors of technique failure, death, and kidney transplantation., Results: In 5162 incident PD patients, the probability of technique success and patient survival at 5 years was 58.2% and 46.9% respectively. Of patients failing PD, 43.5% failed during the first year of treatment. Statistically significant predictors of technique failure included increasing age [hazard ratio (HR) 1.02], diabetes mellitus (HR 1.32), lower neighborhood education level (HR 2.93), and receiving transient (≤ 3 months) hemodialysis before starting PD (HR 1.24). Predictors of patient death included increasing age (HR 1.05), diabetes mellitus (HR 1.44), coronary artery disease (HR 1.26), congestive heart failure (HR 1.58), and late referral to the nephrologist (HR 1.27). Distance from treating dialysis center and residing in a rural area did not impact the risk of technique failure or death. Male physician gender increased the risk of technique failure (HR 1.31). Increased PD patient volume decreased the risk of technique failure (HR 0.98). None of the physician factors were predictors of patient death., Conclusion: These findings support the need for implementing strategies to reduce technique failure, which could include increasing educational resources for patients initiating PD, aggressive risk factor modification in patients with multiple comorbidities, and increasing physician awareness regarding the detrimental outcomes associated with late referral and late PD start.

Objective: To determine the association of non-invasive cardiac stress testing before elective intermediate to high risk non-cardiac surgery with survival and hospital stay., Design: Population based retrospective cohort study., Setting: Acute care hospitals in Ontario, Canada, between 1 April 1994 and 31 March 2004., Participants: Patients aged 40 years or older who underwent specific elective intermediate to high risk non-cardiac surgical procedures., Interventions: Non-invasive cardiac stress testing performed within six months before surgery., Main Outcome Measures: Postoperative one year survival and length of stay in hospital., Results: Of the 271 082 patients in the entire cohort, 23 991 (8.9%) underwent stress testing. After propensity score methods were used to reduce important differences between patients who did or did not undergo preoperative stress testing and assemble a matched cohort (n=46 120), testing was associated with improved one year survival (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.99; P=0.03) and reduced mean hospital stay (difference -0.24 days, 95% CI -0.07 to -0.43; P<0.001). In an analysis of subgroups defined by Revised Cardiac Risk Index (RCRI) class, testing was associated with harm in low risk patients (RCRI 0 points: HR 1.35, 95% CI 1.05 to 1.74), but with benefit in patients who were at intermediate risk (RCRI 1-2 points: 0.92, 95% CI 0.85 to 0.99) or high risk (RCRI 3-6 points: 0.80, 95% CI 0.67 to 0.97)., Conclusions: Preoperative non-invasive cardiac stress testing is associated with improved one year survival and length of hospital stay in patients undergoing elective intermediate to high risk non-cardiac surgery. These benefits principally apply to patients with risk factors for perioperative cardiac complications.

Objective: To compare the risk of acute myocardial infarction, heart failure, and death in patients with type 2 diabetes treated with rosiglitazone and pioglitazone., Design: Retrospective cohort study., Setting: Ontario, Canada., Participants: Outpatients aged 66 years and older who were started on rosiglitazone or pioglitazone between 1 April 2002 and 31 March 2008., Main Outcome Measure: Composite of death or hospital admission for either acute myocardial infarction or heart failure. In a secondary analysis, each outcome was also examined individually., Results: 39 736 patients who started on either pioglitazone or rosiglitazone were identified. During the six year study period, the composite outcome was reached in 895 (5.3%) of patients taking pioglitazone and 1563 (6.9%) of patients taking rosiglitazone. After extensive adjustment for demographic and clinical factors and drug doses, pioglitazone treated patients had a lower risk of developing the primary outcome than did patients treated with rosiglitazone (adjusted hazard ratio 0.83, 95% confidence interval 0.76 to 0.90). Secondary analyses revealed a lower risk of death (adjusted hazard ratio 0.86, 0.75 to 0.98) and heart failure (0.77, 0.69 to 0.87) with pioglitazone but no significant difference in the risk of acute myocardial infarction (0.95, 0.81 to 1.11). One additional composite outcome would be predicted to occur annually for every 93 patients treated with rosiglitazone rather than pioglitazone., Conclusions: Among older patients with diabetes, pioglitazone is associated with a significantly lower risk of heart failure and death than is rosiglitazone. Given that rosiglitazone lacks a distinct clinical advantage over pioglitazone, continued use of rosiglitazone may not be justified.

Careful projections of the demand for dialysis services are important to assist healthcare planners in forecasting the need for equipment, facilities and personnel. We used time series techniques to model the historical incidence and prevalence counts and to forecast the predicted number of patients requiring dialysis in the province of Ontario to 2011. We showed that the incidence and prevalence of dialysis patients continues to grow rapidly. More importantly, traditional definitions of "chronic dialysis" capture only 52% of all incident patients and ignore the acute dialysis population. Projections about the need for dialysis services based on these definitions may result in underestimation of the resources required to care for the end-stage renal disease (ESRD) population.

Background: In Canada, programs are being developed to supply hospital emergency departments and family doctors with electronic access to their patientsâ drug history profiles. While some of these programs have access to databases that capture information about all out-patient prescriptions that are dispensed to an individual, regardless of payer; others do not, and rely upon claims paid by their provincial drug benefit plans. The completeness of these latter profiles is unknown., Objectives: To estimate the percentage of Ontario seniors who use private drug insurance (as an indicator of the potential for a âpublicâ drug history profile to be incomplete) and to describe the kinds of medications for which private insurance is used., Methods: Cross-sectional time series analysis of Ontario Drug Benefit (ODB) claims and private drug insurance claims for Ontario residents aged 65 years or older (seniors) covering the period January 2000 to December 2005., Results: During the study period, approximately 95% of Ontario seniors filled at least one prescription paid by the provincial drug benefit plan. By comparison, approximately 15-20% filled a prescription paid by a private insurer. Compared to the 20 drugs most frequently subsidized by the ODB Program (all but one of which had ODB full benefit status), the top privately-purchased drugs were more diverse: 8 had ODB full benefit status; 4 had ODB Limited Use status (which requires that patients meet prespecified clinical criteria for coverage); 3 required individual clinical review (prior authorization) by the ODB Program; and 5 were ODB non-benefits., Conclusions: Many Ontario seniors are at risk for an incomplete ODB drug history profile. Further research is needed to confirm whether this causes problems for physicians and patients.

The scale and complexity of palliative care increasingly demands that researchers move beyond their own discipline and explore interdisciplinary collaboration. At a Palliative Care Research Retreat held in January 2006 at the Toronto Sunnybrook Regional Cancer Centre, researchers from multiple care settings with the center and from other Toronto hospitals came together with the vision of becoming Canadian leaders in palliative care research. As a result of this retreat, five interdisciplinary groups were formed to pursue research in the areas of pain and symptom management, access to services, translational research, education, and communication. An overview of the retreat and direction of research for each group is provided.

Ongoing access to medication is required for the management of many chronic diseases. We sought to examine the health impact of entering the provincial drug benefit plan at age 65 years. We constructed cohorts of same-aged individuals with incident heart failure, with diabetes and from the whole population using administrative data. The hazard of hospitalization at a given age compared to one year younger for ages 63 to 67 years was determined. On turning age 65, persons were more rather than less likely to be hospitalized for diabetes and acute infection when compared to the prior year. Among residents of low-income neighbourhoods these effects were no longer significant, but the risk of hospitalization for heart failure was increased. A similar effect was not observed for the paired cohorts at the transition from age 63 to 64 years. A health benefit of obtaining drug insurance was not observed in this study; however, the relationship may have been confounded by the effects of retirement and other changes occurring at age 65. Moreover, a benefit experienced by only a small proportion of the population may not be apparent in this analysis, which included many individuals unaffected by the policy.

Background: The importance of glucose control is recognized both by patients with diabetes and their physicians. However, other preventative interventions, such as using medications to manage lipid and blood pressure levels, are underused for diabetic patients., Objectives: To determine whether patients with diligent glucose management are more likely to use medications that treat lipids and blood pressure., Methods: Administrative data records were evaluated for all diabetic patients aged 65 or older residing in Ontario in 1999 without pre-existing coronary artery disease (n=161,553). Measures of diligent glucose management were insulin use and frequent capillary glucose testing ((3) 2 per day). Outcomes were prescription of a lipid-lowering drug or antihypertensive drug. Using multivariate modeling, odds ratios for each diligence measure were determined for each outcome, adjusting for age, sex, comorbidities, and other covariates., Results: Patients using insulin did not have a clinically important difference in lipid-lowering drug use (adjusted odds ratio 0.9, 99% confidence interval 0.9 - 1.0, P=0.002) or antihypertensive drug use (adjusted odds ratio 1.1, 99% confidence interval 1.0 - 1.1, P<0.001) versus non-users. Adjusted odds ratios for frequent glucose testing were not significantly different from unity for either lipid-lowering or antihypertensive drug use., Conclusions: Patients who required and were capable of diligent glucose management, which is invasive, expensive and time-consuming, were no more likely to use medications to control lipids or blood pressure. Preventative care for patients with diabetes may be too focused on glycemic control, and may be neglecting the management of other cardiovascular risk factors.