Practice issues
Assessing for lifestyle health risk
Physicians can help promote healthy lifestyles and prevent disease through health-risk screening and by advising patients on ways to live healthier lives. The first step is finding out where patients need help, which depends on proper screening practices. A study of 805 general practitioners and 158 obstetrician-gynecologists in Quebec, found that GPs were more likely than ob-gyns to ask patients about tobacco use, alcohol consumption and illicit drug use. Ob-gyns were much more likely to assess condom use, but both GPs and ob-gyns routinely failed to assess sexual orientation, number of sexual partners and the risk of sexually transmitted disease. The authors also found that most physicians in both groups failed to screen routinely for family violence and sexual abuse. [CMAJ 1999;160(13):1830-4]
A related editorial said physicians need consistent messages to pass to patients to achieve the best results. The author adds that many guidelines used by physicians offer conflicting recommendations and this may contribute to the confusion about which issues should be addressed with which patients. [CMAJ 1999;160(13):1849-50]
Blood fungus danger
Fortunately fungal infections of humans usually occur on the skin and are easy to recognize and treat. However in patients who have severe underlying illnesses such as cancer, or who are in intensive care units, fungal infections can be fatal. A review of 415 cases of Candidemia found that almost 50% of such infections resulted in death. Although good antifungal treatments are available, unusual species of Candida are now appearing and this has implications for treatment. [CMAJ 1999;160(4):493-9]
Calcium-channel blockers
The widespread use of calcium-channel blockers (CCBs) in the treatment of hypertension has led to increasing concern about the potential adverse cognitive effects associated with their use. Using data from the Canadian Study of Health and Aging, researchers assessed whether increased risk of cognitive decline exists among hypertensive patients taking CCBs versus those taking other antihypertensive drugs. The authors report that older subjects using CCBs seemed to face significantly greater risk for cognitive decline after five years than users of other antihypertensive drugs.
Although this finding may have significant ramifications for the treatment of hypertension in the elderly, the authors recommend that larger trials be initiated to examine the link between treatment of hypertension, changes in blood pressure and cognitive function in the elderly. [CMAJ 1999;161(5):501-6]
A related editorial cautions that the effects of calcium antagonists remain speculative and require further study. The author recommends physicians rely on the current guidelines regarding treatment of hypertension in the elderly. [CMAJ 1999;161(5):534-5]
Diabetes
Diabetic patients taking insulin to control the levels of glucose in their blood often do not achieve optimal control over their glucose levels. Much effort has been made to find a way to help diabetic patients better manage these levels, but standard methods of health care delivery have not solved the problem. A randomized trial of 46 diabetic patients who were taking insulin but had poor glucose control was conducted to determine if regular telephone contact from an expert nurse improved management of their glucose levels. The authors found that after six months, patients who had regular contact with a trained nurse had significantly reduced levels of glycated hemoglobin. [CMAJ 1999;161(8):959-62]
A related editorial indicates these findings show that most willing subjects with diabetes can improve their glucose control, at least in the short term, provided they have frequent, convenient support from a knowledgeable professional. However, the author cautions, it will take societal and political will to increase available resources and change the approach of diabetes centres to take advantage of these findings. [CMAJ 1999;161(8):975-6]
Early discharge and newborn morbidity
Are we sending newborns home too early? Perhaps so, according to new research. Two researchers assessed the impact of a Toronto-area hospital's decision to implement an early-discharge policy following uncomplicated delivery on the rate of hospital readmission among newborns. They found that as the length of stay shortened, readmission rates rose. After the policy was introduced the mean length of stay dropped from 1.88 days to 1.62 days and the overall rate of hospital readmission among newborns rose from 6.7% to 11.7%.
The authors report that decreases in newborn length of stay may result in substantial increases in morbidity and recommend careful consideration of whether a reduction in the length of stay to less than 24 to 36 hours is harmful to babies. [CMAJ 1999;161(3):249-53]
Ethnic background affects cardiovascular and cancer mortality rates
A new study shows there is ethnic variation in the rates of these two disease. Researchers calculated age-standardized death rates by cause per 100,000 people from 1979 to 1993 and found strikingly different patterns among the rates for Canadians of European, south Asian and Chinese origin. Using data from the population census and the Canadian Mortality Database, the authors found that rates of death due to ischemic heart disease and cancer differed greatly among the various ethnic groups. The rates of death from ischemic heart disease were highest among Canadian of south Asian and European origin and markedly lower among Canadians of Chinese origin. The rates of death from cancer were highest and on the rise among Canadians of European origin. [CMAJ 1999;161(2):132-8]
A related editorial, cautions that the definition of "ethnicity" and the fact that many studies do not take potentially confounding factors into account can skew findings and lead to misinterpretation. [CMAJ 1999;161(2):152-3]
Fitness to drive
Patients who are no longer medically fit to drive can create a thorny issue for physicians. The advent of legislation that makes it mandatory for physicians to report patients who are unfit to drive puts doctors in the uncomfortable position of representing government interests, which may be contrary to those of their patients. New research reveals that more than half of Saskatchewan physicians (58.6%) fear that reporting a patient who is medically unfit to drive will adversely affect the patient-physician relationship. The 523 Saskatchewan physicians they surveyed were willing to do what was needed to protect public safety, but almost all (97%) said they would benefit from some form of ongoing program to help them assess a patient's fitness to drive. [CMAJ 1999;160(12):1701-4]
High blood pressure
With proper treatment, hypertensive patients can reduce their risk of heart attack and stroke. So why do so many of them refuse to take their medication? A study of 27,364 adults with newly diagnosed hypertension found that more than 20% stopped taking their drugs by the end of the first year. Using the Saskatchewan administrative database, researchers tracked the use of medication by almost 80,000 hypertensive patients for one year. They discovered that long-term compliance is related to the class of drug initially prescribed. Six months after diagnosis, 20% of patients for whom a diuretic was initially prescribed were not taking any antihypertensive drug. Angiotensin-converting-enzyme(ACE) inhibitors had marginally higher compliance rates (11%) than other classes of drugs. [CMAJ 1999;160:31-7]; [CMAJ 1999;160(1):41-6]
Another researcher reported that noncompliance may be caused by negative societal attitudes toward taking drugs and the abundance of information now available about side effects. Physicians can help address these problems by prescribing longer-acting, less expensive medications and providing more balanced information. [CMAJ 1999;160(1):64-5]
Patients with hypertension, who are therefore at increased risk of heart attack and stroke, are often plagued by health risks such as obesity and high cholesterol levels. Physicians usually concentrate on controlling the hypertension before tackling the other risk factors but new research shows this might be the wrong approach. The authors studied the prevalence of several risk factors for coronary artery disease (CAD) in a random sample of more than 11,000 Canadians aged 35-74 years to estimate whether treating hyperlipidemia or hypertension did more to reduce the risk of death from CAD. They reported that the potential benefits of treating hyperlipidemia among hypertensive adults demonstrate the need for screening and treating cardiovascular problems other than hypertension. [CMAJ 1999;160(10):1449-55]
One of the main components in treating a hypertensive patient is deciding which drug to prescribe as a first-line therapy. Many new (and expensive) medications are now available for the treatment of hypertension, but clear evidence of a drug's ability to prevent adverse health outcomes is not always available.
In the most comprehensive review yet published, researchers examined 23 trials (representing 50,853 patients) of antihypertensive drugs used as first-line therapy for uncomplicated hypertension and compared not only their effectiveness in lowering blood pressure but also how well they prevented adverse outcomes. The authors report that no other treatment has proved to be more effective in preventing the latter than standard and inexpensive, low-dose thiazide therapy. [CMAJ 1999;161(1):25-32]
The treatment options available for hypertension have multiplied over the last four decades, and although some studies have shown the prevalence of the condition has dropped as a result, other studies report evidence to the contrary. Researchers compared data from surveys conducted in 1985 and 1995 on hypertension and medication to determine the consequences of the availability of new antihypertensive medications. They reported a shift toward monotherapy and an increase in the use of calcium-channel blockers and angiotensin-converting-enzyme inhibitors, with an associated increase in the daily cost of medication (from $0.48 to $0.85 per patient). Perhaps more worrisome is that the rate of uncontrolled hypertension among patients receiving treatment increased for both men (from 32.6% to 57.4%) and women (from 38.0% to 42.6%). The authors report that while physicians prescribed a wider range of antihypertensive drugs in 1995 than 10 years earlier, this did not result in better hypertension control. [CMAJ 1999;161(6):699-704]
Home visits
Although more and more health care services are now being provided in the home, there is little information available on how many physicians still do home visits. A survey of 487 general practitioners in the Quebec City area - almost 70% of the total - found that 58% made home visits. Since GPs in Quebec either practise in a private office, family medicine units or CLSCs (community health centre) the authors also sought to determine whether the practice setting influenced the number of home care visits. They found that private practitioners conducted more home visits (11.5 v. 5.8 per week), were more likely to visit patients with acute conditions (21% v. 14%), and to see patients at their request (28% v. 14%). However, private practitioners were less likely to see patients at the request of a colleague (4% v. 18%) or to do regular follow-up (37% v. 51%). [CMAJ 1999;161(4):369-73]
Another study looked at the rate of home care use following inpatient care and same-day surgery by studying more than 4.6 million Ontario patient records. The researchers discovered that the rate of home care use per 100 hospital discharges was 12.5 for inpatients and 3.6 for day-surgery patients. They also reported that there was a 3.5-fold variation in rates of use following inpatient care and a sevenfold variation in rates of use following same-day surgery. The authors estimate that it would take an extra $48.9 million to equalize services across Ontario alone. They say a research program is needed to look into new ways of delivering home care. [CMAJ 1999;161(4):376-80]
Hormone replacement and heart disease
Although hormone replacement therapy (HRT) is associated with a reduced risk of coronary artery disease (CAD), use of this treatment among postmenopausal women is not widespread. Researchers examined the use of HRT among 80 postmenopausal women who had or were at risk for CAD and found that only 13% of women with definite CAD and 22% who were at risk were using HRT. The authors recommend improving physician awareness and adherence to optimal patient management information. [CMAJ 1999;161(1):33-36]
An accompanying editorial discusses the implications of the low use of HRT among postmenopausal women at risk for coronary artery disease, especially in light of a recent randomized clinical trial showing that HRT does not benefit women with established CAD. [CMAJ 1999;161(1):42-3]
Irritable bowel syndrome
Irritable bowel syndrome can be extraordinarily frustrating both for patients who experience it and physicians who try to diagnose and treat it. The results of a consensus conference on irritable bowel syndrome provide a guide to diagnosis using symptom criteria, describe what little is known about the pathophysiology of the disease and recommend a treatment regimen based largely on symptom management. [CMAJ 1999;161(2):154-60]
Media health reporting
Canadian physicians think journalists could be doing a better job reporting on health issues, according to a recent survey. The random poll of 250 family physicians, conducted in May 1999, revealed that only 34% believe the news media are delivering accurate coverage of medical health information. Despite this, nearly 75% of respondents said health-related news items are beneficial because patients often ask questions about them, which indicates that they are trying to learn more about their health. [CMAJ 1999;161(4):361]
Newspaper medical advice columns can provide a valuable service but the need to deal with complex issues in a brief format can lead to the publication of incomplete, inappropriate or misleading information. A study was conducted of 50 medical advice columns selected randomly from Canadian newspapers to assess the safety and appropriateness of advice given to elderly readers. Five geriatricians reviewed the content and found that in 50% of the columns the advice given was inappropriate, and in 28% it was dangerous and potentially life threatening. [CMAJ 1999;161(4):393-5]
An accompanying editorial cautioned against assuming that readers blindly follow any advice they are given. The author suggested that advice columns prompt patients to consult with their physicians. [CMAJ 1999;161(4):397-8]
Methadone treatment in BC
The College of Physicians and Surgeons of British Columbia is actively recruiting physicians to learn about its methadone maintenance program. The college took over management of the province's program from the federal government in 1996, joining Ontario as the only provinces where professional licensing bodies operate their own methadone programs. Since taking over, the number of BC doctors trained and authorized to prescribe methadone has increased from 110 to more than 400. The number of patients enrolled in the program likewise rose from 1200 to more than 4000. [CMAJ 1999;161(5):579-80]
Myocardial infarction
A study of nearly 90,000 Ontario patients who had a myocardial infarction in Ontario shows that the situation is improving, at least for younger male patients. A trio of researchers studied data from 89,456 patients discharged from Ontario hospitals between 1992 and 1996 and found that mortality rates declined slightly from a one-year mortality rate of 23.7% in 1992 to 22.3% in 1996.
The authors note however, the gains were limited to young men. Those 65 and over and women of all ages showed no statistically significant gains in survival. The gains and nongains occurred in parallel with substantial increases in the use of angiography, percutaneous transluminal coronary angioplasty and CABG surgery. [CMAJ 1999;161(10):1257-61]
Organ donation shortage
Canadians deserve a national organ donor registry, CMA representatives told the House of Commons Standing Committee on Health. The association stated that an organ donor shortage is only one of the problems facing transplant medicine. Since speed is of the essence in getting a donated organ to a patient before it deteriorates, the CMA says Canada should investigate developing a national system a national system to match donated organs with sick patients.
The CMA presented only one of many submissions received by the committee. Testimonials from transplant recipients and from the family members of several Canadians who died while awaiting organs made national headlines. [CMA News 1999;9(4):1]
As Canada continues to search for possible solutions to the shortage of vital organs, the possibility that getting permission to use organs from relatives of those who have died from irreversible cardiopulmonary arrest - now termed a non-heart-beating death - has emerged as another potential way to increase the number of organs available for transplantation. Researchers studied the charts of 209 patients who died in 1995 in either the emergency department or intensive care unit of the Foothills Hospital in Calgary. They found that there might have been 10 additional donors, which would have increased the supply of cadaveric kidneys for transplantation by 48%. [CMAJ 1999;160(11):1573-6]
An accompanying editorial provided ethical guidance in the wake of continued debate surrounding the definition of brain death. [CMAJ 1999;160(11):1590-1]
Pain management
In a systematic review, researchers found that the prevalence of pain among older adults living in nursing homes and long-term-care institutions is high, ranging from 49% to 83% in six studies that involved self-reporting or chart reviews, and from 27% to 44% in five studies that used data on analgesic use. Of the 14 studies identified, only three evaluated treatment for pain. Given that many residents of long-term care facilities have more cognitive impairment than those living in the community, and therefore may have difficulty reporting the presence and severity of pain, the authors recommend more study evaluating interventions to relieve pain in nursing homes. [CMAJ 1999;160(3):329-33]
Palliated deaths
With the introduction of the Edmonton Regional Palliative Care Program in 1995, the percentage of cancer-related deaths in acute care settings dropped from 86% in 1992/93 to 49% in 19996/97, the number of inpatient days decreased by more than 70% and about four times as many patients saw a palliative care team. [CMAJ 1999;161(3):290-3]
Pancreatic resection success
Patients undergoing pancreatic resection for neoplasm may have better outcomes at hospitals with higher surgical volumes. In this retrospective analysis examining pancreatic resection for neoplasm in Ontario, researchers found that the likelihood of postoperative death was higher in low-volume and medium-volume centres than in high-volume ones. Not only did the high-volume centres have lower mortality rates but they also discharged patients earlier. However, they recommend against transferring all patients to the small number of hospitals with optimal outcomes; instead, they suggest designating regional centres as pancreatic resection sites. [CMAJ 1999;160(5):643-8]
Preventive health care
What do patients and family physicians have to say about the recommendations of the Canadian Task Force on Preventive Health Care? Quite a bit, according to the results of focus groups involving 35 physicians and 75 patients. Neither physicians nor patients seem to want to give up the annual health exam. Both value early diagnosis and see it as a legitimate end regardless of its effect on morbidity. [CMAJ 1999;161(5):519-23]
Patients admitted to hospital before receiving preventive care did not get the care during their stay. Researchers interviewed 100 consecutive patients admitted to the internal medicine service at the University of Calgary about information they received concerning preventive health examinations. They found an average of 3.8 potential opportunities for prevention procedures for each patient (out of 10 procedures considered). Although 46.5% of these prevention possibilities were addressed prior to admission, the general internal medicine service addressed only 8.7% more while the patient was in hospital. The authors conclude that even though the focus of general internists in a tertiary care facility is acute illness, they would miss fewer opportunities for prevention if a computer-generated reminder system existed. [CMAJ 1999;160(8):1137-40]
An accompanying editorial cautions that internists are not the only physicians who miss opportunities for preventive care. The author recommends simple quality-control procedures, such as a prevention checklist that could be completed at the time of hospital admission, as the best way to avoid prevention oversights. Up to 70% of disease is considered preventable. [CMAJ 1999;160(8):1171-2]
Slapping, spanking and psychiatric disorders
Spanking as a means to discipline a child remains one of the most hotly debated issues among professionals who work with children and families. However, little information is available on the prevalence of and outcomes associated with a history of slapping and spanking in childhood. A study of a 4,888-person subset of the Ontario Health Supplement Survey found that individuals who reported being slapped and/or spanked "sometimes" or "often" were twice as likely to report current alcohol abuse or dependence. They were also twice as likely to have externalizing problems such as illicit drug abuse or dependence or antisocial behaviours compared with adults who did not report being slapped or spanked as a child. Canada's Criminal Code currently allows for the disciplining of children by teachers and parents "if the force does not exceed what is reasonable under the circumstances." [CMAJ 1999;161(7):805-9]
A related editorial, ponders whether it may be time to join countries such as Sweden that have banned spanking. [CMAJ 1999;161(7):821-2]
Smith-Lemli-Opitz syndrome
Smith-Lemli-Opitz syndrome is the second most common treatable inherited error of metabolism causing mental retardation. Recent developments - a biochemical diagnostic test and the discovery of a potentially beneficial therapy - provide an opportunity for family physicians to facilitate early diagnosis, treatment and genetic counselling. An article reviewed the often subtle clinical features of the syndrome and described the promising results of therapy with dietary cholesterol supplementation. [CMAJ 1999;161(2):165-70]
Stroke-screening tests
Echocardiography is commonly used to treat patients who have had a stroke. The goal is to detect sources of emboli in the heart and then provide therapy to prevent another stroke. The Canadian Task Force on Preventive Health Care reports that there is fair evidence to recommend echocardiography in patients with stroke and clinical evidence of cardiac disease, but insufficient evidence to recommend for or against routine echocardiography in patients without clinical cardiac disease. The task force says transesophageal echocardiography is the preferred initial screening test for stroke patients. [CMAJ 1999;161(8):989-95]
A related editorial advises against using transesophageal echocardiography as the initial screening test, recommending instead transthoracic echocardiography. [CMAJ 1999;161(8):981-2]
Warfarin and atrial fibrillation
Researchers conducted a nonrandomized, prospective observational trial to see whether warfarin's benefits in preventing stroke, as established in randomized trials, would be seen in actual practice. A total of 221 patients with atrial fibrillation were assigned to four groups: ASA (14%), warfarin (39%), blended treatment (29%) and no treatment (17%). Patients receiving warfarin had a significantly lower risk of stroke and transient ischemic attack and a longer median time to stroke than those who received no treatment. The stroke rates in the ASA and blended treatment groups were lower, but not significantly. [CMAJ 1999;161(5):493-7]
An accompanying editorial comments on the low rate of warfarin use (39%) in practice. [CMAJ 1999;161(5):533-4]
White-coat response in patients with hypertension
White-coat response, which means patients have higher blood pressure readings in the doctor's office than outside of it, is common, but few studies have examined its prevalence or determinants among patients treated for hypertension.
This new study looked at 103 patients attending a hypertension outpatient clinic in Saskatoon and found that considerably more women (54%) than men (20%) demonstrated a white-coat response. The authors report that in trying to predict white-coat response from psychometric variables, the patient's sex should be taken into account. [CMAJ 1999;161(3):265-9]
An accompanying editorial cautioned that the widespread assumption that it is not necessary to treat "office hypertension" in patients with "normal" ambulatory blood pressures is an unwarranted and untested assumption that amounts to wishful thinking. [CMAJ 1999;161(3):275-6]
