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Biomedical subjects

Donald A Redelmeier

Publications and source records attributed to Donald A Redelmeier.

At least 37 records · Page 2Linked to original sources
PubMed2004

Waiting for urgent procedures on the weekend among emergently hospitalized patients.

PURPOSE: Many hospital departments tend to have lower staffing levels on weekends. We evaluated the use of selected urgent procedures for emergently hospitalized patients and measured the time until procedure based upon the day of hospital admission. METHODS: We analyzed all acute care admissions from all 190 emergency departments in Ontario, Canada, between 1988 and 1997. We selected patients (n = 126,754) who underwent one of six prespecified procedures as their most responsible procedure: fiberoptic bronchoscopy, esophageal gastroduodenoscopy, magnetic resonance imaging, echocardiography, ventilation-perfusion scanning, or coronary angiography. We noted each patient's day of procedure and day of hospital admission. For waits of less than 8 days, we analyzed the time to procedure based upon the day of admission. RESULTS: Only 5% (n = 5903) of the urgent procedures were performed on the weekend. Of the six selected procedures, coronary angiography showed the most skewed pattern of performance (1.5% performed on the weekend) and esophageal gastroduodenoscopy showed the least skewed pattern (8% performed on the weekend). Patients admitted on Fridays or Saturdays had the longest waits for procedures. For all six procedures, patients with relatively longer waits had relatively longer total in-hospital stays (P <0.001 for each). CONCLUSION: Relatively few urgent procedures are performed in emergently hospitalized patients on the weekend, suggesting that greater attention to weekend care might result in more timely interventions and shorter lengths of stay.

Adolescent↗
PubMed2004

Medical illness and the risk of suicide in the elderly.

BACKGROUND: Suicide is a leading cause of death, and rates are especially high among the elderly. Medical illnesses may predispose to suicide, but few controlled studies have examined the association between specific diseases and suicide. We explored the relationship between treatment for several illnesses and the risk of suicide in elderly patients using a population-based approach. METHODS: All Ontario residents 66 years or older who committed suicide between January 1, 1992, and December 31, 2000, were identified from provincial coroners' records. Their prescription records during the preceding 6 months were compared with those of living matched controls (1:4) to determine the presence or absence of 17 illnesses potentially associated with suicide. RESULTS: During the 9-year study period, we identified 1354 elderly patients who died of suicide. The most common mechanisms involved firearms (28%), hanging (24%), and self-poisoning (21%). Specific illnesses associated with suicide included congestive heart failure (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.33-2.24), chronic obstructive lung disease (OR, 1.62; 95% CI, 1.37-1.92), seizure disorder (OR, 2.95; 95% CI, 1.89-4.61), urinary incontinence (OR, 2.02; 95% CI, 1.29-3.17), anxiety disorders (OR, 4.65; 95% CI, 4.07-5.32), depression (OR, 6.44; 95% CI, 5.45-7.61), psychotic disorders (OR, 5.09; 95% CI, 3.94-6.59), bipolar disorder (OR, 9.20, 95% CI, 4.38-19.33), moderate pain (OR, 1.91; 95% CI, 1.66-2.20), and severe pain (OR, 7.52; 95% CI, 4.93-11.46). Treatment for multiple illnesses was strongly related to a higher risk of suicide. Almost half the patients who committed suicide had visited a physician in the preceding week. CONCLUSIONS: Many common illnesses are independently associated with an increased risk of suicide in the elderly. The risk is greatly increased among patients with multiple illnesses. These data may help clinicians to identify elderly patients at risk of suicide and open avenues for prevention.

Aged↗
PubMed2004

Death rates of medical school class presidents.

Medical professionals often face many competing demands to contribute both to the clinical care of patients and to the public health of society. We studied the long-term survival of doctors graduating from one medical school over one century (n = 1521), comparing those who were presidents of their class to those who appeared alphabetically before or alphabetically after the president in the graduating class photograph. Statistics on long-term mortality were obtained from licensing authorities, medical obituaries, professional associations, alumni records, and national physician directories (follow-up 94% complete, median follow-up duration = 38 years, total deaths = 220). We found that most graduates were male (88%), white (93%), and younger than 30 years at time of graduation (93%). Presidents more frequently made contributions to society than their classmates, as recognized by professional alumni notices (21.9% vs. 13.3%, P < 0.001) and Who's Who directory listings (7% vs. 0.5%, P < 0.001). Nonetheless, survival after medical school was 2.4 years shorter for presidents than their classmates (49.0 vs. 51.4, P = 0.036). The decrease in life-expectancy was unrelated to medical school marks or early career mortality and was accentuated after adjustments for birth year, gender, race, and specialization (P = 0.001 ). We suggest that the type of medical professional who sacrifices themselves for this type of professional prestige may also be the type who fails to look after their health or is otherwise prone to early mortality.

Age Factors↗
PubMed2004

The increasing incidence of severe pelvic injury in motor vehicle collisions.

BACKGROUND: Pelvic fractures constitute a major cause of death and residual disability in motor vehicle collisions (MVC). To date there has been poor documentation of the epidemiology of severe pelvic injuries. A detailed retrospective examination of all abbreviated injury score (AIS) > or = 4 pelvic fractures sustained in occupants of MVCs seen at this lead trauma hospital over the last 12 years and in the province of Ontario over the last 6 years was completed. METHODS: The regional trauma centre registry and provincial database were used to obtain demographics, injuries, course in hospital and crash data on patients sustaining AIS > or = 4 pelvic injuries between May 1988 and April 2000. Data was analysed for drivers (D), front (FP) and rear (RP) passengers in 4-year blocks. Means (S.D.) with t-test for continuous and chi2 for categorical data were used for analysis. RESULTS: AIS > or = 4 pelvic fractures increased significantly in D and FP over 12 years and in RP over the last 8 years. Similar significant increases were seen throughout the province over the last 6 years. No significant change in age, sex, ISS or referral patterns was seen. Lateral impact collisions also increased over the study duration. Occupants with pelvic injury compared to all MVC survivors ISS > or = 16 during the same study period had a higher ISS (P < 0.001), utilised more blood in 24h and in total (P < 0.001) and died more frequently (P < 0.001). However, significantly fewer required ICU support (P < 0.01) which may reflect the associated injuries. Patients with pelvic fractures had significantly fewer head and chest injuries as well as fewer face and neck injuries. They did have significantly more injuries in the region of the pelvis including lumbar and sacral spine fractures, genitourinary, liver, spleen and lower extremity blood vessel, nerve and bone injuries. CONCLUSION: This study documented an increasing incidence of severe pelvic injury resulting from MVCs. This may be related to an associated increase in the incidence of lateral impact collisions. The role of side impact protection and side airbags, introduced to decrease injury severity in lateral impact collisions will require further study.

Accidents, Traffic↗
PubMed2004

Interpreting differences in quality of life: the FACT-H&N in laryngeal cancer patients.

UNLABELLED: Quality of life (QOL) scores can be difficult to interpret, because small statistically significant differences can be clinically unimportant. Our goal was to estimate the magnitude of difference in QOL that is noticeable to patients. METHODS: Laryngeal cancer patients (n = 98, male = 83%, mean age = 65) completed a QOL questionnaire, FACT-H&N. Paired participants rated their own QOL as compared to each other. We estimated the smallest difference in QOL score that was associated with a noticeable difference in patients' subjective ratings. RESULTS: Differences in FACT-H&N score were somewhat correlated with patients' ratings of their well-being relative to other patients (r = 0.195, p < 0.0001). The FACT-H&N score had to differ by 6.22 for patients to rate themselves as 'a little bit better' relative to other patients (95% CI: 1.42-11.02), and by 12.40 for patients to rate themselves as 'a little bit worse' relative to others (95% CI: 5.09-19.71). Results were consistent regardless of patient age, gender or laryngeal subsite but were imperfect predictors of individual judgements. CONCLUSION: The minimal important difference for the FACT-H&N score is about 6-12 units, but laryngeal cancer survivors may be more sensitive to gains than losses.

Aged↗
PubMed2004

Drug-induced lithium toxicity in the elderly: a population-based study.

OBJECTIVES: To study the association between hospital admission for lithium toxicity and the use of diuretics, angiotensin-converting enzyme (ACE) inhibitors, and nonsteroidal antiinflammatory drugs (NSAIDs) in the elderly. DESIGN: Population-based nested case-control study. SETTING: Ontario, Canada. PARTICIPANTS: Ontario residents aged 66 and older treated with lithium. MEASUREMENTS: Estimated relative risk of hospital admission for lithium toxicity. RESULTS: From January 1992 to December 2001, 10,615 elderly patients continuously receiving lithium were identified, of whom 413 (3.9%) were admitted to the hospital at least once for lithium toxicity. After adjustment for potential confounders, a dramatically increased risk of lithium toxicity was seen within a month of initiating treatment with a loop diuretic (relative risk (RR)=5.5, 95% confidence interval (CI)=1.9-16.1) or an ACE inhibitor (RR=7.6, 95% CI=2.6-22.0). Conversely, neither thiazide diuretics nor NSAIDs were independently associated with a significantly increased risk of hospitalization for lithium toxicity. CONCLUSION: The use of loop diuretics or ACE inhibitors significantly increases the risk of hospitalization for lithium toxicity, particularly in naïve recipients.

Aged↗
PubMed2003

Safety of patients isolated for infection control.

CONTEXT: Hospital infection control policies that use patient isolation prevent nosocomial transmission of infectious diseases, but may inadvertently lead to patient neglect and errors. OBJECTIVE: To examine the quality of medical care received by patients isolated for infection control. DESIGN, SETTING, AND PATIENTS: We identified consecutive adults who were isolated for methicillin-resistant Staphylococcus aureus colonization or infection at 2 large North American teaching hospitals: a general cohort (patients admitted with all diagnoses between January 1, 1999, and January 1, 2000; n = 78); and a disease-specific cohort (patients admitted with a diagnosis of congestive heart failure between January 1, 1999, and July 1, 2002; n = 72). Two matched controls were selected for each isolated patient (n = 156 general cohort controls and n = 144 disease-specific cohort controls). MAIN OUTCOME MEASURES: Quality-of-care measures encompassing processes, outcomes, and satisfaction. Adjustments for study cohort and patient demographic, hospital, and clinical characteristics were conducted using multivariable regression. RESULTS: Isolated and control patients generally had similar baseline characteristics; however, isolated patients were twice as likely as control patients to experience adverse events during their hospitalization (31 vs 15 adverse events per 1000 days; P<.001). This difference in adverse events reflected preventable events (20 vs 3 adverse events per 1000 days; P<.001) as opposed to nonpreventable events (11 vs 12 adverse events per 1000 days; P =.98). Isolated patients were also more likely to formally complain to the hospital about their care than control patients (8% vs 1%; P<.001), to have their vital signs not recorded as ordered (51% vs 31%; P<.001), and more likely to have days with no physician progress note (26% vs 13%; P<.001). No differences in hospital mortality were observed for the 2 groups (17% vs 10%; P =.16). CONCLUSION: Compared with controls, patients isolated for infection control precautions experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care.

Canada↗
PubMed2003

An analysis of one potential form of health care fraud in Canada.

Health insurance fraud is a potential source of expense, injustice and adverse events in medical care. We examined one type of such fraud: false claims for prescription benefits after the death of the beneficiary. Of 335,536 elderly people in Ontario who died between Jan. 1, 1991, and Jan. 1, 1997, we identified 113 for whom 1 or more prescription drug benefit claims (about 1 per 3000 deaths) were submitted more than 1 year after their death. Claims for expensive medications were rare, as were those for addictive medications. Our findings suggest that this type of health care fraud occurs infrequently and that countermeasures are unlikely to substantially reduce medication abuse in Canada.

Drug Prescriptions↗
PubMed2003

Traffic-law enforcement and risk of death from motor-vehicle crashes: case-crossover study.

BACKGROUND: Driving offences and traffic deaths are common in countries with high rates of motor-vehicle use. We tested whether traffic convictions, because of their direct effect on the recipient, might be associated with a reduced risk of fatal motor-vehicle crashes. METHODS: We identified licensed drivers in Ontario, Canada, who had been involved in fatal crashes in the past 11 years. We used the case-crossover design to analyse the protective effect of recent convictions on individual drivers. FINDINGS: 8975 licensed drivers had fatal crashes during the study period. 21501 driving convictions were recorded for all drivers from the date of obtaining a full licence to the date of fatal crash, equivalent to about one conviction per driver every 5 years. The risk of a fatal crash in the month after a conviction was about 35% lower than in a comparable month with no conviction for the same driver (95% CI 20-45, p=0.0002). The benefit lessened substantially by 2 months and was not significant by 3-4 months. The benefit was not altered by age, previous convictions, and other personal characteristics; was greater for speeding violations with penalty points than speeding violations without points; was no different for crashes of differing severity; and was not seen in drivers whose licences were suspended. INTERPRETATION: Traffic-law enforcement effectively reduces the frequency of fatal motor-vehicle crashes in countries with high rates of motor-vehicle use. Inconsistent enforcement, therefore, may contribute to thousands of deaths each year worldwide.

Accident Prevention↗
PubMed2003

Iron poisoning in young children: association with the birth of a sibling.

BACKGROUND: Iron is a leading cause of death due to poisoning in young children. Because perinatal iron therapy is common, the presence of these tablets, which have a candylike appearence, in the home may pose a hazard to a mother's other young children. We explored the association between iron poisoning in young children and the birth of a sibling. METHODS: We conducted a population-based case-control study linking health care databases in Ontario. Health care records for the mothers of children less than 3 years of age admitted to hospital with iron poisoning between Apr. 1, 1991, and Mar. 31, 2000, were compared with those for the mothers of age- and sex-matched control children without iron poisoning. RESULTS: We studied records for 40 children admitted to hospital for iron poisoning. Seventeen cases (42%) occurred within a year (before or after) a sibling's birth. Children whose mothers had given birth to a sibling were almost twice as likely as children whose mothers had not given birth to a sibling to be admitted for iron poisoning within 6 months of birth (adjusted odds ratio [OR] 1.9, 95% confidence interval [CI] 0.9 to 3.9). The postpartum year was associated with a consistently elevated risk, including an almost 4-fold increase in the risk of iron poisoning during the first postpartum month (adjusted OR 3.6, 95% CI 0.8 to 16.5). INTERPRETATION: Pregnancy is a major risk factor for iron poisoning in young children, and the period immediately after delivery is associated with the greatest risk. Almost half of all hospital admissions for iron poisoning in young children could be prevented by keeping iron supplements safely out of reach in the year before and after the birth of a sibling.

Accidents, Home↗
PubMed2003

Drug-drug interactions among elderly patients hospitalized for drug toxicity.

CONTEXT: Drug-drug interactions are a preventable cause of morbidity and mortality, yet their consequences in the community are not well characterized. OBJECTIVE: To determine whether elderly patients admitted to hospital with specific drug toxicities were likely to have been prescribed an interacting drug in the week prior to admission. DESIGN: Three population-based, nested case-control studies. SETTING: Ontario, Canada, from January 1, 1994, to December 31, 2000. PATIENTS: All Ontario residents aged 66 years or older treated with glyburide, digoxin, or an angiotensin-converting enzyme (ACE) inhibitor. Case patients were those admitted to hospital for drug-related toxicity. Prescription records of cases were compared with those of controls (matched on age, sex, use of the same medication, and presence or absence of renal disease) for receipt of interacting medications (co-trimoxazole with glyburide, clarithromycin with digoxin, and potassium-sparing diuretics with ACE inhibitors). MAIN OUTCOME MEASURE: Odds ratio for association between hospital admission for drug toxicity (hypoglycemia, digoxin toxicity, or hyperkalemia, respectively) and use of an interacting medication in the preceding week, adjusted for diagnoses, receipt of other medications, the number of prescription drugs, and the number of hospital admissions in the year preceding the index date. RESULTS: During the 7-year study period, 909 elderly patients receiving glyburide were admitted with a diagnosis of hypoglycemia. In the primary analysis, those patients admitted for hypoglycemia were more than 6 times as likely to have been treated with co-trimoxazole in the previous week (adjusted odds ratio, 6.6; 95% confidence interval, 4.5-9.7). Patients admitted with digoxin toxicity (n = 1051) were about 12 times more likely to have been treated with clarithromycin (adjusted odds ratio, 11.7; 95% confidence interval, 7.5-18.2) in the previous week, and patients treated with ACE inhibitors admitted with a diagnosis of hyperkalemia (n = 523) were about 20 times more likely to have been treated with a potassium-sparing diuretic (adjusted odds ratio, 20.3; 95% confidence interval, 13.4-30.7) in the previous week. No increased risk of drug toxicity was found for drugs with similar indications but no known interactions (amoxicillin, cefuroxime, and indapamide, respectively). CONCLUSIONS: Many hospital admissions of elderly patients for drug toxicity occur after administration of a drug known to cause drug-drug interactions. Many of these interactions could have been avoided.

Aged↗
PubMed2003

Emergency department overcrowding and ambulance transport delays for patients with chest pain.

OBJECTIVE: Emergency department overcrowding sometimes results in diversion of ambulances to other locations. We sought to determine the resulting prehospital delays for cardiac patients. METHODS: Data on consecutive patients with chest pain who were transported to Toronto hospitals by ambulance were obtained for a 4-month period in 1997 and a 4-month period in 1999, which represented periods of low and high emergency department overcrowding respectively. Multivariate analyses were used to model 90th percentile system response (initiation of 9-1-1 call to arrival on scene), on-scene (arrival on scene to departure from scene) and transport (departure from scene to arrival at hospital) intervals. Predictor variables were study period (1997 or 1999), day of the week, time of day, geographic location of the patient, dispatch priority, case severity, return priority and number of other patients with chest pain transported within 2 hours of the index transport. RESULTS: A total of 3609 patients (mean age 66.3 years, 50.3% female) who met the study criteria were transported by ambulance during the 2 study periods. There were no significant differences in patient characteristics between the 2 periods, despite the fact that more patients were transported during the second period (p < 0.001). The 90th percentile system response interval increased by 11.3% from the first to the second period (9.7 v. 10.8 min, p < 0.001), whereas the on-scene interval decreased by 8.2% (28.0 v. 25.7 min, p < 0.001). The longest delay was in the transport interval, which increased by 28.4% from 1997 to 1999 (13.4 v. 17.2 min, p < 0.001). In multivariate analyses, the study period (1997 v. 1999) remained a significant predictor of longer transport interval (p < 0.001) and total prehospital interval (p = 0.004). INTERPRETATION: An increase in overcrowding in emergency departments was associated with a substantial increase in the system response interval and the ambulance transport interval for patients with chest pain.

Adult↗