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PubMed2002

Human resources for the approval of new drugs in Canada, Australia, Sweden, the United Kingdom and the United States.

The time required to approve new drugs in Canada is significantly longer than that in Sweden, the United Kingdom and the United States. The timeliness with which a regulatory agency approves drugs may be influenced by the human resources available to review applications. Therefore, the number of full-time equivalent (FTE) staff members who evaluate and approve new drug applications was sought directly from the regulatory agencies of Canada, Australia, Sweden, the United Kingdom and the United States. Information was received from the Therapeutic Products Directorate (TPD) of Health Canada, the Swedish Medical Products Agency (MPA), the United Kingdom Medicines Control Agency (MCA) and the United States Food and Drug Administration (FDA). The Australian Therapeutic Goods Administration (TGA) did not provide data, but the Australian Pharmaceutical Manufacturers Association estimated the number of personnel reviewing drug applications at the TGA to be 102. After adjustment to eliminate staff members whose primary responsibility is reviewing generic applications, there were an estimated 159 FTE staff members at the TPD, 1610 at the FDA, an estimated 76 at the TGA, 60 at the MCA and 46 at the MPA. Thus, the number of personnel in Canada is two to 3.5 times that in Australia, the United Kingdom and Sweden, but less than 10% of that in the United States. Because Sweden, the United Kingdom and the United States all have significantly shorter review and approval times than Australia and Canada, the number of review staff does not appear to be a direct major determinant of the timeliness of an agency's review and approval performance.

Australia↗
PubMed2003

Outcomes of acute myocardial infarction in Canada.

BACKGROUND: Little information is available on recent population-based trends in the outcomes of patients who have had an acute myocardial infarction (AMI) in Canada. METHODS: Data were analyzed from the Discharge Abstract Database and Hospital Morbidity Database of the Canadian Institute for Health Information. All new cases of AMI in Canada between fiscal 1997/98 and fiscal 1999/2000 of patients at least 20 years old were examined. Data were also analyzed from these databases for hospital readmissions for a second AMI, angina and congestive heart failure (CHF). RESULTS: There were 139,523 new AMI cases. The overall crude in-hospital AMI mortality rate in Canada was 12.3%. In-hospital mortality rate after an AMI was worse for women than for men in Canada (16.7% and 9.9%, respectively). The age- and sex-standardized in-hospital mortality rate varied from a low of 10.5% (95% CI 8.4% to 12.6%) in Prince Edward Island to a high of 13.1% (95% CI 12.8% to 13.5%) in Quebec. Among AMI survivors, 12.5% were readmitted within one year for angina, 7.7% for a second AMI and 7.5% for CHF. There were wide interregional differences in age- and sex-standardized mortality rates and one-year readmission rates. CONCLUSIONS: AMI is associated with a substantial acute mortality rate in Canada, especially in the elderly and female patients. Identifying the causes of interregional differences in patient outcomes should be a priority for future research.

Adult↗
PubMed2003

Regional variations in cardiovascular mortality in Canada.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in Canada with wide, unexplained regional variations in heart disease mortality. However, no studies to date have explored the relationship between a number of health region characteristics and regional variation in heart disease mortality rates across Canada. INTRODUCTION: We studied the contribution of various traditional cardiac risk factors, social determinants of health and other community characteristics to regional variations in heart disease mortality rates across Canada. METHODS: Cardiovascular disease and ischemic heart disease (IHD) age-standardized mortality rates were obtained from Statistics Canada for three years - 1995 to 1997. Health region characteristics were taken from the 2000/2001 Canadian Community Health Survey, and the 1996 Canadian Census and the Labour Force Survey. Linear regression analyses and analyses of variance were employed to identify relationships between these health region characteristics and CVD and IHD mortality rates. RESULTS: Significant regional variations in CVD mortality rates per 100,000 population were observed. Newfoundland and Labrador had the highest CVD and IHD mortality rates, while Nunavut and the Northwest Territories had the lowest CVD and IHD mortality rates. Health region smoking and unemployment rates were identified as the most important factors associated with CVD and IHD mortality at the health region level. CONCLUSIONS: Significant regional variations in age-standardized CVD and IHD mortality were noted both at the provincial/territorial level and the health region level. Efforts to reduce CVD and IHD mortality in Canada require attention to both traditional risk factors (eg, smoking) and broader determinants of health (eg, unemployment rates).

Age Distribution↗
PubMed2003

Trends in cardiovascular drug utilization and drug expenditures in Canada between 1996 and 2001.

BACKGROUND: There is increasing interest in studying trends in drug utilization because drug costs are the fastest growing sector of the health care system. OBJECTIVES: To focus on the trends in the utilization of and expenditures for cardiovascular drugs in Canada by drug class and by province over a six-year period. METHODS: Data from the IMS Health Canada CompuScript Audit database were used for this study from the period of February 1996 to January 2002. Patterns of drug utilization and expenditures in Canada were described for cardiovascular drug classes, individual agents within classes and by provincial analyses. RESULTS: Substantial increases in both the utilization of and the expenditures for cardiovascular medications have occurred in Canada over the last six years. Newer medication classes such as angiotensin converting enzyme inhibitors and statins now comprise the majority of cardiovascular drugs prescribed, along with continued high use of diuretics. Increases in some drug classes, such as angiotensin converting enzyme inhibitors, statins and beta-blockers, appear to be based on trial evidence or guidelines. However, marketing may play a larger role in the increases in use of angiotensin receptor blockers and specific drugs, such as amlodipine besylate and atorvastatin, because their increased utilization cannot be explained by major clinical trial evidence and/or practice guidelines. CONCLUSIONS: Changes in patterns of cardiovascular drug utilization and expenditures in Canada may be associated with clinical trial evidence, clinical practice guidelines, policy changes and/or marketing initiatives.

Canada↗
PubMed2004

An overview of the types of physicians treating acute cardiac conditions in Canada.

BACKGROUND: As the issue of physician supply and distribution increases in intensity in Canada, the scope of practice of different types of physicians becomes increasingly important. OBJECTIVE: To determine the type of physician treating hospitalized patients with acute cardiac conditions in the provinces and health regions in Canada. METHODS: Data from the Canadian Institute for Health Information Discharge Abstract Database for all available provinces and the Maintenance et Exploitation des Données pour l'Etude de la Clientèle Hospitalière for Quebec were used to determine the most responsible physician treating patients hospitalized for congestive heart failure and acute myocardial infarction from fiscal years 1997/1998 to 1999/2000. For patients whose most responsible physician was a general practitioner/family doctor, the proportion receiving a consult from a specialist (cardiologist or general internist) was calculated. The type of physician most responsible for treating the acute cardiac conditions with respect to age, sex and urban versus rural hospital was also examined. RESULTS: For approximately 50% of patients in Canada, and in 84% (99 of 118) of the health regions across Canada for which data were available, a general practitioner/family physician was the most responsible physician for patients admitted with congestive heart failure. On a national average, a specialist was the most responsible physician for treating acute myocardial infarction for 65% of patients and in 50% (57 of 115) of the health regions for which data were available. Younger patients, men and people living in urban areas were more likely to be cared for by specialists for both congestive heart failure (age, P<0.0001; sex, P<0.0001; area of admission, P<0.0001) and acute myocardial infarction (age, P<0.0001; sex, P<0.0001; area of admission, P<0.0001). CONCLUSIONS: The results of this study show that general practitioners/family physicians take a leading role in the treatment of hospitalized congestive heart failure patients, whereas cardiologists or internists are more often responsible for treating acute myocardial infarction in Canada. This distribution has important implications for cardiac educational strategies and may aid in the determination of health human resource policies.

Canada↗
PubMed2004

Regional outcomes of heart failure in Canada.

BACKGROUND: Heart failure is a condition associated with significant mortality and morbidity. However, demographic features and outcomes following hospitalization for heart failure, and associated regional comparisons have not been performed in Canada. METHODS: Anonymously rendered records of patients hospitalized for incident heart failure in Canada were selected from the Canadian Institute for Health Information discharge abstract and hospital morbidity databases from fiscal years 1997/1998 to 1999/2000. The demographics, in-hospital mortality rate and heart failure readmission rates were compared among provinces and health regions. RESULTS: A total of 83,406 patients were hospitalized for heart failure across Canada during the study period. The number of cases increased dramatically with each decade after age 50 years, with 85% of hospitalized patients being age 65 years and over. On average, in-hospital mortality per index admission in Canada was 9.5 deaths per 100 hospitalized cases. While the greatest burden of readmissions was among those 65 years of age and over, heart failure readmission rates were similar across age groups. Among all patients surviving the index admission, heart failure readmission rates were 8.7%, 14.1% and 23.6% at 30 days, 90 days and one year, respectively. The highest age- and sex-adjusted in-hospital mortality rates were 11.9% (95% CI 10.6 to 13.2) in Newfoundland/Labrador and 11.6% (95% CI 10.6 to 12.7) in Nova Scotia. The highest readmission rates at one year were 26.9% (95% CI 24.9 to 28.9) in Newfoundland/Labrador, 26.3% (95% CI 25.0 to 27.7) in Saskatchewan and 25.2% (95% CI 24.3 to 26.1) in British Columbia. There were significant regional variations in heart failure readmission rates and mortality. CONCLUSIONS: There is a great burden of heart failure in Canada, increasing significantly with age. The mortality and readmission rates for this condition are high and exhibit variation among health regions and provinces. Factors contributing to regional variations in these outcomes merit further study.

Adult↗
PubMed2004

A macroeconomic review of dentistry in Canada in the 1990s.

OBJECTIVES: To document the trends in expenditures on dental health care services and the number of dental health care professionals in Canada from 1990 to 1999. METHODS: Information on dental and health expenditures, numbers of dentists, hygienists and dental therapists, and the population of Canada and the provinces were obtained from the Canadian Institute for Health Information; data on numbers of denturists were obtained from regional bodies and from Health Canada. Information on the costs of other disease categories was taken from studies by Health Canada (1993 and 1998). International comparisons were made on the basis of data published by the Organisation for Economic Co-operation and Development (OECD). Indices of change over the decade (in which the 1990 value served as the baseline [100]) were calculated. RESULTS: By 1999, the supply of all types of dental care providers had increased to 1 for every 904 people. Dental expenditures during the 1990s increased by 64% overall and by 49% per capita, a rate of increase that exceeded both inflation and costs of health care. Although the public share of dental costs decreased from 9.2% to 5.8%, the direct costs of dental care increased to rank second (6.30 billion dollars) after those for cardiovascular diseases (6.82 billion dollars). Among the OECD nations, Canada had the fourth highest per capita dental expenditures and the second lowest per capita public dental expenditures. CONCLUSIONS: The direct economic costs of dental conditions increased during the 1990s from 4.13 billion dollars to 6.77 billion dollars. Over the same period, the public share for expenditures on dental health care services declined.

Canada↗
PubMed2005

Can Canada sustain paediatric phase I trials? A national survey of cancer relapse in children.

BACKGROUND: Paediatric phase I trials are critical to the evaluation of new agents using standardized methodology. However a large proportion of paediatric patients in Canada do not have access to phase I therapy. OBJECTIVES: A National Paediatric Cancer Relapse Survey was conducted to collect preliminary data to evaluate the feasibility of multi-centre paediatric phase I trials within Canada. METHODS: A survey consisting of 20 individual questions was sent out to all of the 17 paediatric oncology centres in Canada. RESULTS: Fifteen centres (88%) responded to the survey. 1027 children are diagnosed with cancer each year in Canada while 241 present with recurrent cancer. Of the 85 patients who are considered to be eligible for phase I study each year, only 53% were referred for phase I therapy. Two centres have more than 10 eligible patients a year, while the remaining 13 centres have less than 10 eligible patients each year. CONCLUSIONS: We estimate that 20% of the eligible patients could be accrued to phase I trials and Canada may provide sufficient patient number, i.e. 25 to 30 solid tumour patients every 2 years, to allow one multi-centre paediatric phase I trial to be completed over a 2-year period.

Adolescent↗
PubMedDate not supplied

Hepatitis C, illicit drug use and public health: does Canada really have a viable plan?

Some 300,000 individuals are infected with the hepatitis C virus (HCV) in Canada. HCV infection is associated with major morbidity, mortality and health care costs; these indicators are projected to rise over the next decade. The vast majority of prevalent and incident HCV infections in Canada are illicit drug use-related; thus, the HCV disease burden can only be addressed through interventions targeting this primary risk factor. Both preventive (e.g., needle exchange, methadone treatment) and therapeutic (e.g., the accessibility of HCV treatment for illicit drug users) interventions aimed at HCV in illicit drug users have been broadly expanded in Canada in recent years. However, evidence suggests that existing preventive measures only offer limited effectiveness in reducing HCV risk exposure. Also, due to restricted resources, treatment for HCV currently only reaches an extremely small proportion (i.e., <5%) of HCV-infected drug users. Thus, on the basis of current HCV incidence as well as given interventions and their impact, Canada is not achieving a net reduction in the prevalence of HCV-related to illicit drug use. In order to reduce the HCV disease burden, Canada needs to reconsider the scope, delivery and resourcing of both preventive and treatment interventions targeting the primary risk population of illicit drug users.

Blood-Borne Pathogens↗
PubMedDate not supplied

Family practice in Canada.

Family practice in Canada is significantly different in many ways from practice in the United States and is similar in others. This article describes Canada's comprehensive, government-controlled health care system, in which patients have free access to care, and most physicians are still paid on a fee-for-service basis. The status of medical manpower in Canada and medical education for future family physicians in the 16 Canadian medical schools are described. The multiple roles of the College of Family Physicians of Canada are outlined. The article concludes with a description of the nature of family practice in Canada, comparing it with the United States.

Canada↗
PubMed1987

Active abdominal tuberculosis in Canada in 1970-81.

We reviewed all 341 cases of abdominal tuberculosis reported in Canada between 1970 and 1981. Over the study period abdominal tuberculosis accounted for a stable proportion (0.8%) of all reported cases of tuberculosis in Canada. Its incidence declined steadily. It was more common in women, in native Indians and in people born in Asia. Detailed records of the 55 cases reported to Statistics Canada from British Columbia and of an additional 31 cases not reported to Statistics Canada (usually because they involved concomitant disease elsewhere, notably the lungs) were studied. Five of the 55 cases reported to Statistics Canada had been reported incorrectly. Of the 81 cases in British Columbia 51% involved peritonitis, 21% ileocecal disease, 20% anorectal disease, 10% mesenteric lymphadenitis, 1% disease of the sigmoid colon and 1% disease of the liver. The rate of bacteriologic confirmation was low (51%).

Abdomen↗
PubMed1996

Knowledge and attitudes of hospital-based physicians and trainees about HIV infection in the United States, Canada, India, and Thailand.

OBJECTIVE: To examine the attitudes and knowledge of health care professionals regarding human immunodeficiency virus (HIV) infection in countries with a varying prevalence of HIV infection to assist in the development of acquired immunodeficiency syndrome (AIDS) educational programs. DESIGN: Anonymous questionnaire with four sections: demographics, attitudes, knowledge, and an open-ended question investigating feelings about the potential impact that HIV infection may have on respondents' practices. PARTICIPANTS: Final-year medical students, house staff, and attending physicians at teaching hospitals in India, Thailand, Canada, and the United States. RESULTS: From January to October 1992, 819 health care professionals completed the questionnaire: 340 from India, 196 from Canada, 155 from the United States, and 128 from Thailand. The percentage of respondents who had previous contact with patients with HIV/AIDS varied from 30% to 98%; it was lowest in India, followed by Thailand and then Canada, and highest in the United States. Percentages of respondents uncomfortable performing a physical examination on a patient with HIV/AIDS were 24%, 25%, 9%, and 4%, respectively. Mean HIV/AIDS knowledge scores were 83%, 84%, 92%, and 93%, respectively. Most respondents correctly identified modes of transmission of HIV infection. Only 67% of Indian health care professionals understood the concept of a false-negative screening serologic test, compared with 98% of Canadian health care professionals. In Canada and the United States, only 78% and 76%, respectively, understood the concept of a false-positive screening serologic test. Awareness of an asymptomatic stage of HIV infection ranged from 32% in India to 74% in Canada. Despite their concerns of becoming infected, health care professionals in countries with a lower prevalence of HIV infection reported a strong ethical duty to care for these patients. CONCLUSIONS: Level of comfort in caring for HIV-infected patients and HIV/AIDS knowledge scores varied directly with the amount of previous contact with these patients. Disturbing numbers of health care professionals from all four countries did not understand the potential problems of the enzyme-linked immunosorbent assay serologic test and a significant percentage were unaware of the asymptomatic stage of HIV infection. There is a universal need for increased education of health care professionals about HIV infection and AIDS.

Attitude of Health Personnel↗
PubMed1997

Declining sex ratios in Canada.

OBJECTIVE: To examine the trends in the proportion of annual live births that were male in Canada and to compare the trends with those in the United States. DESIGN: Analysis of census data. SETTING: Canada as a whole and 4 main regions (West, Ontario, Quebec and Atlantic). SUBJECTS: All live births from 1930 to 1990. OUTCOME MEASURES: Sex ratio (expressed as the proportion of total live births that were male [male proportion]) overall and by region. RESULTS: The male proportion in Canada decreased significantly after 1970 (p < 0.001); this represented a cumulative loss of 2.2 male births per 1000 live births from 1970 to 1990. Although a decrease was observed in all four regions studied, only that in the Atlantic region was significant (p < 0.001), representing a cumulative loss of 5.6 male births per 1000 live births from 1970 to 1990. A significant decrease in the male proportion was also observed in the United States from 1970 to 1990 (p < 0.001), although to a lesser degree than that observed in Canada, and represented a cumulative loss of 1.0 male births per 1000 live births. CONCLUSIONS: The decreased sex ratio in Canada adds to the growing debate over changes in biological markers and their potential causes. In addition, the study illustrates the potential use of the sex ratio as a widely available, unambiguous measure of the reproductive health of large populations.

Birth Rate↗
PubMed1997

Regional and rural-urban differences in obesity in Canada. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To describe regional and rural-urban differences in weight and weight loss patterns in Canadian adults. DESIGN: Population-based, cross-sectional surveys. SETTING: Nine Canadian provinces (excluding Nova Scotia) from 1986 to 1992. PARTICIPANTS: A probability sample of 27,120 men and women aged 18 to 74 years was selected using the health insurance registration files in each province. Anthropometry was performed on 18,043 participants (67%). OUTCOME MEASURES: Region of Canada (Atlantic, central, western); rural or urban residence (rural if participant resided in a community whose population was < 10,000, urban if population > or = 10,000); body mass index (BMI, kg/m2); percentage of participants trying to lose weight; reasons for trying to lose weight; level of leisure-time physical activity. RESULTS: Overall, mean BMI values in rural men (26.1 kg/m2) and women (25.3 kg/m2) were not significantly different from urban counterparts (25.7 kg/m2 and 24.8 kg/m2, respectively). Similarly, obesity (BMI > or = 27 kg/m2) was as prevalent in rural men (37%) and women (30%) as in urban participants (34% and 28%, respectively). However, a difference was observed in western Canada where 41% of rural and 34% of urban men were obese (odds ratio [OR], adjusted for age and education = 1.29; 95% confidence interval [CI] 1.06, 1.57), as were 35% of rural and 25% of urban women (OR, adjusted for age and education = 1.47; 95% CI 1.17, 1.84). Among men in western Canada, the rural-urban differences were greatest in the 25-64 year age group, whereas in women the differences were present at all ages. Overall, in Canada, urban men (26%) are more likely than rural men (23%) to be trying to lose weight; the reverse was true for women (39% and 42%, respectively). CONCLUSION: Considerable regional and rural-urban differences are seen in the patterns of weight and weight loss in Canada. A fuller understanding of the underlying behavioural determinants of these differences is needed. On the basis of such an understanding, effective programs to promote healthy weights for individuals and communities in these areas might be developed.

Adult↗
PubMed1997

Results of the National Dental Examining Board of Canada written examination and implications for certification.

In 1994, following a request from the ten Provincial Licensing Authorities, the National Dental Examining Board of Canada (NDEB) implemented significant changes to the certification process for dentists seeking a license to practice in Canada. Prior to 1994, graduates of accredited Canadian dental programs were certified without further examination while graduates of United States and other international programs (non-Canadian, non-U.S.) were required to complete successfully a written and three-phase clinical certification examination. Changes implemented in 1994 required graduates of accredited Canadian programs to take both a Written and Objective Structured Clinical Examination (OSCE) Examination. The analysis of the results of the Written Examination for all candidates over the 1994-1996 period supports the following conclusions. There was no meaningful difference in performance of graduates across the ten Canadian dental programs; there was a small difference between the performance of graduates of Canadian and U.S. programs; and Canadian and U.S. graduates performed significantly better than graduates of other international programs. This level of candidate performance and changes to the respective accreditation processes supported the formal agreement providing reciprocal recognition of dental accreditation in Canada and the United States. As of January 1, 1997, graduates of dental programs in Canada and the United States are required to take the same certification examination while international graduates are required to complete a different certification process. These changes to the certification process were ratified by all ten Provincial Licensing Authorities, therefore maintaining a system of national portability for dental licensure in Canada that does not require preclinical or clinical board examinations for graduates of accredited North American dental programs.

Accreditation↗
PubMed1998

How many physicians does Canada need to care for our aging population?

BACKGROUND: There is concern that the aging of Canada's population will strain our health care system. The authors address this concern by examining changes in the physician supply between 1986 and 1994 and by assessing the availability of physicians in 1994 relative to population growth and aging, and relative to supply levels in the benchmark province of Alberta. METHODS: Physician numbers were obtained from the Canadian Institute for Health Information. The amount of services provided by each specialty to each patient age group was analysed using Manitoba physician claims data. Population growth statistics were obtained from Statistics Canada. Age- and specialty-specific utilization data and age-specific population growth patterns were used to estimate the number and type of physicians that would have been required in each province to keep up with population growth between 1986 and 1994, in comparison with actual changes in the physician numbers. Physician supply in Alberta was used as a benchmark against which other provinces were measured. RESULTS: Overall, Canada's physician supply between 1986 and 1994 kept pace with population growth and aging. Some specialties grew much faster than population changes warranted, whereas others grew more slowly. By province, the supply of general practitioners (GPs) grew much faster than the population served in New Brunswick (16.6%), Alberta (6.5%) and Quebec (5.3%); the GP supply lagged behind in Prince Edward Island (-5.4%). Specialist supply outpaced population growth substantially in Nova Scotia (10.4%), Newfoundland (8.5%), New Brunswick (7.3%) and Saskatchewan (6.8%); it lagged behind in British Columbia (-9.2%). Using Alberta as the benchmark resulted in a different assessment: Newfoundland (15.5%) and BC (11.7%) had large surpluses of GPs by 1994, whereas PEI (-21.1%), New Brunswick (-14.8%) and Manitoba (-11.1%) had substantial deficits; Quebec (37.3%), Ontario (24.0%), Nova Scotia (11.6%), Manitoba (8.2%) and BC (7.6%) had large surpluses of specialists by 1994, whereas PEI (-28.6%), New Brunswick (-25.9%) and Newfoundland (-23.8%) had large deficits. INTERPRETATION: The aging of Canada's population poses no threat of shortage to the Canadian physician supply in general, nor to most specialist groups. The marked deviations in provincial physician supply from that of the benchmark province challenge us to understand the costs and benefits of variations in physician resources across Canada and to achieve a more equitable needs-based availability of physicians within provinces and across the country.

Adolescent↗
PubMed2000

Surgically treated Cronkhite-Canada syndrome associated with gastric cancer.

Cronkhite-Canada syndrome is generally accepted to be a benign disorder, with 374 reported cases to the present. Worldwide, there have been 18 previously reported cases of Cronkhite-Canada syndrome associated with gastric cancer. In this report we describe a case of a 52-year-old man with the clinical features of Cronkhite-Canada syndrome combined with gastric cancer. Although the gastric tumor was located at the antrum of the stomach, we performed a total gastrectomy because of the edematous swelling and high risk of malignancy in the remnant stomach. As Cronkhite-Canada syndrome may be a premalignant condition for gastric cancer, as well as for colorectal cancer, we suggest periodic examination of the stomach, colon, and rectum for patients with Cronkhite-Canada syndrome.

Journal Article↗
PubMed2003

Synergy between publication and promotion: comparing adoption of new evidence in Canada and the United States.

PURPOSE: Few studies have examined the effect of new evidence from clinical trials on physician practice. We took advantage of differences in promotional activity in Canada and the United States for the Heart Outcomes Prevention and Evaluation (HOPE) study and the Randomized Aldactone Evaluation Study (RALES) to determine if publication of new evidence changes practice, and the extent to which promotion influences adoption of new evidence. METHODS: We used longitudinal dispensing data, collected from 1998 to 2001, to examine changes in prescribing patterns for ramipril and other angiotensin-converting enzyme (ACE) inhibitors before and after the HOPE study. We also obtained estimates for promotional expenditures. We stratified analyses by country, to isolate the effect of promotion, and used interrupted time series methods to adjust for pre-existing prescribing trends. Similar analyses were conducted for spironolactone use before and after RALES. RESULTS: Publication of the HOPE study results was associated with rapid increases in the use of ramipril. After adjusting for pre-existing prescribing trends, ramipril prescribing increased by 12% per month (P = 0.001) in Canada versus 5% per month (P = 0.001) in the United States after the study results were presented and published. One year later, ramipril accounted for 30% of the ACE inhibitor market in Canada versus 6% in the United States. The year before publication of these results, expenditures for detailing increased by 20% in Canada (to 18 US dollars per physician) but decreased by 7% in the United States (to 13 US dollars per physician); the year after publication, spending increased to 27 US dollars per physician in Canada versus 23 US dollars per physician in the United States. In the absence of promotional activity for RALES in either country, publication of results was associated with more modest but similar increases of 2% per month (P = 0.001) in spironolactone use in both countries. CONCLUSION: Publication of new evidence is associated with modest changes in practice. Promotional activity appears to increase the adoption of evidence. Rather than relying on the publication of articles and creation of guidelines, those wishing to accelerate the adoption of new evidence may need to undertake more active promotion.

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