Volume 17, Issue 3, Winter 2017

Recent Literature from the ACHORD Journal Club

(Paper discussed Tuesday, December 5, 2017; Commentary by Ming Ye)

Ronksley PE, Ravani P, Sanmartin C, Quan H, Manns B, Tonelli M, Hemmelgarn BR. (2013) Patterns of engagement with the health care system and risk of subsequent hospitalization amongst patients with diabetes. BMC Health Services Research. 2013 Oct 9;13:399. doi: 10.1186/1472-6963-13-399. PMID: 24103159

Background
Re-hospitalization is common among patients with diabetes, which not only indicates the disease severity of diabetes patients, but also places substantial financial burden on the healthcare system. According to Andersen Behavioral Model for health care utilization, many patient-level factors including sociodemographic (age, sex, race, and socioeconomic status), clinical (comorbidity, diabetes duration), and behavioral factors (glycemic control, and adherence to medication), might contribute to re-hospitalization in patients with diabetes. Given that re-hospitalization is an important driver of morbidity and costs in diabetes, identifying which patients are at higher risk of subsequent hospitalization is relevant to improving quality and efficiency of healthcare.

In this Journal Club, we discussed a research paper by Ronksley et al. using province-wide administrative healthcare data to study the impact of healthcare engagement on risk of subsequent hospitalization in patients with diabetes.

Summary of the study
This study was a population-based cohort study of 33,811 Alberta Kidney Disease Network (AKDN) participants aged 18+ years with diabetes and at least one hospitalization (all-cause) following their diabetes diagnosis in Alberta, Canada between January 1, 2004 and March 31, 2011. Diabetes cases were identified using the validated National Diabetes Surveillance System (NDSS) algorithm: one hospital discharge or two physician claims within two years for diabetes. Index date was the date of first hospitalization (all-cause) following diabetes diagnosis.

Healthcare engagement, including the number of emergency department (ED) visits and primary care physician visits per year in the year prior to the index hospitalization and the discharge disposition of the index hospitalization, were estimated from the linked Alberta Health (AH) administrative data. Participants were followed up for a maximum of one year from the index date with subsequent hospitalization (>=1 day gap) as the primary outcome during follow-up. Factors considered as potential confounders included age, sex, urban/rural status, First Nations Status, household income, diabetes duration, A1c measurement prior to index hospitalization, kidney function, comorbidities defined in Charlson index, and factors related to index hospitalization [length of stay, hospitalization types (emergent or elective), and most responsible diagnosis].

Multivariable Cox regression was used to estimate the association between healthcare engagement and the risk of subsequent hospitalization. Of the 33,811 study participants, 11095 (32.8%) experienced a subsequent all-cause hospitalization with a mean follow-up of 0.68±0.3 years. For every ED visit prior to the initial hospitalization, there was a 4 percent increased risk of a subsequent hospitalization (HR=1.04; 95% CI: 1.03–1.05). Compared to patients with 1–4 visits of primary care physician, patients with no visits or more than 4 visits were more likely to experience a subsequent hospitalization (HR=1.11; 95% CI: 0.99–1.25 and HR=1.06; 95% CI: 1.00–1.12, respectively). Compared to patients discharged home, those leaving against medical advice were at a higher risk of experiencing subsequent hospitalization (HR=1.74; 95% CI: 1.50–2.02).

Discussion
Results of this study suggest that higher frequency of ED visit and limited or increased use of primary care were associated with increased risk of subsequent hospitalization. In addition, patients discharged against medical advice among the high-risk group of re-hospitalization.

Comments and discussions include i) other than categorizing the degree of healthcare engagement (e.g. simply by number of visits of primary care or by nominal categories of hospital discharge), no results were provided for the “patterns” of healthcare utilization, which was suggested by the authors as the main interest in this study; ii) some important information for charactering “patterns” of healthcare utilization, such as continuity of care [e.g. usual provider continuity (UPC) and known provider continuity (KPC) ], could have been estimated from the administrative data and included in the analyses; iii) participants of this study may have limited representativeness as incident cases of diabetes, especially when high percentage of participants had severe comorbidities (e.g.~20% cancer and ~30% cardiovascular diseases) even before diabetes diagnosis, which could contribute to a higher risk of subsequent hospitalization in this group of participants; iv) in addition to hazard ration (HR), the relative measurement of the association, this population-based study could have provided more informative results, such as absolute changes in the risk of subsequent hospitalization for different healthcare engagement; v) as the authors have mentioned, some important factors, such as lifestyle factors and self-management of diabetes, were not included in the analysis of this study; vi) future study should focus on building a clinical applicable prediction model for re-hospitalization, based on patients clinical, behavioral and social characteristics, and/or estimating the financial burden of the subsequent hospitalization and the avoidable cost.

ACHORD Seen and Heard

Recent Publications

Alsabbagh MW, Eurich DT, Lix LM, Wilson TW, Blackburn DF. Does the association between adherence to statin medications and mortality depend on measurement approach? A retrospective cohort study. BMC Med Res Methodol. 2017;20;17(1):66. PMID 28427340.

Bowker SL, Savu A, Yeung RO, Johnson JA, Ryan EA, Kaul P. Patterns of Glucose-Lowering Therapies and Neonatal Outcomes in the Treatment of Gestational Diabetes in Canada, 2009-2014. Diabet Med 2017;34(9):1296-1302. PMID: 28586507.

Crick K, Thomson D, Fernandes RM, Nuspl M, Eurich DT, Rowe BH, Hartling L. Descriptive Analysis of Cochrane Child-Relevant Systematic Reviews: An Update and Comparison Between 2009 and 2013. BMC Pediatr. 2017 11;17(1):155. PMID: 28693463.

Ekwaru JP, Ohinmaa O, Tran BX, Setayeshgar S, Johnson JA, Veugelers PJ. Cost-effectiveness of a school-based health promotion program in Canada: A life-course modeling approach. PLOS One 2017;12(5):e0177848. PMID: 28542399.

Johnson ST, Mladenovic AB, Mathe N, Davenport MH, Butalia S, Qiu W, Johnson JA. Healthy Eating and Active Living after Gestational Diabetes Mellitus (HEALD-GDM): Rationale, design and proposed evaluation of a randomized controlled trial. Contemp Clin Trials 2017;61:23-28. PMID: 28700892.

Marrie TJ, Tyrell GJ, Majumdar SR, Eurich DT. Rates of, and risk factors for, septic arthritis in patients with invasive pneumococcal disease: prospective cohort study. BMC Infect Dis. 2017;17(1):680. PMID: 29025402.

Marrie TJ, Tyrrell GJ, Majumdar SR, Eurich DT. Concurrent Infection with Hepatitis C Virus and Invasive Pneumococcal Disease. Emerg Infect Dis. 2017;23(7):1118-1123. PMID: 28628455.

Naicker K, Overland S, Johnson JA, Skogen JC, Manuel D, Sivertson B, Colman I. Symptoms of Anxiety and Depression in Type 2 Diabetes: Associations with Clinical Diabetes Measures and Self-Management Outcomes in the Norwegian HUNT Study. Psychoneuroendocrinology 2017;84:116-123. PMID: 28704763.

Schultz M, Keeling SO, Katz SJ, Maksymowych WP, Eurich DT, Hall JJ. Clinical effectiveness and safety of leflunomide in inflammatory arthritis: a report from the RAPPORT database with supporting patient survey. Clin Rheumatol. 2017;36(7):1471-1478. PMID: 28550389.

Simpson SH, MacCallum L, Mansell K. Pharmacy Practice and Diabetes Care. Can J Diabetes. 2017;41(6):549-550. PMID: 29224632.

Simpson SH, Lin M, Eurich DT. Community Pharmacy-Based Inducement Programs are Associated with Better Medication Adherence: A Cohort Study. Annals of Pharmacotherapy. 2017;51(8):630-639. PMID: 28372491.

Soprovich A, El Kurdi S, Eurich DT. An analysis of redactions in Canada’s Common Drug Review Clinical Review Reports and how they relate to the patients’ voice BMJ Open 2017;7:e015497. PMID: 28893743..

Ye M, Robson PJ, Eurich DT, Vena JE, Xu JY, Johnson JA. Cohort Profile: Alberta’s Tomorrow Project. Int J Epidemiol 2017;46(4):1097-1098l. PMID: 28338725.

Meeting Presentations and Invited Talks

Dubois TB "Secondary failure following metformin monotherapy in patients with type 2 diabetes: Canada compared to the United States” at two conferences: INSIGHTS 2017, University of Alberta School of Public Health, November 2, 2017, and at ADI’s Research in Progress Seminar.

Eurich DE, Majumdar SR, Wozniak LA, Soprovich A, Meneen K, Johnson JA, Samanani S. RADAR: Reorganizing the Approach to Diabetes through the Application of Registries (RADAR) in First Nations Communities. Canadian Journal of Diabetes. 2017; 41(1): S81. Poster presented at Diabetes Canada/ Canadian Society of Endocrinology and Metabolism Professional Conference and Annual Meetings, Edmonton, AB, November 1-4, 2017.

Huffman S, Al Sayah F, Ohinmaa A, Johnson JA. What does the “usual activities” dimension of the EQ-5D measure? ISOQOL 24th Annual International Meeting, Philadelphia, PA, October 18-21, 2017. Quality Life Research 2017;26: Suppl. 1:(A2035):90.

Ingstrup, M.S., Wozniak, L.A., Mathe, N., Alghamdi, A., Cormier, L., Butalia, S., Davenport, M., Johnson, J.A., Johnson, S.T. (2017, November). Social Support and Peer Counselling Perceived as Useful in Promoting Behavior Change among Women with a Previous Gestational Diabetes Mellitus Pregnancy. Poster Presented at the Accelerating Primary Care Conference in Calgary, Alberta, November 17 & 18, 2017.

Ingstrup, M.S., Wozniak, L.A., Mathe, N., Alghamdi, A., Cormier, L., Butalia, S., Davenport, M., Johnson, J.A., Johnson, S.T. (2017, November). Established Social Support Trumps Peer Counselling Support in Helping Women who Experienced Gestational Diabetes Adhere to Healthy Lifestyle Changes. Poster presented at the Diabetes Canada/ Canadian Society of Endocrinology and Metabolism Professional Conference and Annual Meetings Edmonton, Alberta, November 1-4, 2017.

Ingstrup, M.S., Wozniak, L.A., Mathe, N., Alghamdi, A., Cormier, L., Butalia, S., Davenport, M., Johnson, J.A., & Johnson, S.T. (2017, October). Rapport essential to provide effective social support for women who had a gestational diabetes pregnancy adhere to an active living behavior intervention. Oral Presentation at the 2017 Alberta Diabetes Institute Research Day, Edmonton, Alberta, October 5, 2017.

Mathe N, Jarman M, and the ENRICH Study Group. Pre-Pregnancy Dietary Patterns and Pregnancy Complications. Alberta Diabetes Institute Research Day, Edmonton, Alberta, October 5, 2017.

Meneen K, Van Weelden D, Samanani S, Johnson JA, Wozniak LA, Majumdar SR, Eurich DE. RADAR: Perceived Barriers and Facilitators to Diabetes Management in First Nations Communities. Canadian Journal of Diabetes. 2017; 41(1): S82. Poster presented at Diabetes Canada/ Canadian Society of Endocrinology and Metabolism Professional Conference and Annual Meetings, Edmonton, AB, November 1-4, 2017.

Short H, Al Sayah F, Ohinmaa A, Johnson J.A. The relationship of material and social deprivation with health status. 24th Annual Conference of the International Society for Quality of Life Research, October 18-21, 2017, Philadelphia, United States. Quality of Life Research 2017; 26: Suppl. 1:(A2064):109. (Poster presentation).

Wozniak LA, Meneen K, Samanani S, Majumdar SR, Johnson JA, Eurich DE. Reimagining the 5Rs through RADAR in First Nations Communities. Canadian Journal of Diabetes. 2017; 41(1): S81. Poster presented at Diabetes Canada/ Canadian Society of Endocrinology and Metabolism Professional Conference and Annual Meetings, Edmonton, AB, November 1-4, 2017.

ACHORD Accolades

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Upcoming Events

15th Annual ACHORD Retreat

March 1-2, 2018

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