Starting insulin therapy in hospitalized patients may be associated with an increase in serious adverse events after discharge. Determine whether post-discharge risks of death and rehospitalization are higher for older hospitalized patients prescribed new insulin therapy compared with oral hypoglycemic agents (OHAs). Retrospective population-based cohort study including hospital admissions in Ontario, Canada, between April 1, 2004, and Nov 30, 2013. Persons aged 66 and over discharged after a hospitalization and dispensed a prescription for insulin and/or an OHA within 7 days of discharge. We included 104,525 individuals, subcategorized into four mutually exclusive exposure groups based on anti-hyperglycemic drug use in the 7 days post-discharge and the 365 days prior to the index admission. Prescriptions at discharge were categorized as new insulin (no insulin before admission), prevalent insulin (prescribed insulin before admission), new OHA(s) (no OHA or insulin before admission), and prevalent OHA (prescribed OHA only before admission) as the referent category. The primary and secondary outcomes were 30-day deaths and emergency department (ED) visits or readmissions respectively. Of 104,525 patients, 9.2% were initiated on insulin, 4.1% died, and 26.2% had an ED visit or readmission within 30 days of discharge. Deaths occurred in 7.14% of new insulin users, 4.86% of prevalent insulin users, 3.25% of new OHA users, and 3.45% of prevalent OHA users. After adjustment for covariates, new insulin users had a significantly higher risk of death (adjusted hazard ratio (aHR) 1.59, 95% confidence interval (CI) 1.46 to 1.74) and ED visit/readmissions (aHR 1.17, 95% CI 1.12 to 1.22) than prevalent OHA users. Initiation of insulin therapy in older hospitalized patients is associated with a higher risk of death and ED visits/readmissions after discharge, highlighting a need for better transitional care of insulin-treated patients.

Importance Nursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown. Objective To evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia. Design, Setting, and Participants This population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n = 27 243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019. Exposure Sex of the nursing home resident. Main Outcomes and Measures Burdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life. Results The final cohort included 27 243 nursing home residents with advanced dementia (19 363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%];P < .001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%];P < .001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%];P < .001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%];P < .001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%];P < .001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%];P = .005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%];P < .001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49;P < .001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41;P < .001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54);P < .001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81;P < .001). Conclusions and Relevance In this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.

OBJECTIVEWomen with breast cancer and diabetes face worse outcomes than those with breast cancer without diabetes; however, the contribution of comorbidity to these disparities remains unclear. We evaluated the impact of diabetes on receipt of cancer treatments as well as mortality while accounting for other comorbidities.RESEARCH DESIGN AND METHODSOntario administrative databases were used to compare the rate of receipt of breast cancer treatments between women with and without diabetes. We also performed adjusted cause-specific hazard models to account for comorbidities when evaluating differences in treatments received and mortality outcomes between the two groups.RESULTSWomen with diabetes and stage III breast cancer were slightly less likely to receive chemotherapy (relative risk [RR] 0.93 [95% CI 0.89-0.97]), although this difference was not significant when we adjusted for comorbidities (adjusted hazard ratio [aHR] 1.03 [95% CI 0.93-1.13]). We saw similar trends for receipt of guideline-adherent radiotherapy (RR 0.97 [0.95-0.99], aHR 0.98 [0.94-1.02]). All-cause mortality was increased in women with diabetes after adjusting for comorbidities (aHR 1.16 [1.06-1.27]), but breast cancer-specific mortality was not increased overall. Women with a longer duration of diabetes and those with preexisting cardiovascular disease had increased all-cause and cancer-specific mortality.CONCLUSIONSAlthough cancer treatments received were similar between women with and without diabetes, breast cancer-specific mortality remains higher among women with diabetes who have longer diabetes duration or preexisting cardiovascular disease. This study uncovers new information about key risk factors for poorer prognosis in women with diabetes and breast cancer.

BACKGROUND: Patients receiving Bevacizumab, a vascular endothelial growth factor inhibitor used to treat metastatic colorectal cancer, may be at greater risk of complications after colorectal surgery because of impaired healing. OBJECTIVE: The purpose of this study was to describe population-based rates of complications of colorectal surgery after Bevacizumab treatment and evaluate the relationship between time since last treatment and risk of complications. DESIGN: This was a population-based retrospective cohort study using administrative and cancer registry data. SETTINGS: The study was conducted in Ontario, Canada. PATIENTS: Patients with metastatic colorectal cancer receiving Bevacizumab between January 2008 and December 2011 were followed for a year after treatment or until death. MAIN OUTCOME MEASURES: Administrative data were used to identify patients who underwent colorectal surgery after initiation of Bevacizumab and to determine whether they experienced a complicated postoperative course. The relationship between time since last Bevacizumab treatment (⩽28 d, 29 d to 3 mo, and >3 mo) and risk of postoperative complications was evaluated using logistic regression. RESULTS: Of the 2759 patients who received Bevacizumab for the treatment of metastatic colorectal cancer, 265 underwent a colorectal procedure after exposure. The majority had a bowel resection or repair with no stoma (47.5%) and had emergency surgery (61.1%). Overall, 96 (36.2%) had a complicated postoperative course, including 20.4% readmission, 12.5% wound complications, and 7.9% mortality rate within 30 days of surgery. Adjusted multivariate analysis showed no difference in the likelihood of a complicated postoperative course among patients undergoing surgery within 28 days of receiving their last Bevacizumab dose compared with 29 days to 3 months (OR = 1.23 (95% CI, 0.53–2.84), or 3 to 12 months (OR = 0.98 (95% CI, 0.46–2.09) after receiving Bevacizumab. LIMITATIONS: Reliance on administrative data to measure complications limited the scope of this study. CONCLUSIONS: Patients with metastatic colorectal cancer requiring colorectal surgery after exposure to Bevacizumab experience substantial morbidity and mortality. The risk of complications is not detectably associated with time since exposure. See Video Abstract at http://links.lww.com/DCR/A474.

strength, a proportional reporting ratio (PRR) was calculated and compared with drug-ADR pairs with no known associations to calibrate the threshold at which the PRR represents true ADR signal. 3 To establish time-to-detection comparisons against literature, we reviewed extractions, excluding noncausal drug-ADR mentions, and compared the frequency and timing of these detections against published clinical reports.

PURPOSE:To assess prechemotherapy cardiac imaging practices in relation to patients' heart failure (HF) risk.METHODS:We performed a population-based retrospective cohort study of women receiving chemotherapy for early-stage breast cancer in Ontario between 2007 and 2012. We surveyed for baseline cardiac imaging 6 months before chemotherapy or within 30 days thereafter. The proportion of patients who underwent imaging and cumulative incidence of major adverse cardiac event (MACE) rates was determined based on chemotherapy regimen and HF risk factors. Logistic regression was used to assess predictors of pretreatment cardiac imaging.RESULTS:We studied 18,444 women who had been treated with chemotherapy (median age, 55 years). There was near-universal imaging of women treated with trastuzumab-containing regimens, including those without additional HF risk factors. Women who received anthracyclines without trastuzumab underwent imaging more frequently if they had additional HF risk factors (73.3% v 62.6%; P < .001). The 5-year incidence of MACE was two to six times higher in patients with HF risk factors across all treatment regimens. Patients with HF risk factors who received anthracyclines without trastuzumab had a higher 5-year incidence of MACE (4.5%) than patients without HF risk factors who received trastuzumab without anthracyclines (2.6%). However, cardiac imaging was less frequent in the former group (73.3% v 93.6%; P < .001). Logistic regression indicated that most variation in baseline imaging was related to chemotherapy, followed by physician-level factors. The odds of imaging were doubled with female physicians. Patient-specific factors, including HF risk factors, made minimal contribution to variation in imaging.CONCLUSION:Baseline cardiac imaging was driven by chemotherapy regimen rather than HF risk. This risk-imaging mismatch is an impetus to reconsider current cardiac imaging practices in patients who receive chemotherapy for breast cancer.

Abstract Background A cancer diagnosis may disrupt diabetes management, increasing the risk of preventable complications. The objective was to determine whether a cancer diagnosis in patients with diabetes is associated with an increased risk of diabetic complications. Methods This retrospective cohort study using health care data from Ontario, Canada, included persons age 50 years or older diagnosed with diabetes from 2007 to 2011 and followed until 2014. We examined the effects of cancer as a time-varying covariate: breast cancer (in women), prostate cancer (in men), colorectal cancer, and other cancers (in men and women). Each cancer exposure was categorized as stage I–III, IV, or unknown, and by time since cancer diagnosis (0–1 year, >1–3 years, and >3 years). The primary outcome was hospital visits for diabetic emergencies. Secondary outcomes were hospital visits for skin and soft tissue infections and cardiovascular events. Results Of 817 060 patients with diabetes (mean age = 64.9 +/- 10.7 years), there were 9759 (1.2%) colorectal and 45 705 (5.6%) other cancers, 6714 (1.7%) breast cancers among 384 257 women and 10 331 (2.4%) prostate cancers among 432 803 men. For all cancers except stage I–III prostate cancer, rates of diabetic complications were significantly higher zero years to one year after diagnosis compared with no cancer (adjusted relative rates ranging from 1.26, 95% confidence interval [CI] = 1.08 to 1.49, to 4.07, 95% CI = 3.80 to 4.36); these differences were attenuated in the subsequent periods after cancer diagnosis. Conclusions Patients with diabetes are at increased risk for preventable complications after a cancer diagnosis. Better diabetes care is needed during this vulnerable period.

BACKGROUND:Despite the fact that many older adults receive home or long-term care services, the effect of these care settings on hospital readmission is often overlooked. Efforts to reduce hospital readmissions, including capacity planning and targeting of interventions, require clear data on the frequency of and risk factors for readmission among different populations of older adults.METHODS:We identified all adults older than 65 years discharged from an unplanned medical hospital stay in Ontario between April 2008 and December 2015. We defined 2 preadmission care settings (community, long-term care) and 3 discharge care settings (community, home care, long-term care) and used multinomial regression to estimate associations with 30-day readmission (and death as a competing risk).RESULTS:We identified 701 527 individuals (mean age 78.4 yr), of whom 414 302 (59.1%) started in and returned to the community. Overall, 88 305 in dividuals (12.6%) were re admitted within 30 days, but this proportion varied by care setting combination. Relative to individuals returning to the community, those discharged to the community with home care (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.39-1.46) and those returning to long-term care (adjusted OR 1.35, 95% CI 1.27-1.43) had a greater risk of readmission, whereas those newly admitted to long-term care had a lower risk of readmission (adjusted OR 0.68, 95% CI 0.63-0.72).INTERPRETATION:In Ontario, about 40% of older people were discharged from hospital to either home care or long-term care. These discharge settings, as well as whether an individual was admitted to hospital from long-term care, have important implications for understanding 30-day readmission rates. System planning and efforts to reduce readmission among older adults should take into account care settings at both admission and discharge.

BACKGROUND:Catheter ablation of ventricular tachycardia (VT) can reduce the burden of ventricular arrhythmia (VA) but its effect on health care utilization and costs after such therapy is poorly known. We sought to compare the rates of cardiovascular (CV)-related hospitalizations, survival, and health care costs in patients with recurrent VT treated either with VT ablation or with medical therapy.METHODS:One-hundred implantable cardioverter-defibrillator patients with structural heart disease who underwent VT ablation were included. Propensity score-matched patients with recurrent VT treated with medical therapy were identified from a prospective registry of approximately 7000 de novo implantable cardioverter-defibrillator patients. Outcomes and costs were ascertained using health administrative databases.RESULTS:Among patients who underwent VT ablation, the cumulative rates of VA-related hospitalizations were lower in the 2 years after their ablation procedure compared with the year before (rate ratio, 0.3; 95% confidence interval [CI], 0.22-0.43). Rates of CV-related hospitalization and hospitalization because of VA post index date were similar between the VT ablation and medical therapy groups (hazard ratio [HR], 0.94; 95% CI, 0.57-1.54 and HR, 1.04; 95% CI, 0.57-1.91, respectively). Health care costs in the VT ablation patients were not increased post-ablation compared with the medical management group. The risk of all-cause mortality was lower among patients in the VT ablation group relative to the medical therapy group (HR, 0.64; 95% CI, 0.4-0.99).CONCLUSIONS:Patients who underwent VT ablation experienced a significant reduction in their rate of VA-related hospitalizations. Patients treated with VT ablation had similar rates of CV-related hospitalization compared with those treated with medical therapy without increased health care-related costs.

Introduction CorHealth Ontario, formerly Cardiac Care Network (CCN), maintains a registry of patients undergoing select cardiac procedures/surgeries in Ontario, Canada. This population-based database contains over 35 datasets with complex structure, linked by unique primary key or multiple keys. Objectives and Approach We aimed to simplify the complex CorHealth database so that research analysts could create study cohorts more efficiently and effectively, and to enrich the study cohort by getting more clinical information through database linkage. Through internal linkage, we could combine clinical fields from multiple CorHealth datasets. While the CorHealth dataset may not have all the clinical information needed for a given study, we may link the CorHealth study cohort externally to other administration databases to obtain additional fields via the probability matching (i.e., identical patient ID, hospital ID and procedure/surgery date). Results After identifying the primary keys on the relational database flowchart, we designed new data structures by combining similar topic datasets. The total number of datasets was reduced from 35 to 13. This simplified CorHealth dataset includes one main CorHealth dataset (including demographic information, referral data, comorbidities) plus 12 other linkable specific datasets (including stent, vessel, TAVI, STEMI). Through internal linkage, we can get the stent numbers, lengths and types of Percutaneous Coronary Interventions from the Stent dataset. Linking to Discharge Abstract Database (DAD), we can get the hospital length of stay and the episode of care of hospital transfer for each procedure; linking to The Ontario Health Insurance Plan database (OHIP), we can find the graft numbers and vessel types of Coronary Artery Bypass Graft. Conclusion/Implications To improve the research capacity and increase the value of the CorHealth database, analysts could create enhanced cardiovascular study cohorts derived from the simplified CorHealth database, plus internal linkage from other CorHealth datasets, and external data linkage from population-based administrative sources. We have accomplished three reports (PCI/CABG/TAVI) accordingly in 2017/18.

Background: Cancer screening aims to detect malignant disease early in its natural history when interventions might improve patient outcomes. Such benefits are unclear when screening occurs for patients with an existing high risk of death. Our aim was to study the extent of routine cancer screening for a new primary cancer in patients with existing metastatic cancer. Methods: We used administrative databases from Ontario to identify a retrospective cohort of adults of eligible screening age (≥ 50 yr) who had a diagnosis of stage IV (metastatic) colorectal, lung, breast or prostate cancer between 2007 and 2012. We calculated the cumulative incidence of cancer screening over time for colorectal and breast cancer. Results: Among the 20 992 patients with metastatic lung, breast or prostate cancer, 2.9%, 6.3% and 13.3% of patients, respectively, underwent testing for colorectal cancer within 1 year of cancer diagnosis. Within 3 years of diagnosis, rates reached 4.1%, 12.3% and 27.5%, respectively (8.5% of all patients). Incidence of colorectal cancer testing was higher among patients who received their diagnoses more recently compared with patients with diagnoses from earlier time periods (p = 0.0143). Among the 10 034 women with metastatic lung or colorectal cancer, 8.7% and 8.0% of patients, respectively, underwent breast cancer screening within 1 year of cancer diagnosis. Within 3 years of diagnosis, screening rates reached 10.2% and 13.1%, respectively. Interpretation: Our findings indicate excessive rates of cancer screening among patients with metastatic cancer who are unlikely to benefit. Further studies are warranted to identify predictors for screening, resource implications, potential and real harms borne by patients, and the impact of a recent Choosing Wisely statement recommending against the practice.

BACKGROUNDIn the United States, certain minority groups have been shown to have inferior cancer outcomes compared with the white majority population. However, to the authors' knowledge, the majority of research has not separated ethnicity from immigration status. The objective of the current study was to determine the impact of ethnicity, independent of immigration status, on cancer outcomes in Chinese and South Asian populations in Ontario, Canada.METHODSThe authors conducted a population‐based retrospective cohort study using administrative databases in Ontario, Canada. Incident cancer cases were captured in Canadian‐born Chinese and South Asian individuals, Chinese and South Asian immigrants, and the general Ontario reference population (non‐Chinese/non‐South Asian and non‐immigrant) between 2000 and 2012. Subjects were followed until death (all‐cause and cancer‐specific), and Cox proportional hazard models were used to estimate the impact of Chinese and South Asian ethnicity on cancer outcomes after adjusting for explanatory variables.RESULTSA total of 423,678 cancer cases were identified; at total of 6631 cases were identified in Canadian‐born Chinese individuals and 2752 cases in Canadian‐born South Asian individuals. After adjustment, the rate of all‐cause mortality was lower for Canadian‐born Chinese (hazard ratio [HR], 0.829; 95% confidence interval [95% CI], 0.795‐0.865), Canadian‐born South Asian (HR, 0.856; 95% CI, 0.797‐0.919), and Chinese immigrant (recent immigrant: HR, 0.661 [95% CI, 0.610‐0.716] and non‐recent immigrant: HR, 0.853 [95% CI, 0.803‐0.906]) populations compared with the general Ontario population. A similar effect was found for cancer‐specific mortality.CONCLUSIONSChinese and South Asian ethnic groups appear to have lower cancer mortalities compared with the general Ontario population. After removing the well‐documented protective effect of immigration, Chinese and South Asian ethnicities were found to be associated with a cancer survival advantage in Ontario, Canada. Cancer 2018;124:1473‐82. © 2018 American Cancer Society.

Background: Neuroendocrine tumours (NETs) are uncommon. Little data exist to guide follow-up in resected disease, with no consensus regarding the optimal follow-up frequency or modality. Follow-up imaging regimens are extrapolated from other gastrointestinal tumours. As NETs are heterogeneous, this may result in both over-use and underuse of investigations in patients. Methods: A population-based retrospective cohort study using linked data from the Institute for Clinical Evaluative Sciences and the Ontario Cancer Registry (capturing more than 99% of incident cases in Ontario) was conducted to evaluate patients diagnosed with gastroenteropancreatic NETs in Ontario, Canada from 1994 to 2012. Recurrence-free survival and the frequency of cross sectional imaging (abdominal computed tomography (aCT), magnetic resonance imaging (aMRI) and ultrasound (aUS)) were the main outcomes. Results: Nine hundred and thirty-six patients were identified with median follow-up 47 months. The mean age was 59, 51% were female, and distribution of primary cancers was: small intestine 47%, pancreas 20%, large intestine 21%, rectum 6.4%, stomach 6.0%. The median survival time to a composite outcome of recurrence or death was 7.2 years, and 9.5 years if censoring on death. The cumulative incidence of recurrence was 8.4% (95% CI 6.8% to 10.3%) within one year, 33.7% (95% CI 30.4% to 36.9%) within five years, and 48.5% (95% CI 44.4% to 52.4%) within 10 years. The rate of recurrence significantly increased with age (HR = 1.529 for age 50-70 compared to < 50, p = 0.0003) and pancreatic primary (HR = 1.463, p = 0.0006), but not income quintile (p = 0.1071), rurality (p = 0.1931) or gender (p = 0.3787). The rate of use of aCTs, aMRIs and aUS decreased over time, from 1.04 per 100 patient-days in months 1-3 to 0.22 at months 49-60. On average, 1.59 abdominal CTs per patient were performed in the first year, 0.83 in the second year and 0.52 in years 3-5. Conclusions: Unlike colon cancer, significant numbers of NETs recur between 5-10 years after curative surgical resection. These data support the lengthening of follow-up for resected NETs to a minimum of 10 years. Future research should focus on the impact of imaging on early detection of recurrence and survival outcomes. Legal entity responsible for the study: Sunnybrook Research Institute Funding: AGITG Disclosure: D. Chan: Travel support from Novartis; honoraria from Ipsen. E. Segelov: Honoraria from Roche, Bayer, Ipsen and Pfizer; research funding from Merck Serono and Ipsen; travel support from Roche and Ipsen. S. Singh: Honoraria and travel funding from Ipsen, Pfizer and Novartis. All other authors have declared no conflicts of interest.

Background: Prior studies have documented inferior health outcomes in vulnerable populations, including racial minorities and those with disadvantaged socioeconomic status. The impact of immigration on cancer-related outcomes is less clear. Methods: Administrative databases were linked to create a cohort of incident cancer cases (colorectal, lung, prostate, head and neck, breast, and hematologic malignancies) from 2000 to 2012 in Ontario, Canada. Cancer patients who immigrated to Canada (from 1985 onward) were compared with those who were Canadian born (or immigrated before 1985). Patients were followed from diagnosis until death (cancer-specific or all-cause). Cox proportional hazards models were estimated to determine the impact of immigration on mortality after adjusting for explanatory variables. Additional adjusted models studied the relationship of time since immigration and cancer-specific and overall mortality. Results: From 2000 to 2012, 11,485 cancer cases were diagnosed in recent immigrants (0 to 10 years in Canada), 17,844 cases in nonrecent immigrants (11 to 25 years), and 416,118 cases in nonimmigrants. After adjustment, the hazard of mortality was lower for recent immigrants (hazard ratio [HR], 0.843; 95% CI, 0.814 to 0.873) and nonrecent immigrants (HR, 0.902; 95% CI, 0.876 to 0.928) compared with nonimmigrants. Cancer-specific mortality was also lower for recent immigrants (HR, 0.857; 95% CI, 0.823 to 0.893) and nonrecent immigrants (HR, 0.907; 95% CI, 0.875 to 0.94). Among immigrants, each year from the original landing was associated with increased mortality (HR, 1.004; 95% CI, 1.000 to 1.009) and a trend to increased cancer-specific mortality (HR, 1.005; 95% CI, 0.999 to 1.010). Conclusion: Immigrants demonstrate a healthy immigrant effect, with lower cancer-specific mortality compared with Canadian-born individuals. This benefit seems to diminish over time, as the survival of immigrants from common cancers potentially converges with the Canadian norm.

Little is known about resource use in the care of neuroendocrine tumors (NETs). This study defined patterns of costs in NET management and compared them with those of a more common malignancy, colon cancer (CC).

There is limited information on stage at breast cancer diagnosis in Canadian immigrant women. We compared stage at diagnosis between immigrant women and Canadian-born women, and determined whether ethnicity was an independent factor associated with stage. 41,213 women with invasive breast cancer from 2007 to 2012 were identified from the Ontario Cancer Registry. Women were classified as either immigrants or Canadian-born by linkage with the Immigration, Refugees, and Citizenship Canada's Permanent Resident database. Women's ethnicity was classified as Chinese, South Asian, or remaining women in Ontario. Logistic regression was performed to calculate the odds ratio (OR) of being diagnosed at stage I breast cancer (versus stage II-IV). 4,353 (10.6%) women were immigrants and 36,860 (89.4%) were Canadian-born women. The mean age at breast cancer diagnosis was 53.5 years for immigrants versus 62.3 years for Canadian-born women (p < 0.0001). Immigrant women were less likely than Canadian-born women to be diagnosed with stage I breast cancers (adjusted OR = 0.85; 95% CI: 0.79-0.91; p < 0.0001). The adjusted OR of being stage I was 1.28 (95% CI: 1.14-1.43; p < 0.0001) for women of Chinese ethnicity and was 0.82 (95% CI: 0.70-0.96; p = 0.01) for women of South Asian ethnicity, compared to the remaining women in Ontario. Canadian immigrant women were less likely than Canadian-born women to be diagnosed with early-stage breast cancers. Ethnicity was a greater contributor to the stage disparity than was immigrant status. South Asian women, regardless of immigration status, might benefit from increased breast cancer awareness programs.

OBJECTIVES: To determine the prevalence of and resident characteristics associated with the prescription of medications of questionable benefit (MQBs) near the end of life in older adults with advanced dementia in nursing homes.DESIGN: Population-based, cross-sectional study using Resident Assessment Instrument Minimum Data Set 2.0 linked to health administrative data.SETTING: Ontario, Canada.PARTICIPANTS: All 9,298 nursing home residents with advanced dementia who died between June 1, 2010, and March 31, 2013; were aged 66 and older at time of death; and received at least one MQB in their last year of life.MEASUREMENTS: Prevalence of eight classes of MQBs (e.g., lipid-lowering agents, antidementia drugs) used in the last 120 days and last week of life.RESULTS: Of older nursing home residents with advanced dementia who received at least one MQB in the last year of life, 8,027 (86.3%) received them in the last 120 days and 4,180 (45.0%) in the last week of life. The most commonly prescribed MQB were antidementia (63.6%) and lipid-lowering agents (47.8%). Severe cognitive impairment (adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.07-1.33, P = .002) and fewer signs and symptoms of health instability (aOR = 1.58, 95% CI = 1.44-1.74, P < .001) were associated with MQB use into the last week of life. Seeing a neurologist or psychiatrist was associated with less likelihood of MQB use in the last week of life.CONCLUSION: Many nursing home residents with advanced dementia are dispensed MQBs in the last week of life. Given that MQBs may cause more harm than benefit in this vulnerable population, it is important for physicians to actively reassess the role of all medications toward the end of life.

The true incidence of chemotherapy-induced peripheral neuropathy among elderly patients treated with oxaliplatin for colorectal cancer is not known. Using the Ontario Cancer Registry, we identified 3607 patients aged > 65 years with colorectal cancer and found a greater rate of peripheral neuropathy among patients aged >= 70 years at the time of cancer diagnosis who subsequently received an oxaliplatin-based regimen. Background: The addition of oxaliplatin to adjuvant treatment regimens for colorectal cancer has been shown to improve overall survival at the expense of increased toxicity. The incidence and severity of toxicity might be greater among older patients who might also derive less benefit from oxaliplatin. We evaluated the association between adjuvant oxaliplatin-based chemotherapy and neurotoxicity outcomes in an elderly cohort of patients. Patients and Methods: A population-based cohort of patients aged > 65 years with stage II and III colorectal cancer treated with adjuvant therapy in Ontario, Canada was identified using the Ontario Cancer Registry. Cause-specific hazard models were used to estimate the effect of oxaliplatin exposure on the cause-specific hazard ratio (CHR) of peripheral neuropathy after accounting for the competing risk of death. Results: We identified 3607 patients aged > 65 years with stage II and III colorectal cancer. Of these patients, 1541 (43%) had been treated with an oxaliplatin-based regimen. Compared with subjects receiving non eoxaliplatin-based regimens, patients aged >= 70 years at the time of cancer diagnosis who are subsequently treated with oxaliplatin were more likely to develop peripheral neuropathy (CHR, 2.3; 95% confidence interval [CI], 1.53-3.35; P < .0001). This association was not significant in patients aged 66 to 69 years (CHR, 0.93; 95% CI, 0.50-1.72; P = .812). Formal interaction testing confirmed that the effect of oxaliplatin on neuropathy was more pronounced in patients aged >= 70 years compared with patients aged 66 to 69 years (P = .03). Conclusion: Colorectal cancer patients aged >= 70 years at the time of cancer diagnosis who are subsequently treated with oxaliplatin have a significant risk of developing peripheral neuropathy. This should be considered in clinical decision making, especially because of the limited data supporting an oxaliplatin benefit in this age group. (C) 2017 Elsevier Inc. All rights reserved.

OBJECTIVE Lithium is an essential mood disorder treatment; however, it remains unclear whether lithium increases chronic kidney disease (CKD) risk. There are few data on this in the elderly, even though older adults may be particularly susceptible to CKD. We wished to determine whether lithium is associated with increased CKD risk relative to valproate in older adults. METHODS This nested case-control study analyzed province-wide administrative health data from mental health service users aged ≥ 66 years in Ontario, Canada, from 2003 to 2014. Five-year incident CKD risk was compared in lithium users, valproate users, and patients who used neither medication. ICD-10 was used to assign CKD diagnosis. We used conditional logistic regression to control for hypertension, diabetes mellitus, acute kidney injury, medications associated with lithium toxicity, and other potential confounders. RESULTS 21,741 cases and 86,930 age- and sex-matched controls were identified, including 529 lithium users and 498 valproate users. After controlling for confounders, we found that lithium use was associated with increased risk of incident CKD (adjusted odds ratio [OR] = 1.76 [95% CI, 1.41-2.19]), while valproate use was not (adjusted OR = 1.03 [95% CI, 0.81-1.29]). CONCLUSIONS Lithium is independently associated with an almost 2-fold increase in CKD risk in this community sample of older mental health service users. In the absence of clear information about certain contributing factors, such as inadequate monitoring and acute and chronic lithium level elevations, causes for this increase will need to be determined in future research.