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Objective Stimulants are first-line pharmacotherapy for individuals with attention-deficit hyperactivity disorder. However, disparities in drug coverage may contribute to inequitable treatment access. In January 2018, the government of Ontario, Canada, implemented a publicly-funded program (OHIP+) providing universal access to medications at no cost to children and youth between the ages of 0 and 24. In April 2019, the program was amended to cover only children and youth without private insurance. We studied whether these policy changes were associated with changes in prescription stimulant dispensing to Ontario children and youth. Methods We conducted a population-based observational natural experiment study of stimulant dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the association between OHIP+ and its subsequent modification with stimulant dispensing trends. Results The implementation of OHIP+ was associated with a significant immediate increase in the monthly rate of stimulant dispensing of 53.6 individuals per 100,000 population (95% confidence interval [CI], 36.8 to 70.5 per 100,000) and a 14.2% (95% CI, 12.8% to 15.6%) relative percent increase in stimulant dispensing rates between December 2017 and March 2019 (1198.6 vs. 1368.7 per 100,000 population). The April 2019 OHIP+ program amendment was associated with an increase in monthly stimulant dispensing trends of 10.2 individuals per 100,000 population (95% CI, 5.0 to 15.5), with rates increasing 7.5% (95% CI, 6.2% to 8.7%) between March 2019 and March 2020 (1368.7 vs. 1470.8 per 100,000 population). These associations were most pronounced among males, children and youth living in the highest income neighbourhoods and individuals aged 20 to 24. Conclusion A publicly-funded pharmacare program was associated with more children and youth being dispensed stimulants.

Objectives The uptake of endovascular aortic repair for elective and ruptured abdominal aortic aneurysm repair is not well studied. We aimed to examine the trends in open surgical repair and endovascular aortic repair of eAAA and rAAA and to examine the effects of randomized trial publications on elective open surgical repair and endovascular aortic repair rates. Methods We conducted a population-based time-series analysis of eAAA and rAAA repairs in Ontario, Canada from 2003 to 2016. We examined changes in overall and approach-specific rates of eAAA and rAAA repair using exponential smoothing models. Interventional autoregressive integrated moving average models were fit to the eAAA rates to examine the impact of randomized trial results on these rates. Results We identified 19,489 eAAA (12,232 open (63%) and 7257 endovascular (37%)) and 2732 rAAA (2466 open (90%) and 266 endovascular (10%)) repairs from 2003 to 2016. The rate of eAAA repair declined from 6.39/100,000 in 2003 to 5.59/100,000 in 2016 (13% decrease, p = 0.17). The rate of elective open surgical repair decreased nearly three-fold from 6.07/100,000 to 2.12/100,000 ( p Conclusions While elective open surgical repair use has significantly decreased from 2003 to 2016, elective endovascular aortic repair use has significantly increased. The DREAM and EVAR-1 results significantly impacted the observed rates of elective open surgical repair only. The reasons for these trends require further characterization.

Objective: Although antidepressants and antipsychotics are valuable medications in the treatment of select psychiatric disorders, there is increasing focus on the balance of risks and benefits of these drugs as prescribed, particularly in the pediatric population. We examined recent national trends and interprovincial variation in dispensing of antipsychotic and antidepressant prescriptions to the Canadian pediatric population. Method: We conducted a population-based cross-sectional study of antidepressant and antipsychotic prescriptions dispensed by Canadian pharmacies to the pediatric population (≤18 years) between 2010 and 2013. Prescription volumes were obtained from IMS Health. Analysis was stratified by drug, year, quarter, and province and population-standardized using age-adjusted population estimates. Results: From the first quarter of 2010 to the fourth quarter of 2013, dispensing of antipsychotics to the pediatric population increased 33% (from 34 to 45 prescriptions per 1000) and dispensing of antidepressants increased 63% (from 34 to 55 per 1000). We observed a 1.5-fold interprovincial difference in dispensing rates for antidepressants (range: 189 per 1000 to 275 per 1000) and a 3.0-fold difference for antipsychotics (range: 85 per 1000 to 253 per 1000) in 2013. Among antidepressants, selective serotonin reuptake inhibitors were the most dispensed (76%), with fluoxetine being the leading agent. Among antipsychotics, atypical antipsychotics were the most dispensed (97%), with risperidone being the leading agent. Conclusions: Antipsychotic and antidepressant dispensing to the Canadian pediatric population increased from 2010 to 2013, with considerable interprovincial variation. Future research is required to explore reasons for observed patterns to optimize care for the Canadian pediatric population.

Health care organizations continue to implement organization-wide educational approaches to enhance patient safety with less attention on evaluating the impact of these approaches. In this context, a study was conducted to measure the impact of an organization-wide patient safety network approach on patient safety event reporting. A time-series analysis with reported rates of adverse events (major and moderate), near misses, sentinel events, and incidents from 2 years prior through 13 months following implementation was conducted. Study findings include a significant increase in reporting of patient safety events (an approximately 50% increase in overall reporting of safety events was observed; p < .001), especially near misses (an approximately 100% increase following implementation; p = .002). Study findings suggest that a multifaceted networked approach does contribute to improving patient safety event reporting.

Background: The AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) trial demonstrated that rate control and rhythm control strategies result in similar survival and quality of life for patients with atrial fibrillation (AF). Because of superior safety and lower cost, rate control is now the recommended strategy (or the management of most elderly, high-risk AF patients. Objective: To determine the extent to which the AFFIRM trial results have been adopted into actual practice. Methods: We conducted a time-series analysis of 3 population-based cohorts of patients with AF who were 66 years of age or older in Pennsylvania and Ontario. We stratified patients in Ontario by socioeconomic status (SES) and examined changes in quarterly prescription rates for rate control and rhythm controlling medications as well as cardioversion procedures before and after publication of the AFFIRM trial. Results: The publication of the AFFIRM trial resulted in statistically significant reductions in the use of rhythm controlling medications in all 3 cohorts (p < 0.01). The magnitude of these changes in the non-low SES Canadian cohort was approximately 1% per quarter and was greater than the magnitude observed in the other cohorts (p < 0.001). The use of cardioversion procedures also decreased in all study regions (p < 0.01). In contrast, AFFIRM publication was also associated with a small increase in the use of rate controlling medications in Canada (p < 0.01) but not in the US (p = 0.23). Conclusions: Publication of the AFFIRM trial resulted in small but statistically significant changes in the care of patients with AF.

BACKGROUND:The use of nonsteroidal antiinflammatory drugs (NSAIDs) has been associated with increased blood pressure and hypertension. However, less is known about how the risk of hypertension is associated with cyclooxygenase 2 selective inhibitors (coxibs), especially celecoxib, the only coxib remaining on the market.OBJECTIVE:To compare the risk of incident hypertension associated with the use of celecoxib and nonselective (NS) NSAIDs.METHODS:A cohort study was conducted using secondary data from the GE Centricity Electronic Medical Record database, which contains millions of patient records seen by thousands of physicians across the US. The index date was defined as the date of the first NSNSAID or celecoxib prescription between January 1, 1999, and June 30, 2004. Patients were included if they were aged 18 years or older and were enrolled for at least 365 days prior to the index date. Excluded were patients who had any prior diagnosis of hypertension or pregnancy-related hypertension during the pre- or postindex date period. Also excluded were patients who had any prior prescription for antihypertensive drugs, coxibs, or NSNSAIDs. After applying inclusion/exclusion criteria, each celecoxib user was matched to 2 NSNSAID users by sex, age (±5 y), propensity score (within 0.2 SD), and number of unique drugs (±20%). Descriptive and survival analyses were conducted.RESULTS:The final sample consisted of 51 444 patients, of whom 17 148 were on celecoxib and 34 296 were on NSNSAIDs. Relative to NSNSAID users, patients on celecoxib had a similar rate of postexposure hypertension incidence (HR 1.013; 95% CI 0.862 to 1.190).CONCLUSIONS:Results from a population-based cohort analysis of electronic medical records did not show any difference in the hazard rates of incident hypertension between celecoxib and NSNSAID users.ANTECEDENTES:El uso de antiinflamatorios no esteroidales (AINEs) ha sido asociado a un incremento en la presión arterial y en el riesgo de hipertensión. Sin embargo, el riesgo de hipertensión asociado al uso de una nueva clase de AINEs conocidos como los inhibidores selectivos de la ciclooxigenasa II ó COX-2, es menos claro.

Objectives: To examine temporal trends in electroconvulsive therapy (ECT) use among all 12 million Ontario residents between January 1992 and December 2004 and to examine the differential trends in older adults, compared with younger ones. Methods: We undertook a time-series analysis to examine annual trends in the use and prevalence of ECT, using linked provincial datasets. Descriptive data were presented for the population as a whole, and then trends were described separately by age groups (younger and older). As a comparator, we similarly examined antidepressant prevalence for older adults over the same time period. Results: Overall rates of ECT prevalence were stable. Annual population rates of individuals receiving ECT increased by about 27%, from 12.3 per 100 000 population in 1992 to 15.6 per 100 000 in 1997, and then decreased to 12.5 per 100 000 by 2004. The population rates of ECT were about threefold higher among older adults, relative to the younger population. Antidepressant prevalence increased by 90.1% among older adults over the same time period. The female-to-male ratio was relatively stable over time. Conclusions: The rate of ECT has been relatively stable since the early 1990s. Older adults were much more likely to be prescribed a course of ECT than younger adults. ECT remains a commonly prescribed treatment, particularly in old age.

Background: The increasing availability of “me-too” drugs has provided considerable treatment options for clinicians. However, the number of such drugs within a class that are actually used by clinicians has not been well studied. Objective: To determine the number of different statins that individual physicians use in practice. Methods: The Ontario Drug Benefit database was used to identify physicians who issued at least 10 incident statin prescriptions between October 2001 and May 2003 for patients aged 66 years and older. A preferred statin was defined for each physician, and the proportion of each physician's incident prescriptions written for that agent was determined. We then determined the number of different statins required to fill each physician's incident prescribing needs. Results: A total of 3426 physicians wrote 73 571 incident statin prescriptions. The mean percentage of prescriptions written for each physician's preferred statin formulation was 73.7%. Repeat analysis to examine the proportion of prescriptions filled using each physician's top 2 statin formulations found that the average physician wrote the vast majority of his or her incident prescriptions (94.9%) for only 1 or 2 statins. Half of all physicians used, at most, 2 different statins for all incident prescribing, while 91.3% of physicians used, at most, 3 different statins for all of their incident prescribing. Conclusions: A high proportion of Ontario physicians issued the majority of their incident statin prescriptions for the same statin formulation. Most physicians required, at most, 3 different statins for all incident statin prescribing.

Objective: To determine whether the climate of increased anxiety following the terrorist attacks of September 11, 2001, and the subsequent anthrax cases led to increased anxiety-related physician visits. Method: We undertook a retrospective, population-based study of all Ontario residents. We identified physician visits using Ontario's universal health care insurance program. Interventional autoregressive integrated moving average (ARIMA) time series models were used to examine the impact of the terrorist attacks and anthrax infections on the rate of anxiety-related physician visits. Results: Neither the terrorist attacks of September 11 ( P ≥ 0.40) nor the anthrax infections in October and November ( P ≥ 0.14) had a statistically significant impact on the rate of anxiety-related visits to physicians. Conclusions: The climate of heightened anxiety did not result in increased demand for mental health services.

A number of case reports have suggested a possible association between atypical antipsychotic medications and hyponatremia. Currently, there are no reliable estimates of hyponatremia risk from atypical antipsychotic drugs.The objective of this study was to examine the 30-day risk of hospitalization with hyponatremia in older adults dispensed an atypical antipsychotic drug relative to no antipsychotic use.The design of this study was a retrospective, population-based cohort study.The setting of this study was in Ontario, Canada, from 2003 to 2012.Adults 65 years or older with an identified psychiatric condition who were newly dispensed risperidone, olanzapine, or quetiapine in the community setting compared to adults with similar indicators of baseline health who were not dispensed such a prescription.The primary outcome was the 30-day risk of hospitalization with hyponatremia. The tracer outcome (an outcome that is not expected to be influenced by the study drugs) was the 30-day risk of hospitalization with bowel obstruction. These outcomes were assessed using hospital diagnosis codes.Using health administrative data, we applied a propensity score technique to match antipsychotic users 1:1 to non-users of antipsychotic drugs (58,008 patients in each group). We used conditional logistic regression to compare outcomes among the matched users and non-users.A total of 104 baseline characteristics were well-balanced between the two matched groups. Atypical antipsychotic use compared to non-use was associated with an increased risk of hospitalization with hyponatremia within 30 days (86/58,008 (0.15 %) versus 53/58,008 (0.09 %); relative risk 1.62 (95 % confidence interval (CI) 1.15 to 2.29); absolute risk increase 0.06 % (95 % CI 0.02 to 0.10)). The limited number of events precluded some additional analyses to confirm if the association was robust. Atypical antipsychotic use compared to non-use was not associated with hospitalization with bowel obstruction within 30 days (55/58,008 (0.09 %) versus 44/58,008 (0.08 %); relative risk 1.25 (95 % CI 0.84 to 1.86)).We could only study older adults within our data sources.In this study, the use of an atypical antipsychotic was associated with a modest but statistically significant increase in the 30-day risk of a hospitalization with hyponatremia. The association was less pronounced than that described with other psychotropic drugs.De nombreux exposés de cas font état d’une possible corrélation entre la prise de médicaments antipsychotiques atypiques et l’hyponatrémie. Or actuellement, il n’existe aucune évaluation fiable qui vienne corroborer cette association.L’étude visait à évaluer le risque, sur une période de 30 jours, d’hospitalisation pour cause d’hyponatrémie chez des patients adultes sous ordonnance d’un antipsychotique atypique, par rapport à un groupe de patients qui n’en consommaient pas.Il s’agit d’une étude de cohorte, représentative de la population et rétrospective, qui s’est tenue en Ontario, au Canada, de 2003 à 2012.L’étude a porté sur un groupe d’adultes de plus de 65 ans avec un trouble psychiatrique établi et qui débutaient un traitement par risperidone, olanzapine ou quétiapine en milieu communautaire. Ils ont été comparés à un groupe d’individus ayant des indicateurs de santé initiaux équivalents, mais ne prenant pas d’antipsychotiques atypiques.Le critère de jugement principal était le risque d’hospitalisation pour cause d’hyponatrémie à l’intérieur d’une période de 30 jours. À titre de traceur (événement sur lequel le médicament administré ne devait avoir aucune influence), on a utilisé le risque d’hospitalisation pour occlusion intestinale. Ces résultats ont été évalués en utilisant les codes de diagnostic des hôpitaux.À l’aide des données administratives de la santé, la méthode statistique de l’appariement par scores de propension a été utilisée pour jumeler chaque patient sous médication antipsychotique avec un patient n’en consommant pas (58,008 patients dans chacun des groupes). On a eu recours à une régression logistique conditionnelle pour comparer les résultats observés au sein des couples de patients ainsi jumelés.On a identifié 104 caractéristiques initiales bien balancées entre les deux groupes de participants. La prise d’antipsychotiques atypiques a été associée à un risque accru d’hospitalisation pour cause d’hyponatrémie à l’intérieur d’une période de 30 jours, lorsque comparée à la non-consommation (86/58 008 [0,15 %] contre 53/58 008 [0,09 %] ; risque relatif de 1,62 [95 % intervalle de confiance [IC] entre 1,15 et 2,29] ; augmentation absolue du risque à 0,06 % [95 % IC entre 0,02 et 0,10]. Le nombre limité d’événements empêche quelques analyses complémentaires qui permettraient de confirmer la robustesse de l’association entre l’hospitalisation pour hyponatrémie et la médication. Par ailleurs, la prise d’antipsychotiques atypiques n’a pas été associée à une hospitalisation pour obstruction intestinale pour la même période de 30 jours lorsque comparée au groupe de patients n’en consommant pas [55/58 008 [0,09 %] contre 44/58 008 [0,08 %] ; risque relatif de 1,25 [95 % IC entre 0,84 et 1,86]].Les sources de données consultées n’ont permis que d’étudier les cas de patients adultes et âgés.Dans la présente étude, la consommation d’un médicament antipsychotique atypique a été associée à une légère, quoique significative, augmentation du risque d’être hospitalisé pour cause d’hyponatrémie, à l’intérieur d’une période de 30 jours. Toutefois, l’association s’est avérée moins marquée que pour d’autres médicaments psychotropes.