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Aim To study the population-based prevalence of potentially inappropriate medication (PIM) among older individuals with diabetes, and to identify factors associated with their use. Methods We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS) database to conduct a population-based cohort study of individuals with diabetes ≥66 years between April 1st, 2014 and March 31st, 2015. PIMs were defined according to the 2015 Beers Criteria. Factors associated with PIM use were identified using robust Poisson regression models. Risk ratios (RR) and 99% confidence intervals (99%CI) were calculated. Results More than half (56%) of the 286,962 older individuals with diabetes used at least one PIM over a year. Benzodiazepines (41%), proton pump inhibitors (27%) and endocrine medication (mainly glibenclamide) (25%) were the most common PIMs used. Factors associated with PIM use included female sex (RR: 1.17; 99%CI: 1.16–1.18), and comorbidities such as schizophrenia (1.48; 1.45–1.51), anxiety disorders (1.34; 1.33–1.35) and Alzheimer's disease (1.14; 1.13–1.25). Risks of using PIMs increased both with increasing comorbidities and number of medications. Conclusion PIM use is highly prevalent among older individuals with diabetes. Interventions to promote optimal medication use should particularly target individuals with comorbidities and polypharmacy who are most vulnerable to adverse drug events.

The use of multiple medications is common in older adults but is associated with negative health outcomes. However, polypharmacy is not uniformly defined, and there is scant data on how the variety of definitions and their limitations hinder the development of sound scientific knowledge. The article intends to illustrate the challenges of this exposure definition. The array of thresholds for defining polypharmacy renders comparisons between results difficult. Few studies take into account the fact that polypharmacy is a changing exposure over time. In addition, although studies tend to recognize the confounding effect of multimorbidity, residual bias remains a concern. Current studies in polypharmacy often ignore basic epidemiological principles for defining exposure. Future research should integrate time-varying exposure and methods to better control confounding bias. This will help determine the positive/negative impacts of polypharmacy and help establish if polypharmacy conveys information beyond being a marker of health status.

Investigating human consciousness based on brain activity alone is a key challenge in cognitive neuroscience. One of its central facets, the ability to form autobiographical memories, has been investigated through several fMRI studies that have revealed a pattern of activity across a network of frontal, parietal, and medial temporal lobe regions when participants view personal photographs, as opposed to when they view photographs from someone else’s life. Here, our goal was to attempt to decode when participants were re-experiencing an entire event, captured on video from a first-person perspective, relative to a very similar event experienced by someone else. Participants were asked to sit passively in a wheelchair while a researcher pushed them around a local mall. A small wearable camera was mounted on each participant, in order to capture autobiographical videos of the visit from a first-person perspective. One week later, participants were scanned while they passively viewed different categories of videos; some were autobiographical, while others were not. A machine-learning model was able to successfully classify the video categories above chance, both within and across participants, suggesting that there is a shared mechanism differentiating autobiographical experiences from non-autobiographical ones. Moreover, the classifier brain maps revealed that the fronto-parietal network, mid-temporal regions and extrastriate cortex were critical for differentiating between autobiographical and non-autobiographical memories. We argue that this novel paradigm captures the true nature of autobiographical memories, and is well suited to patients (e.g., with brain injuries) who may be unable to respond reliably to traditional experimental stimuli.

RESEARCH OBJECTIVE: Effective health innovations are rarely scaled‐up—missing countless opportunities to improve health systems. Yet, little evidence exists on strategies to support large scale implementation of proven innovations. eConsult is an asynchronous online platform connecting primary care providers to specialists to discuss patients’ care, that improves access, patient experience, provider satisfaction, and reduces costs. eConsult services have been implemented in 16 countries, most widely in the United States and Canada. In Canada, each province has a single payer health system with universal coverage and efforts to scale‐up eConsult are underway in several provinces, with over 75 000 eConsult cases completed across the country thus far. This provides a unique opportunity to understand the strategies used to support scale‐up of this type of innovation across a range of contexts. Our objective is to present the strategies used to scale‐up eConsult in multiple jurisdictions. STUDY DESIGN: We conducted a multiple case study, where the cases were four Canadian provinces at varying stages of scaling‐up eConsult (Ontario, Quebec, Newfoundland and Labrador and Manitoba). Our data sources include document review (e.g., meeting minutes, reports, websites, presentations), meeting observations where provincial scale‐up of eConsult is discussed (n = 26), semi‐structured interviews (n = 25) and focus groups (n = 2). We conducted deductive and inductive thematic analysis using Milat et al.’s scaling‐up conceptual framework (2016) to identify strategies and emerging themes. POPULATION STUDIED: Our study was conducted with key stakeholders (e.g., patients, family physicians, specialists, policy makers, decision makers) involved in the scaling‐up of eConsult in four Canadian provinces. PRINCIPAL FINDINGS: We identified 6 common strategies used to support scaling‐up of eConsult in Canada : (a) Linking eConsult to research has helped develop and improve the innovation (e.g., technological infrastructure), establishing rigorous evidence to support the rationale for scaling‐up provincially, and maintaining eConsult activities during the scaling‐up process through funding and other resources; (b) building on a “coalition of the willing” by engaging partners who believe in the innovation and are willing to support it; (c) having physicians (both primary care and specialists) lead and adapt the innovation to their practice contexts, and relying on physician champions to help spread and scale the innovation; (d) engaging patient partners to strengthen the case to scale‐up eConsult through compelling patient stories and help drive scaling‐up efforts; (e) creating a “buzz” by engaging stakeholders across Canada, getting endorsements from organizations with influence, holding an annual national eConsult policy forum, presenting at various events, and building on other provinces’ experiences and expertise to help catalyze scale‐up efforts; (f) keeping the innovation simple to avoid becoming side‐tracked by peripheral challenges thus facilitating widespread adoption by physicians. CONCLUSIONS: These strategies have been used in a range of contexts across Canada and are perceived by stakeholders as instrumental in scaling‐up efforts to date. The next step of this study is to foster cross‐level and cross‐jurisdictional knowledge exchange between key stakeholders. IMPLICATIONS FOR POLICY OR PRACTICE: This provides a new real‐world understanding of how stakeholders have tackled the challenges of scaling‐up eConsult and may be useful to inform future scaling‐up efforts for eConsult and similar innovations. PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research.

Aims To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada. Methods A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM. Results In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases. Conclusions One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.

Our objectives were to describe the use of pharmacological treatments in older adults with diabetes and to identify the factors associated with the use of a combination of hypoglycemic, antihypertensive and lipid-lowering agents. Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study among individuals aged 66&ndash, 75 years with diabetes in 2014&ndash, 2015. We described the number of medications and the classes of medications used and calculated the proportion of individuals using at least one medication from each of these classes: hypoglycemics, antihypertensives and lipid-lowering agents. We identified the factors associated with the use of this combination of treatments by performing robust Poisson regressions. The 146,710 individuals used an average of 12 (SD 7) different medications, mostly cardiovascular (91.3% of users), hormones, including hypoglycemic agents (84.5%), and central nervous system medications (79.8%). The majority of individuals (59%) were exposed to the combination of treatments and the factor most strongly associated was the presence of cardiovascular comorbidities (RR: 1.29, 99% CI: 1.28&ndash, 1.31). Older individuals with diabetes are exposed to a large number of medications. While the use of the combination of treatments is significant and could translate into cardiovascular benefits at the population level, the potential risk associated with polypharmacy needs to be documented.

BackgroundNon-optimal medication use among older adults is a public health concern. A concrete picture of potentially inappropriate medication (PIM) use is imperative to ensure optimal medication use.ObjectiveTo assess the prevalence of PIMs in community-dwelling older adults and identify associated factors.MethodsA retrospective population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System (QICDSS). The QICDSS includes data on drug claims for community-dwelling older adults with chronic diseases or at risk of developing chronic diseases aged ≥65 years who are insured by the public drug insurance plan. Individuals aged ≥66 years who were continuously insured with the public drug plan between 1 April 2014 and 31 March 2016 were included. PIMs were defined using the 2015 Beers criteria. We conducted multivariate robust Poisson regression analyses to explore factors associated with PIM use.ResultsA total of 1 105 295 individuals were included. Of these, 48.3% were prescribed at least one PIM. The most prevalent PIMs were benzodiazepines (25.7%), proton-pump inhibitors (21.3%), antipsychotics (5.6%), antidepressants (5.0%) and long-duration sulfonylureas (3.3%). Factors associated with PIM exposure included being a woman [rate ratio (RR): 1.20; 95% confidence interval (CI): 1.20–1.21], increased number of medications and having a high number of chronic diseases, especially mental disorders (RR: 1.50; 95% CI: 1.49–1.51).ConclusionAlmost one out of two community-dwelling older adults use a PIM. It is imperative to reduce the use of PIMs, by limiting their prescription and by promoting their deprescribing, which necessitates not only the active involvement of prescribers but also patients.

The use of multiple medications is rising steadily among older individuals, but little is known about the impact of polypharmacy at a population level, both over time and across countries. Surveillance of polypharmacy is required to overcome these gaps. There currently exists no standard population indicator of polypharmacy. The objective of this survey was to query expert opinion on establishing a gold standard method for polypharmacy surveillance at the population level. We invited 71 experts in geriatrics, pharmacoepidemiology, pharmacology and surveillance to respond to an Internet-based survey. Participants were asked to rate their degree of agreement on statements related to the definition of polypharmacy, the goals of polypharmacy surveillance and knowledge transfer issues. Consensus was reached when 70 % of participants either strongly or moderately agreed with the statements. Qualitative content analysis was performed on optional comments provided by the participants. Thirty individuals (42 %) completed the survey. Consensus was reached on most items. However, there was no agreement on a quantitative indicator of polypharmacy. Participants resolved that the indicator include a quality component, and that levels of polypharmacy be created. Defining exposure also proved problematic: cumulative (e.g. total annual number) and/or simultaneous (concomitant) prescriptions could be considered. A gold standard indicator of polypharmacy should include both quantity and quality. There is a need to better inform the relevant outcomes of polypharmacy, to identify the most appropriate threshold(s) and quality measure(s) of interest to decision makers.

The Clock Drawing Test (CDT) is frequently used to screen for cognitive impairment, however, normative data for Rouleau et al.'s scoring system are scarce. The present study aims to provide norms for Rouleau et al.'s scoring system that are tailored to Quebec French-speaking mid- and older aged healthy adults.Six researchers from various research centers across the Province of Quebec (Canada) sent anonymous data for 593 (391 women) healthy community-dwelling volunteers (age range: 43-93 years; education range: 5-23 years) who completed the CDT 'drawing on command' version. This command version (setting the clock hands to 11:10, without a pre-drawn circle) was administrated as part of a more extensive neuropsychological assessment, or along with cognitive screening instruments. Each drawn clock was scored according to the quantitative criteria set by Rouleau et al.'s scoring system.CDT scores were significantly correlated with age (r(592) = -.132, p = .001) and years of education (r(592) = .116, p = .005), but not with sex (r(592) = .065, p = .112). Since data were skewed towards higher test scores, the percentiles method was used for analysis. Percentile ranks stratified by age and education are presented.These normative data for Rouleau et al.'s scoring system will contribute towards adequately screening for cognitive decline in Quebec French-speaking healthy adults, by also taking into account individual characteristics such as age and education.

In this article, we compare the characteristics of workplace-provided training and its effects on wages in Quebec with other Canadian provinces. It is widely argued that training tends to be under-provided by employers. The institutions of training provision vary across Canada. Quebec is most distinct. With Law 90, it attempted to address what was seen as a distinctly severe problem of under-supply; it required that firms invest a specified proportion of their sales in training or turn over the difference between what they spent and the specified proportion to the government. We use data from the Workplace and Employee Survey to explore the possible effects of this measure. There are differences between Quebec and the other provinces in the incidence of on-the-job and formal training, and in the relations between training and the wage rate. In Quebec, the incidence of on-the-job training is distinctly low and the use of external training providers distinctly high. We suggest that these outcomes are encouraged by Law 90, which encourages employers to use readily documentable forms of training. We also find that the association between on-the-job training and the wage rate is much stronger in Quebec than in the comparator provinces. We argue that this is probably because, being less abundantly provided, on-the-job training is likely to be provided to employees who, on average, are more talented than their counterparts in the rest of Canada. We set our discussion of the possible effects of Law 90 in the context of a broader consideration of the relation between institutions and training choices and outcomes, including international comparison., Cet article vise à comparer les caractéristiques de la formation offerte dans les entreprises et leurs impacts sur les salaires des employés au Québec et dans les autres provinces canadiennes. Au Canada, comme dans de nombreux pays industrialisés, l’une des préoccupations majeures dans le dossier de la formation continue est le sous-investissement des entreprises. Le contexte institutionnel canadien de la formation en entreprise diffère d’une province à l’autre et le Québec se distingue, entre autres, par l’adoption d’une loi en 1995, appelée « loi 90 », exigeant de la part des entreprises assujetties d’investir annuellement dans le développement de la formation de leur main-d’oeuvre. Dans une perspective comparative, nous examinons les effets potentiels de cette mesure obligatoire de financement en formation. Nos analyses sont fondées sur un ensemble de micro-données longitudinales sur les milieux de travail canadiens et leurs employés. Des différences provinciales sont observées dans la formation structurée et en cours d’emploi, ainsi que sur l’impact de l’investissement sur les salaires. Au Québec, nous observons une incidence plus faible de la formation en cours d’emploi pour laquelle nous pensons que les dépenses sont plus difficilement justifiables dans le cadre de la loi. Les résultats indiquent également une tendance plus forte au Québec à recourir à des formateurs externes qu’ailleurs au Canada et ils mettent aussi en évidence des retombées plus élevées de la formation en cours d’emploi sur les salaires dans cette province, tandis que les effets engendrés par la formation structurée sont de tailles similaires à travers les provinces et les régions. Nous discutons des résultats en regard des différences provinciales et de leur environnement institutionnel, ainsi que des expériences internationales de politiques gouvernementales en matière de formation continue. Nous posons certaines hypothèses quant à l’impact plus élevé de la formation en cours d’emploi sur les salaires observé au Québec comparativement aux autres provinces., Este artículo pretende comparar las características de la formación dispensada en las empresas y sus impactos sobre los salarios de empleados del Quebec y en las otras provincias canadienses. En Canadá, como en números países industrializados, una de las preocupaciones mayores en el folio de la formación continua es la sub-inversión de las empresas. El contexto institucional canadiense de la formación en empresa difiere de una provincia a otra y el Quebec se distingue, entre otros, por la adopción de una ley en 1995, llamada «ley 90», que exige a las empresas sujetas a dicha ley de invertir anualmente en el desarrollo de la formación de su respectiva mano de obra. En una perspectiva comparativa, se examina los efectos potenciales de esta medida obligatoria de financiamiento de la formación. Nuestros análisis son basados en un conjunto de micro-datos longitudinales sobre los lugares de trabajo canadienses y sus empleados. Se observan diferencias provinciales en la formación estructurada y en la formación durante el empleo, así como sobre el impacto de la inversión sobre los salarios. En Quebec, se observa una incidencia más débil de la formación durante el empleo por la cual nosotros pensamos que los gastos son más difícilmente justificables en el marco de la ley. Los resultados indican también una tendencia más fuerte en Quebec a recurrir a formadores externos comparativamente al resto de Canadá y ponen en evidencia los impactos más elevados de la formación durante el empleo sobre los salarios de esta provincia, mientras que los efectos engendrados por la formación estructurada son de talla similar a través las provincias y las regiones. Se discuten los resultados en relación con las diferencias provinciales y su entorno institucional, e igualmente con relación a las experiencias internacionales de políticas gubernamentales en materia de formación continua. Se plantean ciertas hipótesis en cuanto al impacto más elevado de la formación durante el empleo sobre los salarios, tal que observado en Quebec comparativamente a las otras provincias.

Un examen de l’efficacité de la formation complémentaire pour les interviewers d’enquêtes téléphoniques : Cet article présente une expérience faite à l’agence d’enquêtes responsable pour l’enquête canadiennne de 2004 sur la consommation de drogues (N=14.000) après une courte séance de formation cognitive. Un total de 79 intervieweurs y ont participé représentant 2.436 journées-intervieweur de travail, avec des intervieweurs travaillant un maximum de 65 jours : l'enquête de terrain a duré 109 jours. Nous avons conçu une séance d’une heure centrée sur l’acquisition des connaissances dans deux secteurs : l'échantillonnage et la sélection dans le foyer d'une part, et les raisons de refus d'autre part. L’évolution quotidienne des performances des intervieweurs, dont les trajectoires basés sur des groupes ont été analysées, nous ont permis d’identifier les intervieweurs à performances basses (n=25) et hautes (n=42) deux semaines avant la formation. La séance de formation était à l’intention des intervieweurs à performances basses ou des nouveaux intervieweurs. Parmi ces intervieweurs, tous ceux qui travaillaient le jour de la séance (n=18) ont participé à l'une des trois séances de formation. Les retombées de la formation ont été évaluées dans trois secteurs : connaissances acquises et attitudes (via une questionnaires rempli deux semaines plus tard), rétention de connaissances et performances. Les résultats montrent pour les intervieweurs participants (a) qu’ils trouvaient que la formation les avaient aidés à comprendre l’échantillonnage et les raisons de refus, (b) qu'ils sentaient plus que les intervieweurs à hautes performances que leur performances s'étaient améliorées depuis le début du projet, (c) qu'ils avaient tendance à continuer plus longtemps à travailler sur les projet qu’un groupe de contrôle, et (d) qu'ils ont amélioré leur performance de .04 par jour après la formation, par rapport à.015 par jour avant la formation, atteignant presque la performance des intervieweurs à hautes performance This article presents an experiment in which a short cognitive training session was given at the private pollster conducting the 2004 Canadian Addiction Survey of 14,000 people. Overall, 79 interviewers worked on the project for a total of 2,436 interviewer-days, interviewers worked a maximum of 65 days, and the survey was in the field for 109 days. We devised a one-hour training session that focused on knowledge acquisition in two areas: sampling and selection within household, and reasons for refusals. The evolution of interviewers’ daily performance, analyzed using group-based trajectory analysis, allowed us to identify low (n=25) and high (n=42) performers two weeks before training. The training session was aimed at low performers and newly hired interviewers. Among these, all the interviewers working on training day (n=18) attended one of the three training sessions. The impact of the training was assessed in three areas: knowledge acquisition and attitudes (through a post-training questionnaire two weeks later), retention, and performance. The results show that trained interviewers a) felt that the training helped them understand sampling and the reasons for refusals b) were more likely than high performers to feel that their performance had improved since the beginning of the project, c) were likely to go on working on the project after training longer than the control group, and d) improved their performance by .04 per day after training, compared with .015 per day before training, almost reaching the performance of high performers.

e19126 Background: Lepidic bronchioalveolar adenocarcinomas (LBA) are tumors with historically longer survival and a good response rate to EGFR TKIs, as they are more frequently associated with EGF...