2 Minute Medicine Rewind September 20 – September 27, 2015
Primary care has an important economic impact on the health care system. Different models exist each with their own advantages and disadvantages on costs and health outcomes. Using population-based administrative data, the authors evaluated team-based capitation, non-team based capitation or enhanced fee-for-service models on the monitoring of diabetes and screening for cervical, breast and colorectal cancer between 2001 and 2011 in Ontario, Canada to understand the effect of each type of primary care model on the management and prevention of chronic diseases in Canada. The authors found that in 2011, patients enrolled in a team-based capitation setting were more likely to receive diabetes monitoring(39.7% vs 31.6%, adjusted relative risk [RR] 1.22, 95% confidence interval [CI]1.18 to 1.25), mammography (76.6% vs 71.5%, adjusted RR 1.06, 95% CI 1.06 to 1.07) and colorectal cancer screening (63.0% vs 60.9%, adjusted RR 1.03, 95% CI 1.02 to 1.04)compared to those in an enhanced fee-for-service setting.Over time teach based capitation experienced the greatest improvement in diabetes monitoring (absolute difference in improvement 10.6% compared with enhanced fee-for-service 6.4%, compared with non–team-based capitation) and cervical cancer screening (absolute difference in improvement 7.0% compared with enhanced fee-for-service 5.3%). For breast and colorectal cancer screening there were no significant differences in change over time between the different models. Therefore, the results provide evidence that capitation payment models in Ontario, Canada are associated with moderate improvements in diabetes care, however their effects on cancer screening (specifically for breast and colorectal cancer) are less clear.
Genetics plays an important role in the etiology of anxiety disorders as children of anxious parents have an increased risk of developing an anxiety disorder. The authors examined the efficacy of family-based intervention in preventing the development of an anxiety disorder in children of parents with anxiety disorders. In this randomized controlled trial, families (parent meeting DSM-IV criteria for anxiety disorder and one child 6-13 years old without anxiety disorder) were randomly assignedto the family-based intervention or to an information-monitoring control condition. The primary outcome was incidence of any anxiety disorder and secondary outcome was anxiety symptom severity (assessed using the Anxiety Disorders Interview Schedule for Children) at 12 months. The authors found the incidence of child anxiety disorders was 31% in the control group and 5% in the intervention group (odds ratio=8.54, 95% CI=2.27, 32.06). At 1-year follow-up, the control group had higher anxiety symptoms ratings. Importantly the number needed to treat was 3.9 at 12 months. Of the moderators used in the study (i.e. child age, child gender, parent gender, parent comorbidity, parent-child gender match, and baseline child an parent anxiety level), the child’s baseline level of anxiety was a significant moderator. Of the mediators used (i.e. global parental psychopathology, parental anxiety severity, parental modeling of anxiety, and child maladaptive cognitions), the parental distress was the only significant mediator. Therefore, this intervention program was able to significantly reduce the incidence at 1-year of anxiety disorders in families with parental anxiety disorders.
Perihematomal edema (PHE) is a radiological manifestation of injury from an intracerebral hemorrhage (ICH). Given our understanding of the pathophysiology of PHE, it is typically associated with poor outcomes. The authors used data from the Virtual International Stroke Trials Archive to study the effect of PHE volume expansion in the first 72 hours and its relationship with functional outcome. A total of 596 patients were included in the study. Median baseline hematoma volume was 15.0 mL (IQR, 7.9–29.2) and median baseline PHE volume was 8.7 mL (IQR, 4.5–15.5). Median volume expansion in the first 72 hours was 14.7mL and the odds of poor outcome (based on modified Rankin Scale score of greater than 3) were greater with increasing expansion in the first 72 hours (OR, 1.78; CI, 1.12–2.64 per mL increase). Particularly with basal ganglia ICH, rather than lobar ICH (in which there was no relationship between volume expansion in first 72 hours and outcomes in lobar ICH patients), poor outcomes were associated with increasing expansion in the first 72 hours. These results suggest that subcortical hematomas and ICHs with hematoma volume <30 cc may represent an optimal target for interventions designed to reduce secondary injury in ICH.
Association Between Atrial Fibrillation and Dementia in the General Population
There are multiple proposed mechanisms that may explain the association between atrial fibrillation (AF) and dementia, which include the incidence of stroke, chronic cerebral hypoperfusion, and overlapping risk factors. Despite the association between these two diseases, longitudinal studies have shown inconsistent results. The purpose of this study was to determine the effect of AF burden on future risk of developing dementia. The authors investigated the association of prevalent and incident AF with incident dementia from 1989 to 2010 in 6514 dementia free participants. They also investigated whether this associated varied according to duration of exposure. They found that15.3% AF patients developed incident dementia. Prevalent AF was related to an increased risk of dementia (RR 1.33; CI 1.02-1.73). Newly diagnosed AF was associated with an increased risk of dementia in younger participants (<67 years: 1.81; 1.11-2.94 vs >67 years: 1.12; 0.85-1.46; P = .02). The risk of dementia was strongly associated with duration of exposure to AF in the younger participants. Therefore, AF is associated with increased risk of dementia, independent of stroke risk, and was strongest for younger individuals with greatest AF burden.
Intravascular Complications of Central Venous Catheterization by Insertion Site
Insertion of central venous catheters (CVC) into either the subclavian, jugular or femoral veins are associated with thrombotic, infectious or mechanical complications. The authors hypothesized that the risks of these complications for patients admitted to the intensive care unit would differ based on insertion location. They conducted a multicenter study in 3027 patients to evaluate this hypothesis. The primary outcome measure was a composite of bloodstream infection and symptomatic deep-vein thrombosis. They found that there fore 8 primary outcomes events in the subclavian insertion site, 20 in the jugular insertion site and 22 in the femoral insertion site (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). Comparing the femoral insertion side group to the subclavian group, there were significantly higher adverse events in the femoral insertion site group (hazard ratio, 3.5;95% confidence interval [CI], 1.5 to 7.8; P=0.003). Adverse events were also significantly higher in the jugular group compared to the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04). Comparing the two groups with the greatest events, the risk in the femoral group was similar to that in the jugular group (hazard ratio,1.3; 95% CI, 0.8 to 2.1; P=0.30). However, pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions. Therefore, although the risk of bloodstream infection and symptomatic thrombosis was lower in the subclavian group, it was associated with a higher risk of pneumothorax.
Image: PD
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