Population-based Health Care Research Articles

Effect of Sedatives on In-hospital and Long-term Mortality of Critically Ill Patients Requiring Extended Mechanical Ventilation for ≥ 48 Hours.

BackgroundThe purpose of this study was to assess the correlation between sedatives and mortality in critically ill patients who required mechanical ventilation (MV) for ≥ 48 hours from 2008 to 2016.MethodsWe conducted a nationwide retrospective cohort study using population-based healthcare reimbursement claims database. Data from adult patients (aged ≥ 18) who underwent MV for ≥ 48 hours between 2008 and 2016 were identified and extracted from the National Health Insurance Service database. The benzodiazepine group consisted of patients who were administered benzodiazepines for sedation during MV. All other patients were assigned to the non-benzodiazepine group.ResultsA total of 158,712 patients requiring MV for ≥ 48 hours were admitted in 55 centers in Korea from 2008 to 2016. The benzodiazepine group had significantly higher in-hospital and one-year mortality compared to the non-benzodiazepine group (37.0% vs. 34.3%, 55.0% vs. 54.4%, respectively). Benzodiazepine use decreased from 2008 to 2016, after adjusting for age, sex, and mean Elixhauser comorbidity index in the Poisson regression analysis (incidence rate ratio, 0.968; 95% confident interval, 0.954–0.983; P < 0.001). Benzodiazepine use, older age, lower case volume (≤ 500 cases/year), chronic kidney disease, and higher Elixhauser comorbidity index were common significant risk factors for in-hospital and one-year mortality.ConclusionIn critically ill patients undergoing MV for ≥ 48 hour, the use of benzodiazepines for sedation, older age, and chronic kidney disease were associated with higher in-hospital mortality and one-year mortality. Further studies are needed to evaluate the impact of benzodiazepines on the mortality in elderly patients with chronic kidney disease requiring MV for ≥ 48 hours.

A Study on the Applicability of the Population-Based Health Care Model: Focusing on Social Cooperative-type Medical Clinics in a Local Area

A Study on the Applicability of the Population-Based Health Care Model: Focusing on Social Cooperative-type Medical Clinics in a Local Area

Suicide Prevention in Older Adults: Evidence-Based Approaches for Care

Suicide in older adults is a major public health concern. Data of suicide rates of older adults from the Centers for Disease Control suggests that suicide is more frequent in older adults and warrants further examination of treatment and public health prevention approaches. Risk factors for suicide in the elderly include functional disability, multiple chronic physical conditions, and social isolation. Several advances have been made in healthcare policy to address practical, evidence-based approaches to preventing suicide and treating behavioral health conditions such as depression, including collaborative care and the Zero Suicide model. This symposium will focus on reviewing the epidemiology and evidence-based approaches for suicide prevention and mental health treatment for older adults. In this presentation, the presenters describe the current trends in suicide rate in older adults in the United States, indicate risk factors (both modifiable and non-modifiable), and present about the collaborative care and Zero Suicide models. Speakers will emphasize the role of these two models in suicide prevention and population-based behavioral healthcare. The presenters will also highlight examples of policy changes and provide recommendations for regulators and hospital systems to adopt these evidence-based models of care for caring for older adults at risk for suicide.

Characteristics of a population-based multiple sclerosis cohort treated with disease-modifying drugs in a universal healthcare setting

ABSTRACT Background: Relatively little is known about the use of disease-modifying drugs (DMDs) for multiple sclerosis (MS) in the population-based universal healthcare setting. This study aimed to describe the characteristics of a population-based cohort with MS and their DMD exposure in four Canadian provinces. Methods: We identified all adults (aged ≥18 years) with MS using linked population-based health administrative data. Individuals were followed from the most recent of their first MS or demyelinating event or 1 January 1996(study entry), to the earliest of death, emigration, or 31 March 2018(study end). Cohort characteristics examined included sex, age, socioeconomic status, and comorbidity burden. Results: Overall, 10,418/35,894 (29%) of MS cases filled a DMD prescription during the 22-year study period. Most were women (n = 7,683/10,418;74%), and 17% (n = 1,745/10,418) had some comorbidity (Charlson Comorbidity Index≥1) at study entry. Nearly 20% (n = 1,745/10,418) were aged ≥50 when filling their first DMD; the mean age was 39.6 years. Conclusions: Almost 1 in 6 people with MS had at least some comorbidity, and nearly 1 in 6 were ≥50 years old at the time of their first DMD. As these individuals are typically excluded from clinical trials, findings illustrate the need to understand the harms and benefits of DMD use in these understudied groups.

Peripheral Arterial Disease Among First Nations People with Diabetes in Ontario, Canada: Linkage of Population-Level Healthcare Data

IntroductionIndigenous people worldwide are overrepresented and adversely effected by diabetes. Peripheral arterial disease and amputation are among the most feared complications of diabetes, leading to profound impacts on patients’ quality of life. This study linked population-level healthcare data to assess the risk of peripheral arterial disease among First Nations people in Ontario with diabetes.&#x0D; Objectives and ApproachWe linked individual-level population-based healthcare administrative datasets with the Indian Register. The latter provides information on all registered or Status First Nations people in Canada. We compared First Nations people with diabetes with other people in Ontario with diabetes . Age and sex-adjusted rates peripheral revascularization procedures and lower-extremity amputations were calculated for each 12-month period from April 1, 1995, to March 31, 2015. Mortality among those with amputation was determined.&#x0D; ResultsFirst Nations people received revascularization procedures at a comparable rate to other people in Ontario. However, they had lower-extremity amputations at 3- to 5-times the frequency of other Ontario residents. First Nations people had increased mortality after lower-extremity amputation (adjusted hazard ratio 1.15, 95% confidence interval 1.05 to 1.26), with median survival of only 3.5 years.&#x0D; Conclusion / ImplicationsFirst Nations people with diabetes in Ontario had a comparable rate of revascularization but a markedly increased risk for lower-extremity amputation compared to other people in Ontario. This discordance suggests that peripheral arterial disease may be underdiagnosed or undertreated among First Nations people in Ontario, and demonstrates an important health inequity faced by First Nations people.

Frailty Is Associated with Increased One-Year Mortality in Patients with Newly Diagnosed Diffuse Large-B-Cell Lymphoma: A Population-Based Study

Introduction: Previous studies have demonstrated that frailty is associated with mortality among patients with non-Hodgkin lymphoma including diffuse large B-cell lymphoma (DLBCL). However, no studies have examined frailty in an unselected population-based sample of patients with DLBCL, nor have data on health care utilization been considered as a potential mediator of this relationship. Objective: To determine whether frailty is associated with one-year survival in an unselected population of patients with DLBCL, and examine whether its impact is mediated by health care utilization during chemotherapy treatment. Methods: A retrospective cohort study was conducted using population-based health care data in Ontario, Canada. Patients &amp;gt;65 years diagnosed with DLBCL or transformed follicular lymphoma between January 2006 and December 2017 and receiving first-line chemo-immunotherapy were included. Frailty was defined by modifying a previously validated score developed for use with population-based data in Ontario, comprising 30 multidimensional variables (McIsaac, Ann Surg. 2019;270(1):102-108). Patients were categorized as "frail" (score &amp;gt;0.21) vs. "non-frail" (score ≤0.21). Covariates included age, number of comorbidities based on the Johns Hopkins Aggregated Diagnosis Groups (ADGs), and health care utilization during chemotherapy (defined as emergency department (ED) visit or inpatient hospitalization not resulting in death during treatment, and analysed as a time-varying covariate). Cox regression was performed to examine the association between frailty and one-year mortality (primary outcome). Secondary outcomes included health care utilization, chemo-immunotherapy exposure, and cause of death. Results: 5,527 patients were included in the study. 5,216 patients (94%) had de novo DLBCL, and 311 (6%) of patients had transformed follicular lymphoma. The median age was 75 years (IQR 70-80), and 48% (N=2672) were female (Table 1). 2,699 (49%) of patients were classified as frail (Table 2). Frail patients tended to be older (median age 76 (IQR 71-81) vs. 74 years (IQR 70-79)). The difference in mortality between frail and non-frail patients was most pronounced in the initial year following start of treatment (Figure 1a). Within 90 days of first-line rituximab, 14% (N=370) of frail vs. 7% (N=185) of non-frail patients had died (p&amp;lt;0.0001). Within one-year of first-line treatment, 32% (N=868) of frail patients had died compared to 20% (N=553) of non-frail patients (unadjusted HR 1.8, 95% CI 1.6-2.0, p&amp;lt;0.0001, Figure 1b). Among frail patients who died within 1 year (N=868), 34% (N=298) had only received 1 cycle of chemotherapy. In multivariable modelling controlling for age, number of ADG comorbidities, and health care utilization during chemotherapy, frailty (binary exposure) remained independently associated with one-year mortality (adjusted HR 1.6, 95% CI 1.5-1.8, p&amp;lt;0.0001). The relationship between frailty and survival remained consistent when measured in quartiles (HR 1.6 (95% CI 1.3-1.9) for Q2, 2.0 (95% CI 1.7-2.4) for Q3, 2.7 (95% CI 2.3-3.2) for Q4, p&amp;lt;0.0001, Figure 1b). Frail patients were significantly more likely to receive only 1 cycle of chemotherapy than non-frail patients (14% vs. 7%, p&amp;lt;0.0001). Frail patients also had higher health care utilization during chemotherapy (mean ED visits 0.75 + 1.47 vs. 0.59 + 1.17, p&amp;lt;0.001; mean hospitalizations 0.9 + 1.12 vs. 0.72 + 1.05, p&amp;lt;0.001). Frail patients were also more likely to die of DLBCL (38.3 vs. 29%, p&amp;lt;0.0001). Conclusion: Frailty is significantly associated with one-year mortality in patients with newly diagnosed DLBCL, even after adjusting for age, comorbidities, and health care utilization. Frailty appears to be associated with poor tolerability of chemotherapy and a higher likelihood for requiring acute hospital-based care, and future analyses will explore whether this is related to patients suffering increased treatment-related toxicity. Future analyses of these data will also address whether frail patients who die within one-year of first-line treatment have different clinical characteristics compared to frail patients who survive beyond one year. Future prospective studies may help clinicians understand whether any frailty-related variables are modifiable and the role of alternative treatment strategies for vulnerable patients. Disclosures Prica: astra zeneca: Honoraria; seattle genetics: Honoraria; Gilead: Honoraria.

Complementary Use of U.S. FDA's Adverse Event Reporting System and Sentinel System to Characterize Direct Oral Anticoagulants-Associated Cutaneous Small Vessel Vasculitis.

Cutaneous small vessel vasculitis (CSVV) has been reported after exposure to direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban. We used the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) to describe clinical characteristics associated with CSVV among DOAC-exposed patients. Furthermore, we characterized this signal in the Sentinel System to relate the clinical data from the individual FAERS cases to population-based electronic healthcare data. We queried FAERS for all cases of CSVV associated with DOACs from U.S. approval date of each DOAC through March 16, 2018. Within the Sentinel System, we identified incident CSVV cases using ICD-9 and ICD-10 diagnosis codes among adults aged≥30years who received a DOAC in the prior 90days between January 1, 2010, and June 30, 2018. We excluded patients with evidence of select autoimmune diagnoses in the 183days prior to their CSVV diagnoses and reported patient characteristics in the 183-day period prior to CSVV diagnoses. In FAERS, we identified 50 cases of CSVV reported with rivaroxaban (n=26), apixaban (n=14), dabigatran (n=9), and edoxaban (n=1). Approximately 50% of the cases reported time to onset within 10days after DOAC exposure. When specified, the predominant type of CSVV reported was leukocytoclastic vasculitis (n=31), followed by Henoch-Schonlein purpura (n=4). Hospitalization occurred in most of the cases (n=37). Switching of the offending agent after the development of CSVV was reported (n=26). Three rivaroxaban (n=3) cases and one dabigatran case (n=1) reported positive rechallenge. In the Sentinel system, we identified 3659 CSVV cases with prior DOAC exposure, with 85% of events occurring within 10days. The assessment of FAERS cases, combined with the temporal clustering of the Sentinel System cases suggest a possible causal relationship of DOACs and CSVV. Future efforts should characterize the risk of CSVV among the various DOAC users.

Epidemiology of potassium derangements among chronic cardiovascular, metabolic and renal conditions: a population-based analysis data from more than 375,000 individuals

Abstract Introduction In patients with chronic cardiovascular, metabolic and renal disorders, potassium (K)+ homeostasis is often delicate, especially in the presence of renin-angiotensin-aldosterone system inhibition (RAASI) and/or diuretic therapies. In this context, current clinical practical guidelines for the management of these patients recommend close monitoring of renal function and K+ levels, particularly in the presence of drug titration. Nevertheless, very limited epidemiological data on their importance at a population level is available. Purpose The objectives of the present analysis are to estimate the prevalence of potassium (K+) derangements in five key chronic cardiovascular, metabolic and renal conditions at the population level, its use of RAASI medication and describe potassium derangements among RAASI users. Methods We used data from more than 375,000 individuals 55 years of age or older included in the population-based healthcare database of a public Institute of Health between 2015 and 2017. The conditions of interest were chronic heart failure (CHF), chronic kidney disease (CKD), diabetes mellitus (DM), ischemic heart disease (IHD), and hypertension (HTN). RAASI medications included angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs), and rennin inhibitors. Hyperkalemia was defined as K+ levels &amp;gt;5.0 mEq/L and hypokalemia as K+ &amp;lt;3.5 mEq /L Results The prevalence of chronic cardiovascular, metabolic and renal conditions was high, particularly of HTN (48.2–48.9%). The prevalence of hyperkalemia was ranging between 10% and 25% depending of the condition, more frequent in CKD and less frequent in HTN patients. In figure, we display the prevalence of hyperkalemia among individuals with each of the relevant chronic conditions, January 1st, 2016 and January 1st, 2017. Use of at least one RAASI medication was very prevalent in HTN patients (75.2–77.3%). Among RAASI users, the frequency of K+ derangements and mainly of hyperkalemia was very noticeable (12% overall), especially in patients with CKD, CHF, elderly individuals, and users of MRAs. Hypokalemia was less frequent (1%). Conclusion The high prevalence of K+ derangements and predominantly hyperkalemia among RAASI users highlights the real-world relevance of K+ derangements and the importance of close monitoring and management of K+ levels in routine clinical practice. This is likely to benefit a large number of patients, particularly those at higher risk. Figure 1. Prevalence of hyperkalemia Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Josep Comin-Colet and Miguel Cainzos-Achirica have participated in other research projects funded by unrestricted grants from Vifor Pharma

A population-based analysis in 375,233 cases of heart failure stages A, B and C. Real world epidemiology of prevalence and temporal trends in South-European populations

Abstract Background Prevalence of congestive heart failure (CHF) and predisposing conditions has described previously. Most of these studies evaluated centre-European or north-American populations. However, the prevalence and evolutionary changes of Heart Failure stages A, B and C has not been fully elucidated in Mediterranean cohorts. Purpose To estimate the prevalence of CHF (HF Stage C) and four additional key chronic cardiovascular, metabolic and renal conditions predisposing to the development of CHF (HF Stages A and B) at a population level in a south-European healthcare area. We analysed the evolutionary changes in the prevalence in these five conditions. Methods In a healthcare area of 1,3Millions inhabitants, we extracted health related information of all individuals ≥55 years old. We analysed data of 375,233 individuals included in the population-based healthcare database of a public Institute of Health between 2015 and 2017. The conditions of interest were CHF, chronic kidney disease (CKD), diabetes mellitus (DM), ischemic heart disease (IHD) and hypertension (HTN). Results The prevalence of chronic conditions was high, particularly of HTN (48.2–48.9%) and DM individuals (14.6–14.8%). The other conditions were less frequent, with prevalence around 2–4% for IHD, 5–9% for CKD and 2–4% for CHF (Table). However, the less frequent conditions had a striking upward trend with over 1,500 new prevalent cases per year between 2015 and 2017 for CHF (45% relative increase), more than 2,500 new prevalent cases for IHD (67% relative increase) and more than 4,000 new prevalent cases per year for CKD (44% relative increase). Conclusion In this south European cohort, there were a high prevalence of HTN and DM as risk factors and a significant trend of increasing prevalence in high cost chronic conditions such as CHF, IHD and CKD. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The present study was funded by an unrestricted research grant from Vifor Pharma.

One Size Does Not Fit All: Diabetes Prevalence Among Immigrants of the South Asian Diaspora.

The risk of diabetes is higher in South Asians compared to the general population. As a result of migration during the twentieth-century postindependence, the South Asian diaspora is incredibly vast. We examined the diabetes prevalence between groups of the South Asian diaspora based on their distinct migration patterns. Population-based health care and immigration administrative data were used to compare crude and standardized diabetes prevalence between immigrants from nine regions of the South Asian diaspora and the non-immigrant population. Diabetes prevalence across groups were also stratified by gender. There were 199,003 South Asian immigrants; 33,882 (crude prevalence of 17.0%) of whom had a diagnosis of diabetes. The nine subgroups varied significantly in the prevalence of diabetes after adjusting for age, sex and income: Sri Lanka 24.3%, Pakistan 22.2%, Fiji 21.5%, Bangladesh 20.7%, the Caribbean 20.4%, India 16.0%, East Africa 13.8%, South Africa 10.8%, and the Middle East 9.6% in comparison to the non-immigrant population 17.8%. Higher prevalence was evident among men compared with women in each subgroup with the exception of Pakistan.Diabetes prevalence is not uniform among South Asians. Our findings highlight potential impacts of their unique migration histories on the risk and burden of diabetes, and move beyond a one size fits all approach in the South Asian population of Ontario to develop targeted interventions.

21.G. Round table: Strengthening national level health systems governance

Abstract Very often, important health system reforms are delayed, rendered ineffective or they simply go badly wrong. All too often this happens not because of a lack of money, health workers or health care facilities but because we adopt unfit ideas and decision and/or implement them insufficiently. The incapacity to develop, adopt and implement good decision is quintessentially the definition of bad governance. If we are to develop our health systems towards Universal Health Coverage and health systems performance improvement, we will need to strengthen our health system governance. Governance is vitally important to health systems reform and refers to how decisions are made and implemented - everything from the ability of policy-makers to take evidence-based and relevant decisions to their ability to implement policies and create alignment between different actors. In this workshop we will share experiences from a governance spring course for policy makers from Eastern Europe and Central Asia. Connected to this we will also share preliminary results of a study on National Level Health Systems Governance. The panelists will address five key issues The contribution of governance to Universal Health Coverage. This contribution will focus on a) the concept of governance defined as the way societies make and implement collective decisions and b) its 5 main domains including transparency, accountability, participation, integrity and capacity. (S Greer)Governance improvement needs in Eastern Europe and Central Asia: experiences from working with policy makers including countries like Azerbaijan, Georgia, Kyrgyzstan, Moldova Tajikistan, Ukraine and Uzbekistan. For purpose of peer-learning and contrasting experiences we have paired these countries with policy makers from Austria, Finland and Ireland (G Pastorino)Stakeholder participation in decision making and implementation: Very often, powerful stakeholders, like the medical profession, is over-represented and exerts immense veto power, while the voice of other professions, patients, and citizens remained unheard. What are the governance strategies and instruments to harness those underrepresented stakeholders for Universal Health Coverage? (G Fattore)Governing centralized and decentralized budgets in primary, social and hospital care: population-based health care in larger countries requires decentralization of part of the health care budget. What are the accountability lines and instruments that ensure that regional and local budget holders aligning with national policies for Universal Health Coverage? (L Hawkins)Governance contribution addressing corruption: According to surveys health systems are perceived prone to corruption. What is the contribution of governance to heal corruption and make the system work according to rules? (D Clarke) Key messages If we are to make progress towards Universal Health Coverage, we will need to strengthen health systems governance. Without strengthening health systems governance we will fail to manage stakeholders, budgets and corruption.

Real-World Epidemiology of Potassium Derangements Among Chronic Cardiovascular, Metabolic and Renal Conditions: A Population-Based Analysis.

BackgroundThe aims of the present analysis are to estimate the prevalence of five key chronic cardiovascular, metabolic and renal conditions at the population level, the prevalence of renin–angiotensin–aldosterone system inhibitor (RAASI) medication use and the magnitude of potassium (K+) derangements among RAASI users.Methods and ResultsWe used data from more than 375,000 individuals, 55 years of age or older, included in the population-based healthcare database of the Catalan Institute of Health between 2015 and 2017. The conditions of interest were chronic heart failure (CHF), chronic kidney disease (CKD), diabetes mellitus, ischemic heart disease and hypertension. RAASI medications included angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs) and renin inhibitors. Hyperkalemia was defined as K+ levels >5.0 mEq/L and hypokalemia as K+ <3.5 mEq/L. The prevalence of chronic cardiovascular, metabolic and renal conditions was high, and particularly that of hypertension (prevalence ranging from 48.2% to 48.9%). The use of at least one RAASI medication was almost ubiquitous in these patients (75.2–77.3%). Among RAASI users, the frequency of K+ derangements, mainly of hyperkalemia, was very noticeable (12% overall), particularly in patients with CKD or CHF, elderly individuals and users of MRAs. Hypokalemia was less frequent (1%).ConclusionThe high prevalence of K+ derangements, and particularly hyperkalemia, among RAASI users highlights the real-world relevance of K+ derangements, and the importance of close monitoring and management of K+ levels in routine clinical practice. This is likely to benefit a large number of patients, particularly those at higher risk.

Outcomes of Pregnant Women With Cirrhosis and Their Infants in a Population-Based Study

The incidence of cirrhosis is increasing among women of childbearing age. Contemporary outcomes of pregnant women with cirrhosis and their infants, as well as liver-related complications, have not been described in North America, to our knowledge. We investigated the association between cirrhosis and perinatal outcomes and evaluated perinatal liver-related events. We performed a retrospective cohort study using population-based administrative health care data from Ontario, Canada (2000-2017). We identified pregnant women with compensated cirrhosis (n= 2022) using validated case definitions and routine mother-infant linkage; the women were matched to 10,110 pregnant women in the general population (1:5) based on birth year and socioeconomic status. Maternal and infant outcomes up to 6 weeks postpartum and liver-related complications up to 1 year postpartum were evaluated by using multivariate log-binomial regression. After we adjusted for demographic and metabolic risk factors, cirrhosis was independently associated with intrahepatic cholestasis of pregnancy (relative risk [RR], 10.64; 95% confidence interval [CI], 7.49-15.12), induction of labor (RR, 1.15; 95% CI, 1.03-1.28), puerperal infections (RR, 1.32; 95% CI, 1.02-1.70), preterm birth (RR, 1.60; 95% CI, 1.35-1.89), infants who were large for gestational age (RR, 1.24; 95% CI, 1.05-1.46), and neonatal respiratory distress (RR, 1.20; 95% CI, 1.02-1.42). Fewer than 2% of pregnant women with cirrhosis had liver-related complications, but these occurred in a significantly higher proportion of women with a history of hepatic decompensation (13%) than women with compensated cirrhosis (1.2%) (P < .001). In a population-based study, we found that cirrhosis is an independent risk factor for adverse perinatal outcomes. However, liver-related complications are rare. Multidisciplinary teams are needed to coordinate care for pregnant women with cirrhosis during pregnancy and postpartum to optimize outcomes.

Occupational exposure to inorganic dust and risk of gout: a population-based study

BackgroundRisk factors operating independently of hyperuricemia could be of importance in determining why only a minority of people with hyperuricemia develop gout. Exposure to inorganic dust has been linked to...

Long-Term Incidence and Predictors of Significant Hearing Loss Requiring Hearing Assistive Devices Among Childhood Cancer Survivors: A Population-Based Study.

Hearing loss is a significant late effect among childhood cancer survivors. Recent guidelines note insufficient evidence to quantify its natural history or risk associated with specific exposures. We examined the long-term incidence and predictors of hearing loss requiring hearing amplification devices (HADs) using population-based health care data. In Ontario, Canada, HAD costs are subsidized by the Assistive Devices Program (ADP). Ontario children < 18 years of age at cancer diagnosis between 1987 and 2016 were identified and linked to ADP claims. Cumulative HAD incidence was compared between cases and matched controls. Patient, disease, and treatment predictors of HAD were examined. We identified 11,842 cases and 59,210 controls. Cases were at higher risk for HAD (hazard ratio [HR], 12.8; 95% CI, 9.8 to 16.7; P < .001). The cumulative incidence of HAD among survivors was 2.1% (95% CI, 1.7% to 2.5%) at 20 years and 6.4% (95% CI, 2.8% to 12.1%) at 30 years post-diagnosis. The 30-year incidence was highest in neuroblastoma (10.7%; 95% CI, 3.8% to 21.7%) and hepatoblastoma (16.2%; 95% CI, 8.6% to 26.0%) survivors. Predictors of HAD in multivariable analyses included age 0-4 years at diagnosis (v 5-9 years; HR, 2.2; 95% CI, 1.4-3.3; P < .001). Relative to no cisplatin exposure, patients receiving < 200 mg/m2 were not at greater risk, unlike those receiving higher cumulative doses. Relative to no cranial or facial radiation, those who had received ≤ 32.00 Gy were at no higher risk, unlike those who had received > 32.00 Gy. Carboplatin exposure was not associated with HAD. Childhood cancer survivors are at elevated risk for requiring HAD, which continues to increase between 20 and 30 years after diagnosis. Thresholds of cisplatin and radiation exposure exist, above which risk substantially increases. Prolonged monitoring and trials of otoprotective agents are warranted in high-risk populations.

Real-world use of liposomal irinotecan-based regimens among patients (pts) with metastatic pancreatic adenocarcinoma (mPDAC) in the United States (U.S.).

e16740 Background: The goals of randomized control trials (RCTs) are to make causal inferences and precise treatment comparisons, not to describe large heterogeneous pt populations. RWE allows population-based healthcare decision makers to assess and manage therapeutic and economic options for their pts, including those who would and would not have met inclusion/exclusion criteria of a given RCT and are instead managed under usual care, irrespective of clinical trial protocols. In the pivotal phase 3 trial, NAPOLI-1, 117 pts were treated with liposomal irinotecan + 5-fluorouracil/folinic acid, median age 63 years; 66% were treated first- (1L) or second line (2L), and 91% had performance score ECOG 0 or 1. Pts in the trial had overall survival (OS) of 6.2 months (mos), time to treatment failure (TTF) 2.3 mos, and 27% experienced grades 3-4 neutropenia. The present study describes the patient characteristics and outcomes of pts with mPDAC treated with liposomal irinotecan in the US. Methods: This retrospective observational study used data from Flatiron Health EHR-derived de-identified database from over 280 cancer clinics. Patient characteristics, OS, TTF, and rates of neutropenia during treatment (tx) were assessed in adult pts diagnosed with mPDAC who received liposomal irinotecan based tx between November 1, 2015 and October 31, 2019. Results: 600 pts with mPDAC treated with a liposomal irinotecan based regimen were identified. Of these, 56% were initially diagnosed with stage IV disease, 53% were male, 21% had undergone a previous Whipple procedure, and 61% initiated liposomal irinotecan in the 1L or 2L metastatic setting. Median age at tx initiation was 68 (IQR: 62 – 75) years. 92% of pts were treated in the community setting. Among pts with available ECOG (n = 440), 77.5% were score 0-1. Grade 3/4 neutropenia was observed in 11% (n = 66). Overall, median OS was 5.0 mos [95%CI: 4.2–5.6]. mOS among pts treated in 1L (n = 88), 2L (n = 280), and third line plus (3L+, n = 232) were 6.9 mos [5.3–9.2], 5.4 mos [4.6–6.4], and 4.0 mos [3.4–4.5], respectively. Overall, median TTF was 1.9 mos [1.6–2.1]. TTF by line was 3.5 mos [2.3–4.8] in 1L, 2.1 mos [1.7–2.8] in 2L, and 1.4 mos [1.2–1.6] in 3L. Conclusions: This real-world cohort of pts with mPDAC were older, had worse performance status, and had more prior lines compared to the pivotal trial for liposomal irinotecan. Median OS, TTF, and neutropenia were similar to those previously reported. As expected, pts receiving liposomal irinotecan in earlier lines had higher median OS and TTF.

Prevalence, incidence and mortality of type 1 and type 2 diabetes in Denmark 1996–2016

IntroductionThe objective of this study was to give an overview of prevalence, incidence and mortality of type 1 (T1D) and type 2 diabetes (T2D) in Denmark, and their temporal trends.Research design and methodsWe constructed a diabetes register from existing population-based healthcare registers, including a classification of patients as T1D or T2D, with coverage from 1996 to 2016. Using complete population records for Denmark, we derived prevalence, incidence, mortality and standardized mortality ratio (SMR).ResultsThe overall prevalence of diabetes at 2016 was 0.5% for T1D and 4.4% for T2D, with annual increases since 1996 of 0.5% for T1D and 5.5% for T2D. Incidence rates of T1D decreased by 3.5% per year, with increase for persons under 25 years of age and a decrease for older persons. T2D incidence increased 2.5% per year until 2011, decreased until 2014 and increased after that, similar in all ages. The annual decrease in mortality was 0.3% for T1D and 2.9% for T2D. The mortality rate ratio between T1D and T2D was 1.9 for men and 1.6 for women. SMR decreased annually 2% for T1D and 0.5% for T2D.ConclusionsIncidence and prevalence of diabetes is increasing, but mortality among patients with diabetes in Denmark is decreasing faster than the mortality among persons without diabetes. T1D carries a 70% higher mortality than T2D.

ANTIPSYCHOTIC REDUCTION IN LONG-TERM CARE: UNINTENDED PRESCRIBING OUTCOMES

Introduction Antipsychotics are widely used to treat neuropsychiatric symptoms (NPS) of dementia in long-term care (LTC), despite many adverse effects. Targeted quality improvement, broader awareness of risks, and other initiatives over the last ten years have resulted in substantial reductions in antipsychotic prescribing in Canadian LTC, but concerning trends have been observed in rates of other medication use. It is not clear whether reductions in antipsychotic use are being propelled by appropriate deprescribing and care decisions or whether alternate, but as risky, drug therapies are being substituted for antipsychotics. Methods This is a retrospective cohort study examining the association between antipsychotic discontinuation and subsequent receipt of other medications that may be used to treat NPS using linked population-based health care databases held at the Institute for Clinical and Evaluative Sciences (ICES) on Ontario, Canada. Older Ontario LTC residents (>65 years) who met cohort entry criteria including at least 6-months of continuous antipsychotic use between April 1st, 2012 - March 31st, 2017 were included. Those who discontinued an antipsychotic were matched to persistent antipsychotic users and followed for up to 12-months. The primary outcome was receipt of a new medication from the following categories: opioids, antidepressants, mood stabilizers, benzodiazepines, and cannabinoids. Cox proportional hazards models were used to determine the hazard ratio (HR) and 95% confidence intervals (CI) for new use of medications for discontinuers compared to persistent users. Results Overall, antipsychotic discontinuers were less likely to start any new drug compare to persistent antipsychotic users (HR: 0.77, 95% CI 0.72-0.82, p Conclusions Preliminary results indicate that antipsychotic discontinuation in LTC is associated with increased initiation of other medications in individuals who survive up to 6 and 12-months following discontinuation. Among specific medication classes, antipsychotic discontinuation is associated with subsequent higher rates of antidepressant use . A more complete understanding of substitute medication prescribing patterns and other consequences of antipsychotic deprescribing will inform ongoing and future interventions in LTC and other settings where antipsychotic use for the treatment of NPS is common. This research was funded by: This project was supported by grants from the Clinical Teacher's Association and Department of Psychiatry at Queen's University, Ontario, Canada.

Abstract P518: Prospective Study of Skipping Meals to Lose Weight as a Predictor of Incident Type 2 Diabetes and Coronary Heart Disease: The Canadian 1995 Nova Scotia Health Survey

Introduction: Skipping meals is an increasingly common practice to lose weight among North American adults of all bodyweights. However, due to a lack of long-term studies, the long-term effect of skipping meals to lose weight on cardiometabolic health outcomes such as a diagnosis of type 2 diabetes mellitus (T2DM) or incident coronary heart disease (CHD) remains unknown, although previous short-term studies of skipping meals and risk factors for T2DM and CHD have suggested plausible biological pathways for a relationship to exist in either direction, protective or harmful. Hypothesis: We assessed the hypotheses that skipping meals to lose weight was associated with long-term risk of incident T2DM and CHD in the Canadian 1995 Nova Scotia Health Survey (NSHS95), and that these associations were influenced by cardiometabolic risk factors. Methods: Skipping meals to lose weight was assessed via questionnaire in a cohort of 2,898 adults in the NSHS95 and was linked to population-based health care administrative databases to determine incidence of T2DM and/or CHD in the following 23 years. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for T2DM and CHD. Results: During 23 years of follow-up, 430 incident cases of T2DM and 632 incident cases of CHD were diagnosed. Compared to participants who did not skip meals to lose weight, those who did skip meals to lose weight (2.7%) had an 87% higher risk of T2DM (multivariable-adjusted HR=1.87, 95% CI: 1.11-3.17). This association was no longer present after adjustment for baseline body mass index (BMI) (HR=1.42, 0.83-2.42). After stratification by BMI, skipping meals was associated with T2DM among participants who had BMI &lt;25 kg/m 2 (n=1,030; HR=4.42, 1.01-19.30) but not among participants with BMIs of 25-29.9 kg/m 2 (n=1,123; HR=1.07, 0.39-2.96) or 30+ kg/m 2 (n=586; HR=1.21, 0.61-2.39). The multivariable-adjusted (including BMI) association was also present within participants with elevated cholesterol (n=1,450; HR=1.88, 1.00-3.53) and high blood pressure (n=1,363; HR=2.07, 1.11-3.85), but not among those without. No significant association was observed between skipping meals to lose weight and CHD risk before (HR=1.14, 0.67-1.96) or after adjustment for BMI (HR=1.05, 0.61-1.81), or within subgroups. Conclusion: These findings suggest that skipping meals to lose weight may be a predictive modifiable risk factor for developing T2DM over time, especially among people with a BMI &lt;25 kg/m 2 , potentially working in connection or iteration with other T2DM risk factors. With the growing number of popular diets that include skipping meals, future studies are warranted to understand perturbations of potential metabolic consequences.

Hospitalization for epistaxis: a population-based healthcare research study in Thuringia, Germany

PurposeEpistaxis is the most common ENT emergency. The aim was to determine population-based data on severe epistaxis needing inpatient treatment.MethodsRetrospective population-based cohort study in the federal state Thuringia in 2016 performed on all 840 inpatients treated for epistaxis in otolaryngology departments (60.1% male, median age: 73 years; 63.9% under anticoagulation). The association between patients’ and treatment characteristics and longer inpatient stay (≥ 4 days) as well as readmission for recurrent epistaxis was analyzed using univariable and multivariable statistics.ResultsThe overall incidence of epistaxis needing inpatient treatment was higher for men (42 per 100,000) than for women (28 per 100,000). The highest incidence was reached for men > 85 years (222 per 100,000). Most important independent predictors for longer inpatient stay were localization of the bleeding not in the anterior nose (OR = 2.045; CI = 1.534–2.726), recurrent bleeding during inpatient treatment (OR = 2.142; CI = 1.508–3.042), no electrocoagulation (OR = 2.810; CI = 2.047–3.858), and blood transfusion (OR = 2.731; CI = 1.324–5.635). Independent predictors for later readmission because of recurrent epistaxis were male gender (OR = 1.756; CI = 1.155–2.668), oral anticoagulant use (OR = 1.731; CI = 1.046–2.865), and hereditary hemorrhagic telangiectasia (OR = 13.216; CI 5.102–34.231).ConclusionsInpatient treatment of epistaxis seems to be variable in daily routine needing standardization by clinical guidelines and strategies to shorten inpatient treatment and to reduce the risk of readmission.