Régie De L'assurance Maladie Du Québec Research Articles

Current era clinical outcomes of castration-resistant prostate cancer in real-life population study in Quebec, Canada.

226 Background: Prostate cancer (PCa) death is mainly due to castration-resistant PCa (CRPC) which results from disease progression despite androgen ablation therapy (ADT). Little is known about clinical outcomes and trends of real-life CRPC management in the present era, which has become very complex. Our study aimed to analyze healthcare services use, clinical outcomes and survival trends in real-life management of CRPC in Quebec, Canada. Methods: The study cohort consisted of 7,123 patients which shown evidence of CRPC from January/2001 to July/2013, selected from the public healthcare insurance programs the Régie de l’Assurance Maladie du Québec (RAMQ) databases. Survival was evaluated by Kaplan-Maier and the difference in survival between pre-/post-docetaxel (Doc) (2002-2005 vs 2008-2011) era by log-rank test. The association between Doc exposure and survival was evaluated by Cox proportional hazards model adjusted for several co-variables. Results: Chemotherapy was offered to 17% of patients, while 45% were kept on maximal androgen blockade (MAB) alone, or offered Abiraterone (3%). Androgen targeted therapies (MAB or Abiraterone) were the treatment of choice for the elderly population (mean age 78.8 and 78 ±7, respectively) while chemotherapy was offered to younger patients (mean age 72 ±7.3). Survival rates at 1 and 2 years after the initiation of chemotherapy were 52% and 26% in post-Doc era vs 46% and 17% in the pre-Doc period. In patients receiving first line chemotherapy only, hospitalization due to PCa was a poor prognostic predictor (HR: 2.0; 95%CI: 1.5-2.6), as expected. In addition among patients without previous hospitalization the risk of death was higher in the pre- vs post-Doc era (HR: 1.7 CI: 1.003-2.851). Conclusions: Patient age seems to be a strong determinant in CRPC therapy selection. In patients without serious complications leading to hospitalization, survival was greatly improved in the post-Doc era. Our data also supports that patients older than those in the TAX327 trial (72 vs 68) may equally benefit from chemotherapy. This is encouraging as we hope to observe comparable results for new approved therapies for CRPC.

Differential low uptake of free vitamin D supplements in preterm infants: the Quebec experience.

BackgroundVitamin D is essential for bone mineralization, particularly in premature infants. For nearly 20 years, Quebec has offered a program of free vitamin D supplements via its public medication insurance plan Régie de l’Assurance Maladie du Québec (RAMQ). The objective of this study is to evaluate the number of preterm infants that obtained at least one bottle (50 doses) of vitamin D supplement through this program and to determine if uptake varied by gestational age.MethodsThis was a retrospective cohort study of preterm infants covered by RAMQ and born from 1998 to 2008; all infants had 1 year of follow-up data regarding supplement use. Data were extracted from the Quebec Pregnancy Cohort, a linked administrative database and were stratified by early (<34 weeks) or late gestational age premature infants. The number of infants obtaining supplements was the primary outcome and their characteristics were compared across gestational age groups. Predictors for participation (obtaining at least 1 bottle) or adherence (2 or more bottles) were identified via logistic regression (GEE).Results10288 infants were eligible; the percentage exposed to vitamin D was 24.5% (37.4%- early; 20.7%-late preterm infants, p < 0.001). The median number of bottles obtained was 2 for early and 1 for late preterms. For all premature infants, there was an apparent geometric decline in the infants obtaining subsequent bottles of supplements over the 12 month period. Additionally, there was a significant decline in program participation over time (OR = 0.90/year, 95% CI: 0.89-0.90) regardless of gestational age. Older or more educated mothers were positive predictors for participation. A prescription from a pediatrician significantly increased the odds of obtaining the supplement.ConclusionEarly preterm infants were more likely to obtain the supplement post-discharge; uptake was low and decreased with time for both age categories. Specifically, targeting late preterm infants and young mothers with less education could improve vitamin D uptake.

Agreement between survey data and Régie de l'assurance maladie du Québec (RAMQ) data with respect to the diagnosis of asthma and medical services use for asthma in children

The goal of this study was to assess the agreement between the results of a respiratory health survey conducted in Montréal on children aged 6 months to 12 years and the Régie de l'assurance maladie du Québec (RAMQ, Quebec health insurance board) database in terms of the diagnosis of asthma and medical services use. A secondary aim was to evaluate the effect of the survey method used (Internet-based survey or telephone survey). We assessed whether a diagnosis of asthma was made for 7922 children. In addition, we compared the use of medical services for asthma (emergency department visits and hospitalizations) in the 12 months preceding the survey for the 402 children considered to have asthma, using 2 groups of respiratory diagnoses and 2 data linkage periods. The agreement between the 2 data sources was evaluated using the kappa statistic (κ) and sensitivity and specificity, as well as percentages of agreement, overreporting and under-reporting with respect to health services use. Moderate agreement was found between the 2 data sources (survey and RAMQ data) in terms of the diagnosis of asthma (κ = 0.54 and κ = 0.60 depending on the definition used). Specificity was high (93% and 96%), but sensitivity varied (50% and 65%). Respondents over-reported health services use, resulting in moderate kappa values (0.49 for emergency department visits and 0.48 for hospitalizations). However, when more diagnoses were included in the definition and when the linkage period was extended (15 rather than 12 months), the kappa values increased (0.59 for emergency department visits and 0.64 for hospitalizations) and sensitivity and specificity were high. Slightly higher agreement was obtained for the Internet-based survey relative to the telephone survey. The findings validate the use of survey data with respect to the diagnosis of pediatric asthma and major health services use for this disease.

Postoperative mortality and complications after radical cystectomy for bladder cancer in Quebec: A population-based analysis during the years 2000-2009.

Radical cystectomy (RC) is a very complex urologic procedure. Despite improvements in practice, technique and process of care, it is still associated with significant complications, including death, with reported postoperative mortality rates ranging from 0.8% to 8%. We examine the quality of surgical care indicators and document the mortality rates at 30, 60 and 90 days after RC across Quebec. Within the Régie de l'assurance maladie du Québec (RAMQ) administrative database (this database provides prospectively collected universal data on all medical services) and the Institut de la statistique du Québec (ISQ) database (this provides vital status data), we used procedure codes to identify patients who underwent RC for bladder cancer in Quebec over 10 years (between 2000 and 2009), as well as RC outcomes and dates of death. Data obtained were retrospectively analyzed in relation to multiple parameters, including patient characteristics and health-care providers' volumes. The outcomes analyzed included postoperative complications and mortality rates at 30, 60 and 90 days. A total of 2778 RC were performed in 48 hospitals by 122 urologists across Quebec. Among them, 851 (30.6%) patients had at least one postoperative complication and 350 (12.6%) patients had more than one complication. The overall mortality rates at 30, 60 and 90 days were 2.8%, 5.3% and 7.5%, respectively, with significantly elevated 90-day mortality rates in some centres. In the multivariate analysis, increased age was associated with increased risk of post-RC complications and mortality. For example, patients over 75 had more chance of having at least one postoperative complication (odds ratio [OR] 1.66, 95% confidence interval [CI]: 1.31-2.11) and mortality at 90 days (OR 3.28, 95% CI: 2.05-5.26). Provider volume effect on outcomes was statistically significant, with large hospitals having decreased risk of 30-day mortality (OR 0.29, 95% CI: 0.12-0.70), 60-day mortality (OR 0.41, 95% CI: 0.26-0.82) and 90-day mortality (OR 0.52, 95% CI: 0.29-0.93) when compared to smaller hospitals. Surgeon volume showed weak, but not statistically significant, evidence of reduced odds of mortality for the high-volume surgeon. Limitations to our study include reliance on administrative data, which lack some relevant clinical information (such as patient functional status and tumour pathological characteristics) to perform risk adjustment analysis. Our study demonstrates that postoperative outcomes after RC in Quebec varies based on several parameters. In addition, 30-day postoperative mortality after RC in Quebec appears acceptable. However, 90-day postoperative mortality rates remain significantly elevated in some centres, particularly in the elderly. This requires further research.

La réforme des soins primaires de santé mentale au Québec et le rôle et les stratégies de coordination des omnipraticiens

The health and mental health systems in Quebec have recently been substantially transformed. At the heart of this restructuring, reforms aimed to strengthen primary care and to better integrate services, which are central trends internationally. This article summarizes Quebec's primary health and mental health reforms. It also presents the key role of general practitioners in the treatment of mental health disorders and their coordination strategies with the mental health care resources in the province. Numerous documents on the Quebec health and mental health reforms and the international literature on primary mental health care were consulted for this study. Information on general practitioner roles in mental health were based on administrative data from the Régie de l'assurance maladie du Québec (RAMQ) for all medical procedures performed in 2006. The data was compared with the results of a survey realized in the same year with 398 general practitioners in Quebec. Complementary qualitative data was collected through one hour interviews on a subsample of 60 of those general practitioners. The central aim of the Quebec healthcare reform was to improve services integration by implementing local healthcare networks. A population health approach and a hierarchical service provision were promoted. For a better access and continuity of care, family medicine groups and network clinics were also developed. The mental health reform (Action Plan in Mental Health, 2005-2010) was launched in this general context. It prioritized the consolidation of primary care and shared-care (i.e. increased networking between general practitioners and psychosocial workers and psychiatrists) by reinforcing the role of general practitioners in mental health, developing mental health interdisciplinary teams in primary care and adding a psychiatrist-respondent function in each Quebec local healthcare network. In mental health, general practitioners played a central role as the primary source of care and networking to other resources either primary or specialized health care services. Between 20-25% of visits to general practitioners are related to mental health problems. Nearly all general practitioners manage common mental disorders and believed themselves competent to do so; however, the reverse is true for the management of serious mental disorders. Mainly general practitioners practiced in silo without much relation with the mental health care resources. Numerous factors were found to influence the management of mental health problems: patients' profiles (e.g. the complexity of mental health problems, concomitant disorders), individual characteristics of the general practitioners (e.g. informal network, training); professional culture (e.g. formal clinical mechanisms), the institutional setting (e.g. multidisciplinary or not) and organizations of services (e.g. policies). Unfortunately, the Quebec health and mental health care reforms have not been fully implemented yet. Family medicine groups and networks clinics, primary mental health teams and psychiatrists-respondent are not optimally operational and therefore, are not having a significant outcome. Support mechanisms to help implement the reforms were not prioritized. Hindering factors should be identified and minimized to increase positive changes in the health and mental health systems. This article concludes on the importance of implementing continuums of care, especially local healthcare networks and best practices in mental health. Furthermore, strong strategies to support the implementation of changes should always accompany sweeping reforms.

L’usage des médicaments chez les enfants et les adolescents ayant reçu un diagnostic de troubles du spectre de l’autisme couverts par le régime public d’assurance médicaments du Québec

BackgroundFew publications have reported the results of studies assessing the use of drugs among populations of children and adolescents diagnosed with autism spectrum disorders (ASD) or according to the old terminology, pervasive developmental disorders (PDD). The authors of the systematic review upon which this study is based, conclude that there is insufficient evidence to evaluate the benefits or adverse effects of any treatments other than the drugs risperidone and aripiprazole. ObjectiveThe overall objective of this study was to document the use of drugs among Quebec children and adolescents diagnosed with ASD who were covered by the Public Prescription Drug Insurance Plan (PPDIP) during the year 2010, and then, verify whether these children and adolescents used some of the drugs therapies presented in the systematic review upon which this study is based. MethodsA retrospective cohort study was carried out using three databases administered by the Régie de l’assurance maladie du Québec (RAMQ), Canada. ResultsOverall, 14.3% of covered 2- to 5-year-old diagnosed with ASD, 35.9% of 6- to 9-year-old, 44.8% of 10- to 12-year-old, 52.3% of 13- to 15-year-old and 50.9% of 16- to 17-year-old used at least one of the 18 specific drugs or a drug from the 4 other classes under study. Finally, with regard to the length of treatment associated with the two most widely used drugs, over 60% and nearly 50% of covered 2- to 17-year-old used risperidone and methylphenidate, respectively, for more than 9months in 2010. ConclusionThe high proportion of children and adolescents who used at least one of the 18 specific drugs or 4 other classes of drug under study in 2010 should generate discussion, given the weak evidence supporting the use of these drugs in this population. In addition, the drugs in question are psychotropics, or drugs that can lead to numerous adverse effects, which can, in turn, have significant consequences.

Effect of External Variables on the Performance of the Geriatric Comorbidity Score Derived from Prescription Claims in the Community-Dwelling Elderly

Comorbidity scores based on medical or prescription claims data are frequently used to control for confounding in pharmacoepidemiological studies. Performance of such scores in predicting the risk of death in community-dwelling elderly adults may be compromised by the absence of mental health and socioeconomic characteristics not captured in claims data. The aim of the study was to assess the impact of adding mental health status and sociodemographic characteristics to the Geriatric Comorbidity Score (GCS), a score derived from prescription claims data in the Quebec community-dwelling elderly population. We used the cohort study from the longitudinal Quebec Seniors' Health Survey (n = 1,494) conducted between 2005 and 2006. For each participant, we obtained mental health and socioeconomic characteristics through validated questionnaires, which we linked with the medical and prescription claims databases of the Quebec Health Insurance Agency [Régie de l'assurance maladie du Québec (RAMQ)]. The main study outcome was death within 1 year, ascertained using the Quebec death registry. The GCS was calculated from prescription claims data, with the c statistic as a measure of performance. Using backward stepwise selection, external variables (marital status, region, family income, social support, daily hassles, perceived physical and mental health status, presence of mental health disorders) were added to the logistic regression model and the marginal effect assessed by comparing the c statistic with and without each covariate. Over 1 year, 77 deaths (5.15 %) were reported. The c statistic for the GCS was calculated as 0.67 (95 % confidence interval 0.64, 0.70). Addition of sex and age to the score yielded a 2.4 % increase. The variable with the greatest impact on the c statistic was marital status (6.1 % increase). Though important contributors, social support and perceived mental health status did not significantly improve performance of the score. While sex, age and marital status significantly improved performance of a predictive score in the community-dwelling elderly population, the absence of data on mental and physical health status did not appear to compromise the validity of claims-based scores. Combining comorbidity scores with other methods to control for confounding thus remains a useful tool in pharmacoepidemiological research.

PIH44 Contraceptive Utilization in Women Who Had an Abortion: A Canadian Cohort-Study

Unintended pregnancies constitute a global problem associated with substantial health care costs. In Canada, approximately 22% of all pregnancies will lead to an abortion, with a higher rate (52%) in women under 20. As leading causes of unintended pregnancies are closely related to the contraceptive method chosen, the objective of this study was to analyze utilization of contraceptives in women who had an abortion. A retrospective cohort study was conducted using a random sample from the Régie de l'assurance-maladie du Québec (RAMQ) prescriptions and medical services databases. Inclusion criteria were: women who had an abortion at less than 14 weeks between January 1, 2008 and December 31, 2009 and who were continuously enrolled 12 months pre- and post-abortion. Claims for contraceptives were analyzed in the year preceding and following the abortion. Of the 7397 women included for analysis, 67.8% were between 15 and 29 years old. Approximately 30.2% filled at least one prescription for a contraceptive in the year preceding the abortion; 82.9% of claims were oral contraceptives. In the year after abortion, the usage of contraceptives increased to 54.3%. Utilization of a long-acting reversible contraception (LARC) increased after abortion. Levonorgestrel intrauterine system (IUS) was inserted on the day of the abortion in 7.5% of women. Within one month of abortion, 47% of women claimed for oral contraceptives, 27% for Levonorgestrel IUS, 12% for transdermal patches, 8% for vaginal rings and 6% for depo-medroxyprogesterone acetate. The data showed that the utilization of contraception increased after an abortion. A valuable benefit of LARCs is that their effectiveness does not rely on continuous user compliance, which could help explain the increased utilization of these methods after an abortion. However, the utilization of LARCs remains low which may indicate an unmet need for a greater variety of LARC options.

Discrepancies between survey and administrative data on the use of mental health services in the general population: findings from a study conducted in Québec

BackgroundPopulation surveys and health services registers are the main source of data for the management of public health. Yet, the validity of survey data on the use of mental health services has been questioned repeatedly due to the sensitive nature of mental illness and to the risk of recall bias. The main objectives of this study were to compare data on the use of mental health services from a large scale population survey and a national health services register and to identify the factors associated with the discrepancies observed between these two sources of data.MethodsThis study was based on the individual linkage of data from the cycle 1.2 of the Canadian Community Health Survey (CCHS-1.2) and from the health services register of the Régie de l'assurance maladie du Québec (RAMQ). The RAMQ is the governmental agency managing the Quebec national health insurance program. The analyses mostly focused on the 637 Quebecer respondents who were recorded as users of mental health services in the RAMQ and who were self-reported users or non users of these services in the CCHS-1.2.ResultsRoughly 75%, of those recorded as users of mental health services users in the RAMQ's register did not report using mental health services in the CCHS-1.2. The odds of disagreement between survey and administrative data were higher in seniors, individuals with a lower level of education, legal or de facto spouses and mothers of young children. They were lower in individuals with a psychiatric disorder and in frequent and more recent users of mental health services according to the RAMQ's register.ConclusionsThese findings support the hypotheses that social desirability and recall bias are likely to affect the self-reported use of mental health services in a population survey. They stress the need to refine the investigation of mental health services in population surveys and to combine survey and administrative data, whenever possible, to obtain an optimal estimation of the population need for mental health care.

Hospitalization and surgical rates in patients with Crohn's disease treated with infliximab: a matched analysis

The majority of subjects with Crohn's Disease (CD) will be hospitalized and will receive surgery for their disease. These interventions account for most of the direct costs of the disease. We sought to explore the association between infliximab use and CD-related surgery and hospitalizations. We obtained patient-level health claims between 1996 and 2007 from the Régie de l'Assurance Maladie du Québec (RAMQ), a Canadian provincial health care insurer. Subjects who were i) enrolled in the RAMQ for at least 2 years, ii) received prescription drug benefits for each year of enrolment and iii) were identified as having CD using a validated algorithm were eligible for the study. For each subject treated with infliximab, up to two closely matched comparison subjects were selected using propensity score methods. We compared time to first CD-related intra-abdominal surgery or hospitalization in infliximab users and non-users. We matched 338 infliximab users (mean age 34, 45% male) to at least one comparison subject using propensity score matching. Subjects who received infliximab had a significantly lower risk of experiencing a CD-related intra-abdominal surgery (hazard ratio [HR] = 0.64; 95% confidence interval [CI] 0.51-0.81) or hospitalization (HR = 0.73; 95% CI 0.63-0.85). Infliximab users also experienced lower rates of hospitalized days (Rate Ratio = 0.69; 95% CI 0.49-0.97). Our results support the real world effectiveness of infliximab therapy in reducing CD-related surgeries and hospitalizations.

Accuracy of administrative claims data for polypectomy

The frequency of polypectomy is an important indicator of quality assurance for population-based colorectal cancer screening programs. Although administrative databases of physician claims provide population-level data on the performance of polypectomy, the accuracy of the procedure codes has not been examined. We determined the level of agreement between physician claims for polypectomy and documentation of the procedure in endoscopy reports. We conducted a retrospective cohort study involving patients aged 50-80 years who underwent colonoscopy at seven study sites in Montréal, Que., between January and March 2007. We obtained data on physician claims for polypectomy from the Régie de l'Assurance Maladie du Québec (RAMQ) database. We evaluated the accuracy of the RAMQ data against information in the endoscopy reports. We collected data on 689 patients who underwent colonoscopy during the study period. The sensitivity of physician claims for polypectomy in the administrative database was 84.7% (95% confidence interval [CI] 78.6%-89.4%), the specificity was 99.0% (95% CI 97.5%-99.6%), concordance was 95.1% (95% CI 93.1%-96.5%), and the kappa value was 0.87 (95% CI 0.83-0.91). Despite providing a reasonably accurate estimate of the frequency of polypectomy, physician claims underestimated the number of procedures performed by more than 15%. Such differences could affect conclusions regarding quality assurance if used to evaluate population-based screening programs for colorectal cancer. Even when a high level of accuracy is anticipated, validating physician claims data from administrative databases is recommended.

Projected economic impact of clinical findings of generic entry of topiramate on G4 European countries

ABSTRACTObjectives: To explore the effects of generic substitution of the antiepileptic drug (AED) topiramate (Topamax in Canada; to convert observed Canadian costs into the settings of France, Germany, Italy, and the United Kingdom (UK); and to forecast the economic impact of generic topiramate entry in these four European countries.† Topamax is a registered trade name of Ortho-McNeil Neurologics, Inc., Titusville, NJ, USAResearch design and methods: Health claims from Régie de l'assurance maladie du Québec (RAMQ) plan (1/2006–9/2008) and IMS Health data (1998–2008) were used. Patients with epilepsy and ≥2 topiramate dispensings were selected. An open-cohort design was used to classify observation into mutually-exclusive periods of branded versus generic use of topiramate. Canadian healthcare utilization and costs (2007 CAN$/person-year) were compared between periods using multivariate models. Annualized per-patient costs (2007€ or 2007£/person-year) were converted using Canadian utilization rates, European prices and service-use ratios. Non-parametric bootstrap served to assess statistical significance of cost differences. Topiramate market was forecasted following generic entry (09/2009–09/2010) using autoregressive models based on the European experience. The economic impact of generic topiramate entry was estimated for each country.Results: A total of 1164 patients (mean age: 39.8 years, 61.7% female) were observed for 2.6 years on average. After covariates adjustment, generic-use periods were associated with increased pharmacy dispensings (other AEDs: +0.95/person-year, non-AEDs: +12.28/person-year, p < 0.001), hospitalizations ( + 0.08/person-year, p = 0.015), and lengths of hospital stays (+0.51 days/person-year, p < 0.001). Adjusted costs, excluding topiramate, were CAN$1060/person-year higher during generic use (p = 0.005). Converted per-patient costs excluding topiramate were significantly higher for generic relative to brand periods in all European countries (adjusted cost differences per person-year: €706–815, p < 0.001 for all comparisons). System-wide costs would increase from 3.5 to 24.4% one year after generic entry.Limitations: Study limitations include the absence of indirect costs, possible claim inaccuracies, and IMS data limitations.Conclusions: Higher health costs were projected for G4 European countries from the Canadian experience following the generic entry of topiramate.

Cost of corneal transplantation for the Quebec health care system

Objective: Although corneal graft is a common, long-standing procedure, little is known about its economic impact. The purpose of this study was to estimate resource use and costs associated with corneal transplantation according to a public third-party perspective. Design: Retrospective study using claim data from the Régie de l’assurance maladie du Québec (RAMQ). Participants: A total of 610 subjects were included in the study. Mean age was 54.8 (SD 20.4) years. Methods: The RAMQ provided medical and pharmaceutical data for a random sample of 75% of the patients who underwent a corneal graft procedure between June 1, 1999, and May 31, 2002. Resource usage data, defined as medical interventions, physician visits, and medication, were collected for a 3-year postoperative follow-up period. Hospital costs associated with corneal graft were obtained from the University of Montreal Hospital Centre costing system. Results: The average costs per patient for graft and anesthesia were $501 (SD $75) and $115 (SD $124), respectively. The mean cost per patient for physician visits was $276 (SD $146). The mean number of physician visits per patient during the follow-up was 14.9 (SD 9.1). The cost per patient for medication was $337 (SD $1075). The average total cost per patient was $1229 (SD $1125). Costs incurred by the hospital represented a total of $1942. Conclusions: The overall cost of corneal graft, including a 3-year follow-up, was estimated at $3171 ($1229 RAMQ, $1942 hospital). The majority of these costs occurred at the time of the procedure.

A retrospective study of cholinesterase inhibitors for Alzheimer's disease: cerebrovascular disease as a predictor of patient outcomes

ABSTRACTBackground: Dementia may be caused by Alzheimer's disease (AD), cerebrovascular disease (CVD), or a combination of both. When CVD is associated with dementia, survival is thought to be reduced. It is unclear whether treatment with cholinesterase inhibitors (ChEIs), which has been found to slow disease progression in AD patients, has similar benefits in vascular forms of dementia.Objectives: The present study was designed to determine whether co-existing CVD is associated with survival or time to nursing home placement (NHP) among AD patients treated with ChEIs. Findings of poorer outcomes in patients with versus without CVD might argue against the use of ChEIs for AD patients in whom CVD co-exists.Methods: A retrospective cohort study was undertaken using the Régie de l’Assurance Maladie du Québec (RAMQ) databases to examine the time to NHP or death for AD patients aged 66+, with or without CVD, treated with ChEIs between July 1, 2000, and June 30, 2003. Because ChEIs are approved only for AD in Canada, a ChEI prescription was used as a surrogate for an AD diagnosis. Separate analyses were performed for patients with persistent ChEI use and those who discontinued ChEI therapy.Results: A total of 4428 patients met inclusion criteria for AD with CVD; 13 512 were classified as having AD alone. For the composite endpoint of NHP or death, 1000-day survival rates were lower among AD patients with versus without CVD (p < 0.01), but absolute differences were very small (84 vs. 86% with continuous ChEI use; 77 vs. 78% with discontinuous ChEI therapy). Of the secondary endpoints, time to death was shorter for patients with versus without CVD, but time to NHP did not differ between groups.Limitations: Results may have been affected by selection (misclassification) bias and between-group differences in smoking, body mass index, and duration of ChEI therapy.Conclusions: Associations between co-existing CVD and time to NHP or death appeared to be of little clinical relevance among AD patients treated with ChEIs. The lack of difference between AD patients with and without CVD suggests that CVD should not be used as a reason to deny AD patients access to ChEI treatment.

Isotretinoin and the Risk of Depression in Patients With Acne Vulgaris

To determine whether isotretinoin increases the risk of depression in patients with acne vulgaris. A case-crossover study was performed among subjects who received > or = 1 isotretinoin prescription from 1984 through 2003. Data were obtained from the Régie de l'Assurance Maladie du Québec (RAMQ) and Quebec's hospital discharge (Med-Echo) administrative databases. Cases were defined as those with a first diagnosis or hospitalization for depression (ICD-9 codes: 296.2, 298.0, 300.4, 309.0, 309.1, and 311) during the study period (1984-2003) and those who filled a prescription for an antidepressant in the 30 days following their diagnosis or hospitalization. The index date was the calendar date of the diagnosis or hospitalization for depression. Cases were covered by the RAMQ drug plan and had > or = 1 acne diagnosis in the 12 months prior to the index date. Those who received an antidepressant in 12 months prior to the index date were excluded. Exposure to isotretinoin in a 5-month risk period immediately prior to the index date was compared to a 5-month control period. Relative risks along with 95% CIs were estimated using conditional logistic regression. Of the 30,496 subjects in the initial cohort, 126 (0.4%) cases met inclusion criteria. The crude relative risk for those exposed to isotretinoin was 2.00 (95% CI = 1.03 to 3.89). After adjusting for potential time-dependent confounders, the relative risk for those exposed to isotretinoin was 2.68 (95% CI = 1.10 to 6.48). This is the first controlled study to find a statistically significant association between isotretinoin and depression. Because depression could have serious consequences, close monitoring of isotretinoin users is indicated.

Isotretinoin therapy and the incidence of acne relapse: a nested case–control study

Previous studies on predictors of acne relapse in patients treated with isotretinoin had either small sample sizes, short follow-up periods, or lacked population-based data. To identify and quantify predictors of acne relapse, and predictors of receiving a second isotretinoin treatment. Using the Régie de l'Assurance Maladie du Québec (RAMQ) and Quebec's hospital discharge (Med-Echo) administrative databases, a population-based cohort of 17 351 first-time isotretinoin users was assembled between 1984 and 2003. A nested case-control analysis was performed to determine predictors of acne relapse (as defined by receiving an antiacne medication). A second nested case-control analysis was performed to determine predictors of receiving a second isotretinoin treatment. The index date of cases was the calendar date of dispensing an antiacne medication (isotretinoin or other). Five controls were matched to each case on follow-up time. Rate ratios were estimated using conditional logistic regression. A total of 7100 (41%) subjects experienced an acne relapse. These were matched to 35 500 controls. Being male, under 16 years of age and living in an urban area, and receiving isotretinoin cumulative doses greater than 2450 mg and an isotretinoin treatment longer than 121 days were statistically associated (P < 0.05) with acne relapse. The publishing of the different Canadian acne guidelines had no impact on the incidence of acne relapse (P > 0.05). A total of 4443 (26%) subjects required a second isotretinoin treatment. These were matched to 22 215 controls. There was a greater probability of receiving a second isotretinoin treatment after the publishing of the Canadian acne guidelines (P < 0.05). A relatively high rate of subjects experienced an acne relapse after an isotretinoin treatment.

Trends and determinants of antiresorptive drug use for osteoporosis among elderly women

It has been established that women who have had a first osteoporotic fracture are at a significantly greater risk of future fractures. Effective antiresorptive treatments (ART) are available to reduce this risk, yet little information is available on trends in ART drug use among the elderly. The objective is to estimate the rate ratio (RR) of having an ART prescription filled among elderly women and its relation to selected determinants from 1995 through 2001. A cohort design was used. Through random sampling, we selected 40% of the women aged 70 years and older listed in the Régie de l'assurance maladie du Québec (RAMQ) health database. The women were grouped into four cohorts (for 1995, 1996, 1998 and 2000). January 1 was established as the index date within each cohort (1995, 1996, 1998 and 2000). The dependent variable was the RR of having at least one prescription of ART drugs filled during the year following the index date among women with and without prior use. ART users were divided in two groups: bone-specific drugs (bisphosphonates, calcitonin, raloxifen) and HRT (hormone replacement therapy). The independent variable was whether or not (control) there had been an osteoporotic-related fracture. The RR was determined for having at least one prescription of bone-specific drugs or of HRT filled during the year following the index date using a Cox regression adjusted for age, chronic disease score (CDS) and prior bone mineral density (BMD) test. Crude rates of BMD testing (per 500 person-years) ranged from 20.4 (1995) to 41.1 (2000) in women who had had an osteoporotic-related fracture, and from 4.4 to 15.3 in controls. The crude rate of women (per 100 person-years) who had had an osteoporotic-related fracture and who took at least one bone-specific drug during follow-up ranged from 1.9 in 1995 to 31 in 2000 among those with prior osteoporotic-related fracture, and from 0.5 in 1995 to 11 in 2000 for controls; the corresponding figures for HRT ranged 6.7 in 1995 to 13 in 2000, and from 8.4 in 1995 to 11 in 2000 respectively. BMD test is the only major factor affecting the adjusted RR of having a prescription filled for bone-specific drugs (RR of 10.44; 6.91-15.79 in 1995 and RR of 3.68; 3.30-4.10 in 2000) or HRT (RR of 2.08; 1.64-2.64 in 1995 and RR of 1.44; 1.17-1.77 in 2000), particularly among women who had not had prior use. The fact of having a fracture status does significantly affect the RR of having at least one bone-specific drug prescription filled only among women without prior use (RR of 1.71; 1.26-2.33 in 1996 and RR of 1.77; 1.44-2.19 in 2000). The fact of being younger did not affect the RR of having at least one prescription of bone-specific drugs filled, but being younger increased the RR of filling a prescription of HRT. Significant change was seen over time in the number of BMD tests ordered and ART use. Effective osteoporosis interventions are not optimal in the treatment of elderly women in a Canadian health-care system who have had an osteoporotic fracture, given that approximately 25% of women who had had an osteoporotic-related fracture were users of ART.

Impact of a cost sharing drug insurance plan on drug utilization among individuals receiving social assistance

Background: A cost-sharing drug insurance plan has been implemented among people receiving social assistance who had previously free access to medications. Objective: To assess the impact of this drug plan on the use of three classes of medications: inhaled corticosteroids, neuroleptics and anticonvulsants. Methods: From the computerized drug databases of the Régie de l'assurance maladie du Québec (RAMQ), we selected three random samples of Quebec residents receiving social assistance between August 1992 and June 1997 and aged 64 years or less: 55 890 users of inhaled corticosteroids, 29 461 users of neuroleptics and 44 916 users of anticonvulsants. We also obtained data for individuals privately insured by the Commission de la construction du Québec (control group). Comparison of the monthly consumption of medications before and after the new drug plan was done using time series models. Results: For individuals receiving social assistance and using inhaled corticosteroids, we observed a statistically significant decrease of 37% of the monthly consumption for the 11 months following the new drug plan. For neuroleptics and anticonvulsants, we observed a non significant decrease of 9 and 10%, respectively. No decrease in drug consumption was observed in the control group. Conclusion: Inhaled corticosteroids was the only class of medications that was found to decrease significantly after the implementation of the drug insurance plan.

Cost of prescribed NSAID-related gastrointestinal adverse events in elderly patients.

It is well established that nonsteroidal anti-inflammatory drugs (NSAIDs) have gastrointestinal (GI) side-effects. However, the cost of health care resources spent on preventing and managing these side-effects is not clear. The objective of this study was to estimate the direct cost of NSAID-related GI events in an elderly population. From the Régie de l'assurance-maladie du Québec (RAMQ) database, we obtained medical, pharmaceutical and demographic records of a 10% random sample (n = 49 033) of seniors who, between January 1, 1993 and December 31, 1997, had a dispensed prescription of a NSAID. Patients who did not have any GI events during the year prior to their first dispensed prescription were included in the cohort. All patients were followed-up for 2 years. The daily direct Canadian dollar costs of GI events that were incurred by these patients while they were on NSAID therapy were compared with those of GI events that were incurred by these same patients while they were not on NSAID therapy. The difference in these daily costs was attributed to NSAIDs. A total of 12 082 new NSAID users were included in the study. Two hundred and seventeen (1.8%) were hospitalized for GI-related problems; of these, 130 (60%) had their GI hospitalization as their first GI event; 3257 (27.0%) used gastroprotective agents (GPAs), and 857 (26.3%) took GPAs without any apparent prior GI symptoms; 801 (6.6%) had GI diagnostic tests; and 661 (5.5%) died. The average direct costs of GI side-effects per patient-day on NSAIDs were 3.5 times higher than those of a patient-day not on NSAIDs. The direct cost of GI side-effects per patient-day on NSAIDs was $1.34, of which more than 70% ($0.94) was attributed to GI events resulting from NSAID treatment. Approximately one Canadian dollar was added to patient costs for every day he/she was on NSAID therapy. Safer therapies and appropriate patient risk management may potentially reduce NSAID-related health care resource use.

Incontinence Drug Utilization Patterns in Québec, Canada

Objective To assess prescription renewal and switch rates in an elderly population receiving oxybutynin or flavoxate for treatment of urinary incontinence in Quebec. Methods Sociodemographic, clinical, and drug claim data for patients ⩾65 years of age, with at least one claim for oxybutynin or flavoxate between January 1, 1994 and December 31, 1997, were randomly extracted from a database maintained by the Régie de l'assurance maladie du Québec (RAMQ). Rates of renewal of the first drug claim and the number of patients switching from one incontinence drug to the other were determined. In addition, survival curves defining the time until cessation of initial treatment were constructed. Results The oxybutynin (n = 5718) and flavoxate (n = 972) treatment groups were similar in terms of gender (62.1% female) and age (mean age 77). For oxybutynin, 56.8% of the claims were written by general practitioners and 36.6% by urologists compared to 40.5% by general practitioners and 51.4% by urologists for flavoxate. Only 39.3% of the oxybutynin patients renewed their first claims, compared to 36.6% of the flavoxate group. Switch rates were higher for flavoxate patients with more than twice as many patients switching from this drug to oxybutynin than vice versa. Survival curves indicated that there was only an 11.4% probability of a patient taking oxybutynin for 6 months compared to 5.7% for flavoxate patients. Conclusions Drug claim renewal rates were low for both oxybutynin and flavoxate, suggesting that money spent on these therapies provides an inadequate clinical return on investment since the majority of patients discontinue treatment prematurely.