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1.  Investigation of test characteristics of two screening tools in comparison with a gold standard assessment to detect developmental delay at 36 months: A pilot study 
Paediatrics & Child Health  2012;17(10):549-552.
The ability of the Rourke Baby Record (Rourke) and the Nipissing District Developmental Screen (NDDS) to detect developmental delay is not known.
To determine the test characteristics of the Rourke and NDDS compared with the Bayley Scales of Infant and Toddler Development III for detecting developmental delay in high-risk children.
Three-year-olds were recruited from the IWK Health Centre (Halifax, Nova Scotia). Two cut-points were evaluated (one and two or more areas of concern) from the Rourke and NDDS, and were compared with a score of ≤85 on the Bayley Scales of Infant and Toddler Development III.
The majority (67.7%) of the 31 participants reported no concern. At one area of concern, sensitivity was 75% for both the Rourke and NDDS. When two areas of concern were noted, specificity was 93% for the Rourke and 96% for NDDS.
Both the Rourke and the NDDS appear to be reasonably sensitive and specific, but further investigation is warranted.
PMCID: PMC3549691  PMID: 24294061
Developmental delay; Developmental screening; Developmental surveillance
Hypertension  2011;57(5):891-897.
We designed this study to explore to what extent the excess risk of cardiovascular events in diabetic individuals is attributable to hypertension. We retrospectively analyzed prospectively collected data from the Framingham Original and Offspring cohorts. Of the 1145 Framingham subjects newly diagnosed with diabetes who did not have a prior history of cardiovascular events, 663 (58%) had hypertension at the time diabetes was diagnosed. During 4154 person-years of follow-up, 125 died and 204 suffered a cardiovascular event. Framingham participants with hypertension at the time of diabetes diagnosis exhibited higher rates of all cause mortality (32 versus 20 per 1000 person years, p<0.001) and cardiovascular events (52 versus 31 per 1000 person years, p<0.001) compared with normotensive subjects with diabetes. After adjustment for demographic and clinical covariates, hypertension was associated with a 72% increase in the risk of all cause death and a 57% increase in the risk of any cardiovascular event in individuals with diabetes. The population attributable risk from hypertension in individuals with diabetes was 30% for all-cause death and 25% for any cardiovascular event (increasing to 44% and 41% respectively if the 110 normotensive subjects who developed hypertension during follow-up were excluded from the analysis). In comparison, after adjustment for concurrent hypertension, the population attributable risk from diabetes in Framingham subjects was 7% for all cause mortality and 9% for any CVD event. While diabetes is associated with increased risks of death and cardiovascular events in Framingham subjects, much of this excess risk is attributable to coexistent hypertension.
PMCID: PMC3785072  PMID: 21403089
diabetes; hypertension; Framingham; population attributable risk
3.  Implementation of ICD-10 in Canada: how has it impacted coded hospital discharge data? 
The purpose of this study was to assess whether or not the change in coding classification had an impact on diagnosis and comorbidity coding in hospital discharge data across Canadian provinces.
This study examined eight years (fiscal years 1998 to 2005) of hospital records from the Hospital Person-Oriented Information database (HPOI) derived from the Canadian national Discharge Abstract Database. The average number of coded diagnoses per hospital visit was examined from 1998 to 2005 for provinces that switched from International Classifications of Disease 9th version (ICD-9-CM) to ICD-10-CA during this period. The average numbers of type 2 and 3 diagnoses were also described. The prevalence of the Charlson comorbidities and distribution of the Charlson score one year before and one year after ICD-10 implementation for each of the 9 provinces was examined. The prevalence of at least one of the seventeen Charlson comorbidities one year before and one year after ICD-10 implementation were described by hospital characteristics (teaching/non-teaching, urban/rural, volume of patients).
Nine Canadian provinces switched from ICD-9-CM to ICD-I0-CA over a 6 year period starting in 2001. The average number of diagnoses coded per hospital visit for all code types over the study period was 2.58. After implementation of ICD-10-CA a decrease in the number of diagnoses coded was found in four provinces whereas the number of diagnoses coded in the other five provinces remained similar. The prevalence of at least one of the seventeen Charlson conditions remained relatively stable after ICD-10 was implemented, as did the distribution of the Charlson score. When stratified by hospital characteristics, the prevalence of at least one Charlson condition decreased after ICD-10-CA implementation, particularly for low volume hospitals.
In conclusion, implementation of ICD-10-CA in Canadian provinces did not substantially change coding practices, but there was some coding variation in the average number of diagnoses per hospital visit across provinces.
PMCID: PMC3411494  PMID: 22682405
International classification of disease version 10; Administrative data; Hospital records; Canada; Coding; Hospital discharge data
4.  Diagnosed hypertension in Canada: incidence, prevalence and associated mortality 
Hypertension is a leading risk factor for cardiovascular diseases. Our objectives were to examine the prevalence and incidence of diagnosed hypertension in Canada and compare mortality among people with and without diagnosed hypertension.
We obtained data from linked health administrative databases from each province and territory for adults aged 20 years and older. We used a validated case definition to identify people with hypertension diagnosed between 1998/99 and 2007/08. We excluded pregnant women from the analysis.
This retrospective population-based study included more than 26 million people. In 2007/08, about 6 million adults (23.0%) were living with diagnosed hypertension and about 418 000 had a new diagnosis. The age-standardized prevalence increased significantly from 12.5% in 1998/99 to 19.6% in 2007/08, and the incidence decreased from 2.7 to 2.4 per 100. Among people aged 60 years and older, the prevalence was higher among women than among men, as was the incidence among people aged 75 years and older. The prevalence and incidence were highest in the Atlantic region. For all age groups, all-cause mortality was higher among adults with diagnosed hypertension than among those without diagnosed hypertension.
The overall prevalence of diagnosed hypertension in Canada from 1998 to 2008 was high and increasing, whereas the incidence declined during the same period. These findings highlight the need to continue monitoring the effectiveness of efforts for managing hypertension and to enhance public health programs aimed at preventing hypertension.
PMCID: PMC3255225  PMID: 22105752
5.  Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades 
Analyses of medication databases indicate marked increases in prescribing of antihypertensive drugs in Canada over the past decade. This study was done to examine the trends in the prevalence of hypertension and in control rates in Canada between 1992 and 2009.
Three population-based surveys, the 1986–1992 Canadian Heart Health Surveys, the 2006 Ontario Survey on the Prevalence and Control of Hypertension and the 2007–2009 Canadian Health Measures Survey, collected self-reported health information from, and measured blood pressure among, community-dwelling adults.
The population prevalence of hypertension was stable between 1992 and 2009 at 19.7%–21.6%. Hypertension control improved from 13.2% (95% confidence interval [CI] 10.7%–15.7%) in 1992 to 64.6% (95% CI 60.0%–69.2%) in 2009, reflecting improvements in awareness (from 56.9% [95% CI 53.1%–60.5%] in 1992 to 82.5% [95% CI 78.5%–86.0%] in 2009) and treatment (from 34.6% [95% CI 29.2%–40.0%] in 1992 to 79.0% [95% CI 71.3%–86.7%] in 2009) among people with hypertension. The size of improvements in awareness, treatment and control were similar among people who had or did not have cardiovascular comorbidities Although systolic blood pressures among patients with untreated hypertension were similar between 1992 and 2009 (ranging from 146 [95% CI 145–147] mm Hg to 148 [95% CI 144–151] mm Hg), people who did not have hypertension and patients with hypertension that was being treated showed substantially lower systolic pressures in 2009 than in 1992 (113 [95% CI 112–114] v. 117 [95% CI 117–117] mm Hg and 128 [95% CI 126–130] v. 145 [95% CI 143–147] mm Hg).
The prevalence of hypertension has remained stable among community-dwelling adults in Canada over the past two decades, but the rates for treatment and control of hypertension have improved markedly during this time.
PMCID: PMC3114892  PMID: 21576297
6.  Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study 
BMJ Open  2011;1(1):e000101.
The objective of this study was to compare international trends in pre-eclampsia rates and in overall pregnancy hypertension rates (including gestational hypertension, pre-eclampsia and eclampsia).
Population data (from birth and/or hospital records) on all women giving birth were available from Australia (two states), Canada (Alberta), Denmark, Norway, Scotland, Sweden and the USA (Massachusetts) for a minimum of 6 years from 1997 to 2007. All countries used the 10th revision of the International Classification of Diseases, except Massachusetts which used the 9th revision. There were no major changes to the diagnostic criteria or methods of data collection in any country during the study period. Population characteristics as well as rates of pregnancy hypertension and pre-eclampsia were compared.
Absolute rates varied across the populations as follows: pregnancy hypertension (3.6% to 9.1%), pre-eclampsia (1.4% to 4.0%) and early-onset pre-eclampsia (0.3% to 0.7%). Pregnancy hypertension and/or pre-eclampsia rates declined over time in most populations. This was unexpected given that factors associated with pregnancy hypertension such as pre-pregnancy obesity and maternal age are generally increasing. However, there was also a downward shift in gestational age with fewer pregnancies reaching 40 weeks.
The rate of pregnancy hypertension and pre-eclampsia decreased in northern Europe and Australia from 1997 to 2007, but increased in Massachusetts. The use of a different International Classification of Diseases coding version in Massachusetts may contribute to the difference in trend. Elective delivery prior to the due date is the most likely explanation for the decrease observed in Europe and Australia. Also, the use of interventions that reduce the risk of pregnancy hypertension and/or progression to pre-eclampsia (low-dose aspirin, calcium supplementation and early delivery for mild hypertension) may have contributed to the decline.
Article summary
Article focus
The population prevalence of factors associated with increased and decreased risk of pregnancy hypertension and pre-eclampsia has changed over time, but the impact of these changes is unknown.
International comparisons of absolute population rates of pregnancy hypertension and pre-eclampsia are hindered by different diagnostic criteria and methods of data collection.
Comparing trends between countries overcomes the difficulties in comparing absolute rates.
Key message
Pregnancy hypertension and/or pre-eclampsia rates declined over time in northern Europe and Australia, but not Massachusetts (USA).
Declining hypertension rates were accompanied by a downward shift in gestational age with fewer pregnancies reaching term, the time when the pregnancy hypertension and pre-eclampsia are most likely to occur.
Strengths and limitations of this study
Strengths include numerous validation studies indicating that the hypertensive disorders are reliably reported in the population data sets used for the study and the consistency of trends across most countries.
Limitations include a different International Classification of Diseases coding version in Massachusetts and lack of available information on clinical interventions.
PMCID: PMC3191437  PMID: 22021762
Trends; pregnancy; pre-eclampsia; gestational hypertension; international classification of diseases; maternal medicine; obstetrics; hypertension; epidemiology; statistics; epidmiology; delivery; birth; infant mortality; information; public health; health economics; health policy; international health services; quality in healthcare; health and socio-economic inequalities; maternal and child health; statistics and research methods; parturition; preterm birth
7.  Hypertension: Are you and your patients up to date? 
While there have been substantive efforts to improve treatment and control of hypertension in Canada, many individuals with hypertension remain unaware of their condition and many health care professionals are unaware of key hypertension management recommendations. The present article reviews the new Canadian strategic direction for increased knowledge translation and dissemination of information to patients and health care professionals by providing new, innovative and easily accessible resources for hypertension education in Canada. A multitude of resources that address the diverse learning needs of health care professionals and the general public are highlighted.
PMCID: PMC2886557  PMID: 20485691
Dissemination; Education; Educational resources; High blood pressure; Hypertension; Knowledge translation
8.  Home blood pressure monitoring among Canadian adults with hypertension: Results from the 2009 Survey on Living with Chronic Diseases in Canada 
The Canadian Journal of Cardiology  2010;26(5):e152-e157.
Canadians with hypertension are recommended to use home blood pressure monitoring (HBPM) on a regular basis.
To characterize the use of HBPM among Canadian adults with hypertension.
Respondents to the 2009 Survey on Living with Chronic Diseases in Canada who reported diagnosis of hypertension by a health professional (n=6142) were asked about blood pressure monitoring practices, sociodemographic characteristics, management of hypertension and blood pressure control.
Among Canadian adults with hypertension, 45.9% (95% CI 43.5% to 48.3%) monitor their own blood pressure at home, 29.7% (95% CI 41.1% to 46.3%) receive health professional instruction and 35.9% (95% CI 33.5% to 38.4%) share the results with their health professional. However, fewer than one in six Canadian adults diagnosed with hypertension monitor their own blood pressure at home regularly, with health professional instruction, and communicate results to a health professional. Regular HBPM was more likely among older adults (45 years of age and older); individuals who believed they had a plan for how to control their blood pressure; and those who had been shown how to perform HBPM by a health professional – with the latter factor most strongly associated with regular HBPM (prevalence rate ratio 2.8; 95% CI 2.4 to 3.4).
Although many Canadians with hypertension measure their blood pressure between health care professional visits, a minority do so according to current recommendations. More effective knowledge translation strategies are required to support self-management of hypertension through home measurement of blood pressure.
PMCID: PMC2886560  PMID: 20485694
Home blood pressure monitoring; Hypertension; Patient education; Self-management
9.  Identification of factors driving differences in cost effectiveness of first-line pharmacological therapy for uncomplicated hypertension 
The Canadian Journal of Cardiology  2010;26(5):e158-e163.
Published practice guidelines and economic evaluations have come to different conclusions regarding optimal pharmacotherapy for the treatment of uncomplicated hypertension. The drivers of these disparities are not clear. Greater understanding is needed for clinicians, researchers and policy makers to determine the most effective and sustainable strategies.
To identify how cost and cost-effectiveness considerations are used to generate recommendations by major hypertension guidelines, and determine key drivers of cost-effectiveness conclusions in available economic evaluations.
A systematic search and narrative review of major hypertension guidelines and health technology assessments of first-line antihypertensive therapy were performed.
Of the eight guidelines identified, formal cost-effectiveness analysis was rarely integrated in the formulation of recommendations. When guidelines considered costs, recommendations remained incongruent. Two economic evaluations were identified (United Kingdom and Canada); however, these differed in their conclusion of the most cost-effective agent and attractiveness of calcium channel blockers. Review of these economic evaluations suggests that cost-effectiveness conclusions are strongly influenced by relative costs of drug classes; when relative differences in drug costs are lower, the impact on associated conditions such as heart failure and diabetes influences cost-effectiveness conclusions.
In the setting of finite health care resources and significant budget impact due to high population prevalence, cost effectiveness is an important consideration in the treatment of uncomplicated hypertension. Identification of key drivers of cost effectiveness will assist interpretation and conduct of current and future economic evaluations.
PMCID: PMC2886561  PMID: 20485695
Clinical practice guidelines; Cost; Cost effectiveness; Hypertension; Pharmacotherapy
10.  Incidence of gestational hypertension in the Calgary Health Region from 1995 to 2004 
The Canadian Journal of Cardiology  2009;25(8):e284-e287.
Hypertension is one of the most common medical conditions complicating pregnancy, and is a major contributor to maternal, fetal and neonatal morbidity and mortality in Canada.
To determine the incidence and trends of gestational hypertension among pregnant women in the Calgary Health Region of Alberta.
Gestational hypertension was classified according to current published Canadian guidelines: without proteinuria and with proteinuria. Hospital discharge abstracts were used to identify women diagnosed with gestational hypertension in the Calgary Health Region between January 1995 and December 2004. The Birth Registry of Vital Statistics was used to determine the number of live births and stillbirths in the Calgary Health Region during the study period. Incidence was calculated with 95% CIs. Age-standardized gestational hypertension rates were calculated using 2004 live births and stillbirths as the reference.
Over the 10-year period, the incidence of nonproteinuric gestational hypertension was relatively stable even after age adjustment, with an average incidence of 6.3% (95% CI 6.1% to 6.4%). When gestational hypertension was stratified by age, women aged 35 years or older had an almost twofold higher incidence of both nonproteinuric and proteinuric gestational hypertension than those younger than 35 years of age.
Interventions to prevent and improve the management of gestational hypertension, particularly among women aged 35 years and older, are required.
PMCID: PMC2732383  PMID: 19668790
Alberta; Gestational hypertension; Incidence; Pregnancy
11.  Authors' opinions on publication in relation to annual performance assessment 
BMC Medical Education  2010;10:21.
In the past 50 years there has been a substantial increase in the volume of published research and in the number of authors per scientific publication. There is also significant pressure exerted on researchers to produce publications. Thus, the purpose of this study was to survey corresponding authors in published medical journals to determine their opinion on publication impact in relation to performance review and promotion.
Cross-sectional survey of corresponding authors of original research articles published in June 2007 among 72 medical journals. Measurement outcomes included the number of publications, number of authors, authorship order and journal impact factor in relation to performance review and promotion.
Of 687 surveys, 478 were analyzed (response rate 69.6%). Corresponding authors self-reported that number of publications (78.7%), journal impact factor (67.8%) and being the first author (75.9%) were most influential for their annual performance review and assessment. Only 17.6% of authors reported that the number of authors on a manuscript was important criteria for performance review and assessment. A higher percentage of Asian authors reported that the number of authors was key to performance review and promotion (41.4% versus 7.8 to 22.2%). compared to authors from other countries.
The number of publications, authorship order and journal impact factor were important factors for performance reviews and promotion at academic and non-academic institutes. The number of authors was not identified as important criteria. These factors may be contributing to the increase in the number of authors per publication.
PMCID: PMC2842280  PMID: 20214826
13.  The influence of onsets and offsets on saccade programming 
i-Perception  2010;1(2):83-94.
When making a saccadic eye movement to a peripheral target, a simultaneous stimulus onset at central fixation generally increases saccadic latency, while offsets reduce latency (‘gap effect’). Visual onsets remote from fixation also increase latency (‘remote distractor effect’); however, the influence of remote visual offsets is less clear. Previous studies, which used a search task, found that remote offsets either facilitated, inhibited, or did nothing to saccade latencies towards a peripheral target. It cannot be excluded, however, that the target selection process in such search tasks influenced the results. We therefore simplified the task and asked participants to make eye movements to a predictable target. Simultaneously with target onset, either one or multiple remote stimulus onsets and offsets were presented. It was found that peripheral onsets increased saccade latencies, but offsets did not influence the initiation of a saccade to the target. Moreover, the number of onsets and offsets did not affect the results. These results suggest that earlier effects of remote stimulus offsets and of the number of remote distractor onsets reside in the target identification process of the visual search task rather than the competition between possible saccade goals. The results are discussed in the context of models of saccade target selection.
PMCID: PMC3563056  PMID: 23397028
eye movements; remote distractor effect; saccadic response times
14.  Improving the quality of care for infants: a cluster randomized controlled trial 
We developed and tested a new method, called the Evidence-based Practice for Improving Quality method, for continuous quality improvement.
We used cluster randomization to assign 6 neonatal intensive care units (ICUs) to reduce nosocomial infection (infection group) and 6 ICUs to reduce bronchopulmonary dysplasia (pulmonary group). We included all infants born at 32 or fewer weeks gestation. We collected baseline data for 1 year. Practice change interventions were implemented using rapid-change cycles for 2 years.
The difference in incidence trends (slopes of trend lines) between the ICUs in the infection and pulmonary groups was − 0.0020 (95% confidence interval [CI] − 0.0007 to 0.0004) for nosocomial infection and − 0.0006 (95% CI − 0.0011 to − 0.0001) for bronchopulmonary dysplasia.
The results suggest that the Evidence-based Practice for Improving Quality method reduced bronchopulmonary dysplasia in the neonatal ICU and that it may reduce nosocomial infection.
PMCID: PMC2761437  PMID: 19667033
15.  Trends in antihypertensive drug prescriptions and physician visits in Canada between 1996 and 2006 
In 1999, the Canadian Hypertension Education Program (CHEP) was launched to develop and implement evidence-based hypertension guidelines.
To determine temporal trends in antihypertensive drug prescribing and physician visits for hypertension in Canada, and correlate these trends with CHEP recommendations.
Longitudinal drug data (Intercontinental Medical Statistics [IMS] CompuScript database; IMS Health Canada) were used to examine prescriptions over an 11-year period (1996 to 2006) for five major cardiovascular drug classes. The IMS Canadian Disease and Therapeutic Index database was used to determine trends in physician office visits for hypertension.
Prescriptions for antihypertensive agents increased significantly over the 11-year period (4054% for angiotensin receptor blockers, 127% for thiazide diuretics, 108% for angiotensin-converting enzyme inhibitors, 87% for beta-blockers and 55% for calcium channel blockers). Time series analyses demonstrated increases in the growth rate for all drug classes, with the greatest annual change in prescriptions occurring during the 1999 to 2002 time period (except in angiotensin receptor blockers). An increase in prescriptions for fixed-dose combination products occurred, which was temporally related to the change in CHEP recommendations encouraging their use in 2001. The proportion of physician office visits for hypertension increased significantly from 4.9% in 1995 to 6.8% in 2005 (P<0.001).
The largest increase in antihypertensive drug prescribing occurred in the period immediately following implementation of CHEP (1999 to 2002). Although prescribing rates are still increasing, the rate of change has decreased, suggesting that the treatment market for hypertension may be becoming saturated. The impact of these changes on blood pressure control and clinical outcomes remains to be determined.
PMCID: PMC2643197  PMID: 18548150
Drug therapy; Hypertension
16.  Measuring agreement of administrative data with chart data using prevalence unadjusted and adjusted kappa 
Kappa is commonly used when assessing the agreement of conditions with reference standard, but has been criticized for being highly dependent on the prevalence. To overcome this limitation, a prevalence-adjusted and bias-adjusted kappa (PABAK) has been developed. The purpose of this study is to demonstrate the performance of Kappa and PABAK, and assess the agreement between hospital discharge administrative data and chart review data conditions.
The agreement was compared for random sampling, restricted sampling by conditions, and case-control sampling from the four teaching hospitals in Alberta, Canada from ICD10 administrative data during January 1, 2003 and June 30, 2003. A total of 4,008 hospital discharge records and chart view, linked for personal unique identifier and admission date, for 32 conditions of random sampling were analyzed. The restricted sample for hypertension, myocardial infarction and congestive heart failure, and case-control sample for those three conditions were extracted from random sample. The prevalence, kappa, PABAK, positive agreement, negative agreement for the condition was compared for each of three samples.
The prevalence of each condition was highly dependent on the sampling method, and this variation in prevalence had a significant effect on both kappa and PABAK. PABAK values were obviously high for certain conditions with low kappa values. The gap between these two statistical values for the same condition narrowed as the prevalence of the condition approached 50%.
Kappa values varied more widely than PABAK values across the 32 conditions. PABAK values should usually not be interpreted as measuring the same agreement as kappa in administrative data, particular for the condition with low prevalence. There is no single statistic measuring agreement that captures the desired information for validity of administrative data. Researchers should report kappa, the prevalence, positive agreement, negative agreement, and the relative frequency in each cell (i.e. a, b, c and d) to enable the reader to judge the validity of administrative data from multiple aspects.
PMCID: PMC2636838  PMID: 19159474
18.  Critical care procedure logging using handheld computers 
Critical Care  2004;8(5):R336-R342.
We conducted this study to evaluate the feasibility of implementing an internet-linked handheld computer procedure logging system in a critical care training program.
Subspecialty trainees in the Interdepartmental Division of Critical Care at the University of Toronto received and were trained in the use of Palm handheld computers loaded with a customized program for logging critical care procedures. The procedures were entered into the handheld device using checkboxes and drop-down lists, and data were uploaded to a central database via the internet. To evaluate the feasibility of this system, we tracked the utilization of this data collection system. Benefits and disadvantages were assessed through surveys.
All 11 trainees successfully uploaded data to the central database, but only six (55%) continued to upload data on a regular basis. The most common reason cited for not using the system pertained to initial technical problems with data uploading. From 1 July 2002 to 30 June 2003, a total of 914 procedures were logged. Significant variability was noted in the number of procedures logged by individual trainees (range 13–242). The database generated by regular users provided potentially useful information to the training program director regarding the scope and location of procedural training among the different rotations and hospitals.
A handheld computer procedure logging system can be effectively used in a critical care training program. However, user acceptance was not uniform, and continued training and support are required to increase user acceptance. Such a procedure database may provide valuable information that may be used to optimize trainees' educational experience and to document clinical training experience for licensing and accreditation.
PMCID: PMC1065023  PMID: 15469577
critical care; handheld computers; internet; procedure logging; training program
20.  Community education on preterm birth. Does it change practice? 
Canadian Family Physician  2002;48:727-734.
OBJECTIVE: To evaluate how well physicians and other prenatal care providers educate women about early recognition of and appropriate response to the signs and symptoms of preterm labour (PTL). To assess use of antenatal steroids for babies born at less than 34 weeks' gestation. DESIGN: Before-after study using a population-based approach. SETTING: Health care providers' offices, hospitals, and prenatal classes in Ottawa, Ont. PARTICIPANTS: Prenatal care providers, women in hospital after giving birth, prenatal class participants. INTERVENTIONS: Prenatal care providers received information and educational materials on PTL and preterm birth (PTB). They passed this information on to pregnant women at their 18- to 20-week prenatal visits. Teachers of prenatal classes gave the same information in early-series classes. Clinical practice guidelines were developed, and hospital staff received education on appropriate response to PTL. MAIN OUTCOME MEASURES: Use of educational materials and steroid treatment. RESULTS: Statistically significant increases were seen in the numbers of care providers who had educational material about PTL and PTB, who reported giving the educational material to all women, and who reported discussing signs and symptoms of PTL and PTB with all women; women who reported that their care providers talked with them about PTL and PTB, and women delivering preterm (< 34 weeks) babies who received steroids. CONCLUSION: Providing knowledge and standardized educational materials to health care providers can help improve preventive practice for PTL and educate women about PTL.
PMCID: PMC2214030  PMID: 12046368
21.  Variations in mortality rates among Canadian neonatal intensive care units 
Most previous reports of variations in mortality rates for infants admitted to neonatal intensive care units (NICUs) have involved small groups of subpopulations, such as infants with very low birth weight. Our aim was to examine the incidence and causes of death and the risk-adjusted variation in mortality rates for a large group of infants of all birth weights admitted to Canadian NICUs.
We examined the deaths that occurred among all 19 265 infants admitted to 17 tertiary-level Canadian NICUs from January 1996 to October 1997. We used multivariate analysis to examine the risk factors associated with death and the variations in mortality rates, adjusting for risks in the baseline population, severity of illness on admission and whether the infant was outborn (born at a different hospital from the one where the NICU was located).
The overall mortality rate was 4% (795 infants died). Forty percent of the deaths (n = 318) occurred within 2 days of NICU admission, 50% (n = 397) within 3 days and 75% (n = 596) within 12 days. The major conditions associated with death were gestational age less than 24 weeks (59 deaths [7%]), gestational age 24–28 weeks (325 deaths [41%]), outborn status (340 deaths [42%]), congenital anomalies (270 deaths [34%]), surgery (141 deaths [18%]), infection (108 deaths [14%]), hypoxic–ischemic encephalopathy (128 deaths [16%]) and small for gestational age (i.e., less than the third percentile) (77 deaths [10%]). There was significant variation in the risk-adjusted mortality rates (range 1.6% to 5.5%) among the 17 NICUs.
Most NICU deaths occurred within the first few days after admission. Preterm birth, outborn status and congenital anomalies were the conditions most frequently associated with death in the NICU. The significant variation in risk-adjusted mortality rates emphasizes the importance of risk adjustment for valid comparison of NICU outcomes.
PMCID: PMC99269  PMID: 11826939

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