The Statistics of Canada

IntroductionA Cochrane systematic review was undertaken to answer the question: "does legislation to ban or restrict tobacco smoking reduce exposure to secondhand smoke and smoking behaviour?"Relevance for nursingSmoking bans are environmental, population-focused approaches that aim to rReducetion in both tobacco smoking behaviours and secondhand smoke exposure. through smoking bans impact the environment and hence population health. Often bans are accompanied by education regarding the need for the ban and support services thato help smokers use the opportunity to quit or reduce their tobacco consumption. Therefore, smoking bans can be associated with the 'settings approach' to health promotion derived from the World Health Organisation's Ottawa Charter (1986). Thise Charter supports population and individual health through integrated, coordinated and multi-dimensional interventions.Study characteristicsAThis was a Cochrane systematic review was undertaken thatwhich produced a 'narrative only' synthesis of 50 studies. Studies (with reported numbers of participants) had samples ranging from of 24 to 10413 subjects. No randomised controlled trials were identified that met review inclusion criteria., Nonethelesshowever, 13 non-randomised controlled studies (quasi-experimental designs) were included; of these 7, were located in a general or workplace setting and 6six related to hospital admissions. A further 37 studies which lacked a control group but recorded data from participants pre and post intervention were also included in the review. In total, In 16 16 of reviewed studies used random sampling was used to select participants from a target population, 11 employed convenience sampling, 5five used randomly selected clusters of bars/public houses; 5five sampling methods were unclear and 2two studies utilised mixed sampling methods.No age, gender or geographic limits were placed on study samples included in the review. ReviewedIncluded studies followed participants for a minimum of six months following the ban (except for 8 studies which measured exposure to second hand smoke). Eight study authors identified that small sample size or low statistical power limited the generalisability of their research findings. No age, gender or geographic limit was placed on participants in reviewed studies. A risk of bias summary table was not included in the review; however, the reviewers note that one source of bias (blinding participants to receipt of the intervention) was not possible in any study, due to the nature of the ban interventions. Eight study authors identified that small sample size or low statistical power was a limitation to the generalisability of their research findings.The most commonly reviewed intervention was a comprehensive legislative ban on indoor smoking that was comprehensive within indoor sites (a total ban in 40 studies). An additional 10Ten ?restriction' intervention studies were also included ; these permitted which the reviewers classified as 'restrictions' as they allowed smoking within a designated area. Twenty two of the reviewed studies were conducted in workplaces, most of these (19) targeted the health of hospitality workers in bars or restaurants. The reviewed studies included bans in 13 countries, mostly the USA (17) or Scotland (8). Exposure to secondhand smoke was collectedmeasured by participants' self-report recordingof either the 'duration of exposure' or 'percentage sample exposed'. Some researchers (mostly those conducting large population studies) also took biochemical samples e.g. of saliva, to validate self-reports. Measures such as: smoking prevalence, tobacco consumption, smoking cessation, and respiratory, cardiac or sensory health outcomes were also considered by the reviewers. …

Legislative Smoking Bans for Reducing Secondhand Smoke Exposure, Smoking Prevalence and Tobacco Consumption

Importance The effect of continuing vs withdrawing treatment with semaglutide, a glucagon-like peptide 1 receptor agonist, on weight loss maintenance in people with overweight or obesity is unknown. Objective To compare continued once-weekly treatment with subcutaneous semaglutide, 2.4 mg, with switch to placebo for weight maintenance (both with lifestyle intervention) in adults with overweight or obesity after a 20-week run-in with subcutaneous semaglutide titrated to 2.4 mg weekly. Design, setting, and participants Randomized, double-blind, 68-week phase 3a withdrawal study conducted at 73 sites in 10 countries from June 2018 to March 2020 in adults with body mass index of at least 30 (or ≥27 with ≥1 weight-related comorbidity) and without diabetes. Interventions A total of 902 participants received once-weekly subcutaneous semaglutide during run-in. After 20 weeks (16 weeks of dose escalation; 4 weeks of maintenance dose), 803 participants (89.0%) who reached the 2.4-mg/wk semaglutide maintenance dose were randomized (2:1) to 48 weeks of continued subcutaneous semaglutide (n = 535) or switched to placebo (n = 268), plus lifestyle intervention in both groups. Main outcomes and measures The primary end point was percent change in body weight from week 20 to week 68; confirmatory secondary end points were changes in waist circumference, systolic blood pressure, and physical functioning (assessed using the Short Form 36 Version 2 Health Survey, Acute Version [SF-36]). Results Among 803 study participants who completed the 20-week run-in period (with a mean weight loss of 10.6%) and were randomized (mean age, 46 [SD, 12] years; 634 [79%] women; mean body weight, 107.2 kg [SD, 22.7 kg]), 787 participants (98.0%) completed the trial and 741 (92.3%) completed treatment. With continued semaglutide, mean body weight change from week 20 to week 68 was -7.9% vs +6.9% with the switch to placebo (difference, -14.8 [95% CI, -16.0 to -13.5] percentage points; P Conclusions and relevance Among adults with overweight or obesity who completed a 20-week run-in period with subcutaneous semaglutide, 2.4 mg once weekly, maintaining treatment with semaglutide compared with switching to placebo resulted in continued weight loss over the following 48 weeks. Trial registration ClinicalTrials.gov Identifier: NCT03548987.

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Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial

Levers for addressing medical underuse and overuse: achieving high-value health care

Although quality improvement (QI) is frequently advocated as a way of addressing the problems with healthcare, evidence of its effectiveness has remained very mixed. The reasons for this are varied but the growing literature highlights particular challenges. Fidelity in the application of QI methods is often variable. QI work is often pursued through time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required. There is insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures. Too many QI interventions are seen as 'magic bullets' that will produce improvement in any situation, regardless of context. Too much improvement work is undertaken in isolation at a local level, failing to pool resources and develop collective solutions, and introducing new hazards in the process. This article considers these challenges and proposes four key ways in which QI might itself be improved.

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Does quality improvement improve quality

Purpose: Lean is a widely used quality improvement methodology initially developed and used in the automotive and manufacturing industries but recently expanded to the healthcare sector. This systematic literature review seeks to independently assess the effect of Lean or Lean interventions on worker and patient satisfaction, health and process outcomes, and financial costs. Data sources: We conducted a systematic literature review of Medline, PubMed, Cochrane Library, CINAHL, Web of Science, ABI/Inform, ERIC, EMBASE and SCOPUS. Study selection: Peer reviewed articles were included if they examined a Lean intervention and included quantitative data. Methodological quality was assessed using validated critical appraisal checklists. Publically available data collected by the Saskatchewan Health Quality Council and the Saskatchewan Union of Nurses were also analysed and reported separately. Data extraction: Data on design, methods, interventions and key outcomes were extracted and collated. Results of data synthesis: Our electronic search identified 22 articles that passed methodological quality review. Among the accepted studies, 4 were exclusively concerned with health outcomes, 3 included both health and process outcomes and 15 included process outcomes. Our study found that Lean interventions have: (i) no statistically significant association with patient satisfaction and health outcomes; (ii) a negative association with financial costs and worker satisfaction and (iii) potential, yet inconsistent, benefits on process outcomes like patient flow and safety. Conclusion: While some may strongly believe that Lean interventions lead to quality improvements in healthcare, the evidence to date simply does not support this claim. More rigorous, higher quality and better conducted scientific research is required to definitively ascertain the impact and effectiveness of Lean in healthcare settings.

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Lean interventions in healthcare: do they actually work? A systematic literature review.

Background
Adhering to weight loss interventions is difficult for many people. The majority of those who are overweight or obese and attempt to lose weight are simply not successful. The objectives of this study were 1) to quantify overall adherence rates for various weight loss interventions and 2) to provide pooled estimates for factors associated with improved adherence to weight loss interventions.

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Weight loss intervention adherence and factors promoting adherence: a meta-analysis.

Background Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence. Objectives The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications. Materials and methods We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model. Results Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence. Conclusion Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.

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Primary nonadherence to chronic disease medications: a meta-analysis.

Objective
To determine if antidepressant drug usage is associated with cognitive impairment or dementia, including Alzheimer disease (AD).

Method
We conducted a systematic search of Medline, PubMed, PsycINFO, Web of Science, Embase, CINAHL, and the Cochrane Library. An initial screen by abstracts and titles was performed, and relevant full articles were then reviewed and assessed for their methodologic quality. Crude effect estimates were extracted from the included articles and a pooled estimate was obtained using a random effects model.

Results
Five articles were selected from an initial pool of 4,123 articles. Use of antidepressant drugs was associated with a significant twofold increase in the odds of some form of cognitive impairment or dementia (OR = 2.17). Age was identified as a likely modifier of the association between antidepressant use and some form of cognitive impairment or AD/dementia. Studies that included participants with an average age equal to or greater than 65 years showed an increased odds of some form of cognitive impairment with antidepressant drug usage (OR = 1.65), whereas those with participants less than age 65 revealed an even stronger association (OR = 3.25).

Conclusions
Antidepressant drug usage is associated with AD/dementia and this is particularly evident if usage begins before age 65. This association may arise due to confounding by depression or depression severity. However, biological mechanisms potentially linking antidepressant exposure to dementia have been described, so an etiological effect of antidepressants is possible. With this confirmation that an association exists, clarification of underlying etiologic pathways requires urgent attention.

The association of antidepressant drug usage with cognitive impairment or dementia, including Alzheimer disease: A systematic review and meta-analysis.

Human papillomavirus (HPV) is the most commonly sexually transmitted infection in the world and the primary cause of cervical cancer. Canada introduced publicly funded HPV vaccination programs in 2006. The objectives of this study are twofold and aim to (1) determine the levels and (2) examine the various factors influencing vaccine uptake among the general Canadian population. A literature search was conducted on seven databases, followed by screening, methodological quality review (using modified Newcastle-Ottawa Scale), and data extraction. Pooled meta-analysis and a subgroup analysis were conducted stratifying by a number of variables (age, sex, type of program, and method of payment) determined apriori. A total of 718 peer-reviewed articles were initially identified with 12 remaining after screening and underwent methodological quality review. HPV vaccination uptake in Canada varied from 12.40% (95% confidence interval [CI] 6.77-20.26) to 88.20% (95% CI 85.72-90.39). The pooled random effects model showed the HPV vaccination uptake to be 55.92% (95% CI 44.87-66.65). The subgroup analysis showed that vaccination uptake was 66.95% (95% CI 55.00-77.89) in participants ≤ 18 years as compared to 13.58% (95% CI 10.93-16.46) in participants > 18 years. Uptake for females was higher 57.23% (95% CI: 45.40-68.66) when compared to that of 47.01% (95% CI: 0.82-97.75) in males. HPV vaccine uptake among school-based programs was 69.62% (95% CI 57.27-80.68) as compared to 18.66% (95% CI 6.66-34.92) for community-based programs. Vaccination uptake for publicly funded programs was significantly higher 66.95% (95% CI 55.00-77.89) when compared to 13.58% (95% CI 10.92-16.46) for programs where participants had to pay out of pocket. To prevent infections and reduce the burden of HPV-related diseases (including cervical cancer), communities should be made aware and encouraged to vaccinate their children. There is a documented need to direct effort and focus interventions toward improving HPV vaccination uptake in Canada.

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Chijioke Nwankwo

Papers

Lean interventions in healthcare: do they actually work? A systematic literature review.

Weight loss intervention adherence and factors promoting adherence: a meta-analysis.

Primary nonadherence to chronic disease medications: a meta-analysis.

The association of antidepressant drug usage with cognitive impairment or dementia, including Alzheimer disease: A systematic review and meta-analysis.

Human papillomavirus vaccination uptake in Canada: A systematic review and meta-analysis