Trends in health service use among persons with Parkinson's disease by rurality: A population-based repeated cross-sectional study.

BackgroundThe global burden of Parkinson's disease (PD) has more than doubled over the past three decades, and this trend is expected to continue. Despite generally poorer access to health care services in rural areas, little previous work has examined health system use in persons with PD by rurality. We examined trends in the prevalence of PD and health service use among persons with PD by rurality in Ontario, Canada.MethodsWe conducted a repeated, cross-sectional analysis of persons with prevalent PD aged 40+ years on April 1st of each year from 2000 to 2018 using health administrative databases and calculated the age-sex standardized prevalence of PD. Prevalence of PD was also stratified by rurality and sex. Negative binomial models were used to calculate rate ratios with 95% confidence intervals comparing rates of health service use in rural compared to urban residents in 2018.ResultsThe age-sex standardized prevalence of PD in Ontario increased by 0.34% per year (pInterpretationLower rates of outpatient health service use among persons residing in rural regions, contrasting with higher rates of emergency department visits suggest inequities in access. Efforts to improve access to primary and specialist care for persons with PD in rural regions are needed

Preeclampsia as a risk factor for diabetes: a population-based cohort study.

Women with preeclampsia (PEC) and gestational hypertension (GH) exhibit insulin resistance during pregnancy, independent of obesity and glucose intolerance. Our aim was to determine whether women with PEC or GH during pregnancy have an increased risk of developing diabetes after pregnancy, and whether the presence of PEC/GH in addition to gestational diabetes (GDM) increases the risk of future (postpartum) diabetes.We performed a population-based, retrospective cohort study for 1,010,068 pregnant women who delivered in Ontario, Canada between April 1994 and March 2008. Women were categorized as having PEC alone (n=22,933), GH alone (n=27,605), GDM alone (n=30,852), GDM+PEC (n=1,476), GDM+GH (n=2,100), or none of these conditions (n=925,102). Our main outcome was a new diagnosis of diabetes postpartum in the following years, up until March 2011, based on new records in the Ontario Diabetes Database. The incidence rate of diabetes per 1,000 person-years was 6.47 for women with PEC and 5.26 for GH compared with 2.81 in women with neither of these conditions. In the multivariable analysis, both PEC alone (hazard ratio [HR]=2.08; 95% CI 1.97-2.19) and GH alone (HR=1.95; 95% CI 1.83-2.07) were risk factors for subsequent diabetes. Women with GDM alone were at elevated risk of developing diabetes postpartum (HR=12.77; 95% CI 12.44-13.10); however, the co-presence of PEC or GH in addition to GDM further elevated this risk (HR=15.75; 95% CI 14.52-17.07, and HR=18.49; 95% CI 17.12-19.96, respectively). Data on obesity were not available.Women with PEC/GH have a 2-fold increased risk of developing diabetes when followed up to 16.5 years after pregnancy, even in the absence of GDM. The presence of PEC/GH in the setting of GDM also raised the risk of diabetes significantly beyond that seen with GDM alone. A history of PEC/GH during pregnancy should alert clinicians to the need for preventative counseling and more vigilant screening for diabetes. Please see later in the article for the Editors' Summary

Cohort flow chart illustrating the inclusion and exclusion of participants into the study.

<p>*Mothers either lacked coverage under Ontario's Health Insurance Plan at the admission delivery date or had health insurance for less than 2 y prior to their delivery.</p

Higher Neighborhood Drivability Is Associated With a Higher Diabetes Risk in Younger Adults: A Population-Based Cohort Study in Toronto, Canada.

OBJECTIVE: Car dependency contributes to physical inactivity and, consequently, may increase the likelihood of diabetes. We investigated whether neighborhoods that are highly conducive to driving confer a greater risk of developing diabetes and, if so, whether this differs by age. RESEARCH DESIGN AND METHODS: We used administrative healthcare data to identify all working-age Canadian adults (20-64 years) who were living in Toronto on 1 April 2011 without diabetes (type 1 or 2). Neighborhood drivability scores were assigned using a novel, validated index that predicts driving patterns based on built environment features divided into quintiles. Cox regression was used to examine the association between neighborhood drivability and 7-year risk of diabetes onset, overall and by age-group, adjusting for baseline characteristics and comorbidities. RESULTS: Overall, there were 1,473,994 adults in the cohort (mean age 40.9 ± 12.2 years), among whom 77,835 developed diabetes during follow-up. Those living in the most drivable neighborhoods (quintile 5) had a 41% higher risk of developing diabetes compared with those in the least drivable neighborhoods (adjusted hazard ratio 1.41, 95% CI 1.37-1.44), with the strongest associations in younger adults aged 20-34 years (1.57, 95% CI 1.47-1.68, P < 0.001 for interaction). The same comparison in older adults (55-64 years) yielded smaller differences (1.31, 95% CI 1.26-1.36). Associations appeared to be strongest in middle-income neighborhoods for younger residents (middle income 1.96, 95% CI 1.64-2.33) and older residents (1.46, 95% CI 1.32-1.62). CONCLUSIONS: High neighborhood drivability is a risk factor for diabetes, particularly in younger adults. This finding has important implications for future urban design policies

Number needed to follow.

<p>Number needed to follow.</p

Multivariable Cox proportional hazards models evaluating the relationship among preeclampsia, gestational hypertension, and gestational diabetes in the development of diabetes.

a<p>Adjusted for age, income quintile, prior hypertension, and co–morbidity using John Hopkins collapsed ambulatory diagnostic groups (CADG).</p

Sub-analysis modeling the relationship among preeclampsia, gestational hypertension, gestational diabetes, and preterm delivery in the development of diabetes.

<p>Model also adjusts for age, income quintile, prior hypertension, and co-morbidity using the Johns Hopkins collapsed ambulatory diagnostic group (CADG). The bands represent 95% confidence intervals.</p

Cumulative future risk of diabetes mellitus in association with a pregnancy affected by preeclampsia, gestational hypertension, and gestational diabetes.

<p>*Follow-up period begins 180 d postpartum. This figure was produced using a competing risk method.</p

Demographic and clinical characteristics of women stratified by gestational diabetes diagnosis.

a<p>Note only the two collapsed ambulatory diagnostic groups (CADGs) relating to chronic medical conditions are presented in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001425#pmed-1001425-t001" target="_blank">Table 1</a>. Nine other CADGs, relating to other categories of medical conditions, were included in the fully adjusted models. Pregnancy, however, was excluded. See <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001425#pmed.1001425.s001" target="_blank">Table S1</a>.</p