Highlights of this issue

Ankle rules

Decision-making rules such as the Ottawa ankle rules have been widely adopted because of their potential for safely reducing a patient's exposure to costly and unnecessary testing. However, Afina Glas and colleagues hypothesized that physicians, aided by a structured data collection form, would be better able to judge the need for a radiograph than would any given ankle rule alone. They asked surgical residents in Amsterdam to perform a history and physical examination of 690 consecutive patients with ankle injuries and complete a standard data collection form that incorporated elements of both the Ottawa and Leiden ankle rules. The physicians then indicated whether they felt a radiograph was necessary, and all patients underwent ankle radiography. The sensitivity and specificity was calculated for the physician's judgement and for each set of ankle rules. The sensitivity and specificity were 89% and 26% respectively for the Ottawa rules, 80% and 59% for the Leiden rule and 82% and 38% for the physicians' judgement. Eight fractures (including 1 clinically significant fracture) were missed with the Ottawa rules, 15 fractures (5 clinically significant) were missed with the Leiden rule, and the residents missed 13 fractures (1 clinically significant). Thus, aided by structured data collection, physician's judgement was similar to existing ankle rules in terms of its sensitivity and ability to safely reduce the number of radiographic examinations.

Figure. Photo by: Alan King

See page 727

South Asian MI profiles

South Asian Canadians (those from India, Pakistan, Sri Lanka and Bangladesh) have higher rates of myocardial infarction (MI) than Canadians of European origin. Exploring these differences, Milan Gupta and colleagues studied 2 groups of patients with acute MI: 553 South Asian subjects and 553 non-South Asian subjects matched by age, sex, discharge date and hospital of admission. The groups were compared in terms of presentation characteristics, cardiac risk factors and in-hospital outcomes. On average, the South Asian patients took longer to present to hospital (3.92 v. 3.08 hours, p = 0.04) and were more likely to have diabetes (43.4% v. 28.2%, p < 0.001) despite having a lower mean body mass index (25.7 v. 28.0, p = 0.05). However, they were less likely to be smokers (29.3% v. 67.8%, p < 0.001) or have pre-existing cardiovascular disease (49.4% v. 55.0%, p = 0.04). Despite their differences, the 2 groups had similar MI mortality and in-hospital outcomes. The authors recommend that special prevention and awareness efforts be targeted at South Asian communities.

See page 717

Prescription drug cost-sharing

As a cost-saving measure, British Columbia introduced reference-based pricing in January 1997, whereby it would cover only the least expensive drug in a medication class (patients prescribed more expensive drugs would have to pay the difference). Using data from provincial health and prescription drug databases, Sebastian Schneeweiss and colleagues studied the use of angiotensin-converting enzyme (ACE) inhibitors by elderly patients for the 2 years before and the year after reference-based pricing was introduced. They found a decline of 29% in the use of higher-priced medications immediately following the change and estimated the government's savings at $6.7 million in the first year alone. Although the use of antihypertensives was unchanged, 11% less people were using an ACE inhibitor after the policy change. Low-income patients were more likely than high-income patients to stop all antihypertensive therapy (odds ratio 1.65, 95% confidence interval 1.43–1.89). In a related commentary Aslam Anis discusses whether the decline in ACE inhibitor use may have an impact on the already undertreated problem of hypertension.

See pages 737 and 763

Collisions with wildlife

Vehicular accidents with wildlife are common and often cause significant property damage and human injury. In this issue's Public Health column, Erica Weir discusses how accidents involving larger animals like deer and moose commonly cause head, face and neck injuries to the vehicle's occupants. Weir briefly discusses strategies to prevent collisions and minimize potential harm from these accidental encounters with wildlife.