Highlights of this issue

Primary care of depression

The World Health Organization has predicted that by 2020 major depression will be second only to heart disease as a contributor to the global burden of disease. Depression is common, is associated with high morbidity and is often difficult to recognize. In the last 20 years, our understanding of its causes has improved and, with this, our capacity to offer effective treatment. Ronald Remick, a psychiatrist from British Columbia, offers a clinical update on the diagnosis and management of major depressive disorder in the primary care setting.

Figure. Photo by: Art Explosion

See page 1253

Risky business: waiting for cardiac catheterization

Public attention has recently been focused on waiting lists for diagnostic and therapeutic procedures. For procedures like cardiac catheterization, which is an essential tool for diagnosis and risk stratification in coronary artery disease, a delay might be harmful to a patient because it may postpone optimal management. Few studies have investigated the risks of being on a waiting list for cardiac catheterization. Madhu Natarajan and colleagues prospectively documented the mortality and morbidity of a group of 8030 patients referred for cardiac catheterization and identified predictors of cardiac events that occurred while patients were waiting for the procedure. They found that 37% of the procedures were performed in the requested time, and 1.4% of patients had a major cardiac event, namely, death, myocardial infarction or congestive heart failure.

In a related commentary, Justin Ezekowitz and Paul Armstrong propose better risk stratification of both inpatients and outpatients, and systematic monitoring of the catheterization process.

See pages 1233 and 1247

Drug cost containment: refining reference-based pricing

Reference-based pricing for drug reimbursement has been a partial success in British Columbia. The extra cost of a more expensive drug in a class that includes other cheaper, equally effective options is transferred to the patient. If a physician feels that the more expensive drug is necessary, he or she may request an exemption. Although studies have shown that this approach has economic benefits and appears clinically safe, the savings are smaller than were anticipated. As drug costs continue to escalate, more effective price control is needed. Sebastian Schneeweiss and colleagues borrow an example from German reference-based pricing, the “physician drug budget,” and suggest that with modifications its implementation might be the answer to increasing pharmaceutical expenses.

See page 1250

Organ donation in the ICU

The issue of organ donation is one often revisited to ensure that, while being as effective as possible, the process is compassionate and sensitive to the needs of grieving families. Many of the discussions around organ donation take place in intensive care units. Often, these discussions involve transplant procurement organizations and, in Canada, require that details of patients nearing death be reported to outside agencies, details that traditionally would be confidential. The Canadian Critical Care Society (CCCS) has produced a position paper on organ and tissue donation that outlines how the process might be improved and collaborative initiatives developed and implemented. Graeme Rocker, for the CCCS, offers an outline of these recommendations.

See page 1248

Management of hypertriglyceridemia

Studies have shown that even mildly elevated levels of triglycerides may predict coronary artery disease and are linearly correlated with incident myocardial infarction. Lipid metabolism is a complex process and treatment of aberrations is often difficult. In a case-based practice piece, Michelle Fung and Jiri Frohlich discuss the risks, causes, diagnosis and management of hypertriglyceridemia.