Marie Paul Nisingizwe
Doctor of Philosophy in Population and Public Health (PhD)
Evaluation of mass screening and treatment program for hepatitis C virus in Rwanda
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The discovery of antibiotics was one of the most significant advances in modern medicine; however, our reliance on antibiotics is threatened by the spread of resistance. Antibiotic resistance is a natural phenomenon that is exacerbated by selection pressure from antibiotic use. Where prescriptions are required for antibiotics, understanding prescribing behaviour is paramount. Guidelines recommend antibiotics for respiratory tract infections (RTIs) only when pneumonia or other serious complications are suspected. Urine cultures are recommended for complicated, but not uncomplicated, urinary tract infections (UTIs). The objectives of this thesis were to identify factors related to patients, physicians, and geographic regions associated with antibiotic use for RTIs, and urine culturing for UTI; and to explore the extent of variations in these practices across physicians.A systematic review of the literature was conducted to assess factors that have previously been empirically associated with antibiotic prescribing. Then, using linked administrative datasets, factors associated with antibiotic prescriptions for paediatric respiratory tract infection were analyzed. Urine culture data was subsequently linked in, to explore urine culturing practices. These analyses demonstrated that observed physician characteristics had a stronger influence on practice patterns that did differences in patient characteristics. In particular, physicians who had been in practice for longer tended to be more likely to prescribe antibiotics, and to order urine cultures. Physicians trained outside of Canada were more likely to prescribe, but less likely to order a urine culture. Female physicians were less likely to prescribe antibiotics, and more likely to order urine cultures. The variation between physicians that remained after accounting for observed characteristics was substantial. This research demonstrates some common features of physicians that are associated with antibiotic prescribing and urine culture use. However, the variation between physicians in practice styles is greater than the effects of these characteristics. These findings have implications for the design and implementation of antibiotic stewardship efforts to improve antibiotic use. For example, audit and feedback interventions and academic detailing have shown some promise, and may be particularly effective if targeted to physicians with higher prescribing or culturing practices. This thesis demonstrates the utility of administrative datasets in identifying such physicians.
Background – Erectile dysfunction (ED) has been described as providing a ‘window of curability’ for men at risk of future cardiovascular disease, however there is little evidence on the relationship between erectile dysfunction and modifiable cardiometabolic risk factors. The primary objectives of this thesis were to: 1) determine whether men with ED have a higher risk of having an undiagnosed cardiometabolic risk factor (hypertension, hypercholesterolemia and diabetes), and 2) determine whether the prescription of a phosphodiesterase type 5 inhibitor (PDE5i) for ED leads to an increase in the diagnosis and treatment of these risk factors. Methods – This thesis comprised of two original studies. The first, a cross-sectional analysis using a nationally representative survey from the United States. The second, a population-based empirical study of changes in drug utilization for cardiometabolic risk factors following PDE5i prescription in British Columbia. An individual-level time series analysis with switching replications was utilized for this analysis. Results – Men with ED were found to have double the odds of having undiagnosed diabetes compared to those without ED. This was most significant among middle-aged men (ages 40-59 years), as the predicted probability of having undiagnosed diabetes increased from 1 in 50 in men without ED to 1 in 10 in men with ED. Among men aged 40 to 59 years old in British Columbia, we found a sudden increase in prescriptions for antihypertensives (28 per 1,000), statins (15 per 1,000), and antidiabetics (18 per 1,000) in the 90 days following a new prescription for a PDE5i. For both hypercholesterolemia and diabetes, relevant screening tests performed in the 30 days following PDE5i prescription were responsible for this change. This increase was followed by a significant declining trend in prescriptions for all three drugs. Conclusions – Men with ED have an increased risk for undiagnosed cardiometabolic risk factors. PDE5is can act as a ‘gateway drug’ for men to be newly treated for these risk factors provided physicians perform the requisite screening investigations. Increased education and awareness of this relationship among both patients and physicians is critical for exploiting the potential for preventing future cardiovascular disease.