Transcript hlee - OoCities

CURE, HARM and GIM
Academic ½ Day
th
October 24 2001
Dr Hui N. Lee, MD, M.Sc., FRCPC
Community GIM, Sault Ste Marie
Clinical Assistant Professor
McMaster University
Objectives

Practical knowledge of current ACS
management (October 2001)
 Overview of CURE study and role of
clopidrogel in ACS therapy
 Principles of evaluation of Harm
 Understanding of Community GIM role
 Invitation for electives Up North
Scenario

67 year old man, non-Q MI with troponin I
8.2 / CK 300
– Diabetes, HTN, dyslipidemia, ex-smoker
– No previous MI or CAD, but GI bleed
– Was on ASA, other standard meds

Now 3 days post MI
– Rx ASA, clopidrogel, stop enoxaparin, other Rx
standard
Non-ST Elevation ACS

When do you add Clopidogrel?
 When do you stop Clopidogrel?
 How do you place Clopidogrel in relation to other
expensive/potentially risky interventions:
– angiogram
– LMW heparin
– IV G2b3 inhibitors

Do you put Clopidogrel on formulary
CURE (OASIS-4)
Clopidogrel in Unstable
Angina to prevent
Recurrent ischemic
Events
Atherothrombosis: a Generalized
and Progressive Process
Normal
Fatty
streak
Fibrous
plaque
Atherosclerotic
plaque
Plaque
rupture/
fissure &
thrombosis
Unstable
angina
MI
}ACS
Ischemic
stroke/TIA
Critical leg
ischemia
Clinically silent
Stable angina
Intermittent claudication
Increasing age
ACS, acute coronary syndrome; TIA, transient ischemic attack
Cardiovascular
death
Efficacy of Antiplatelet Therapy:
Antiplatelet Trialists’ Collaboration
Category
of trial
No. of
trials
with
data
MI, stroke, or
vascular
death
Antiplatelet
Adjusted
controls
Odds ratio and
confidence interval
(Antiplatelet:
control)
% odds
reduction
(SD)
Prior
MI
5% (4)
11
1331/9677
1693/9914
2
Acute
MI
9% (4)
9
992/9388
1348/9385
2
18
1076/5837
1301/5870
7
182/1991
285/2027
Prior
stroke/
2% (4)
TIA
Unstable angina
TIA, transient ischemic attack
0
0.5
1.0
Antiplatelet
therapy
better
1.5
2.0
Antiplatelet
therapy
worse
2
Antiplatelet Trialists’ Collaboration BMJ 1994;308:81–106
Complementary Mode of Action between
Clopidogrel and ASA
COX, cyclooxygenase; ADP, adenosine diphosphate; TxA2, thromboxane A2
Schafer AI Am J Med 1996;101:199–209
Trials of ADP-receptor Antagonists vs
Placebo in Patients with Atherosclerosis
Trial, Year
Setting
Primary Outcome
Definitio
n
Thienopyridine
(n/N)
Odds
Ratio
95% CI
Comparator
(n/N)
Thienopyridine versus Placebo or Control
CATS 1989
(Ticlopidine
vs Placebo
Recent
Stroke
Death,
MI,
Stroke
106/525
134/528
0.74
0.56-0.99
Balsano
1990
(Ticlopidine
vs Control)
Unstable
Angina
Death,
MI
23/314
46/338
0.52
0.31-0.85
STIMS 1990
(Ticlopidine
vs Placebo)
Intermittent
Claudicatio
n
Death,
MI,
Stroke
89/346
99/341
0.85
0.61-1.18
CURE Study Investigators Eur Heart J 2000; 21:
Trials of ADP-receptor Antagonists vs ASA
in Patients with Atherosclerosis
Trial, Year
Setting
Primary Outcome
Definitio
n
Thienopyridine
(n/N)
Comparator
(n/N)
Odds
Ratio
95% CI
Thienopyridine versus ASA
TASS, 1989
(Ticlopidine vs
ASA)
Cerebral
Ischemia
Death,
Stroke
306/1529
349/1540
0.85
0.82-0.97
CAPRIE, 1996
(Clopidogrel
vs ASA)
Recent
Stroke,
Previous
MI or
PVD
Death,
MI,
Stroke
939/9599
1021/9586
0.91
0.83-1.00
1245/11128
1370/11126
0.90
0.83-0.97
TOTAL
CURE Study Investigators Eur Heart J 2000; 21:
ASA + Ticlopidine versus ASA after
Coronary Artery Stenting
Death or MI
Study
Odds Ratio
95% CI
HALL, 1996
0.17
0.01-0.72
STARS, 1998*
0.25
0.10-0.63
0.23
0.11-0.49
TOTAL
P=0.0001
Test for heterogeneity P=0.66
0.1
Combination Better
1.0
10.0
ASA Alone Better
CURE Study Investigators Eur Heart J 2000; 21:2033
Study Design
•Randomized, double-blind, parallel group, clinical
trial of clopidogrel vs placebo in patients with ACS
•All patients receive ASA (75-325 mg)
•International trial (28 countries)
•12,562 patients (482 Hospitals)
•Central randomization
•3-12 month Rx and follow-up
•Main outcomes: -CV death/MI, stroke
-Above + refractory ischemia
Study Objectives
To evaluate if clopidogrel is superior to placebo
in preventing
a) CV death, MI, stroke (Primary at  0.045)
b) Above and refractory ischemia (Co-primary
at  0.01)
Inclusion Criteria

Ischemic symptoms, suspected to represent UA or
MI without ST segment elevation

Randomized within 24 hours of onset of CP

and ECG evidence of ischemia at inclusion or
already elevated cardiac enzymes or Troponin I or
T to at least 2 x ULN*
* Prior to June 1999, pts > 60 yrs with normal ECG
allowed
Revised July, 1999
Outcome Definitions (1/2)
CV Death: Excludes clear non-CV deaths
MI: Two of three usual criteria (CP, ECG or enzyme changes)
Stroke: Neurological deficit  24 hrs (CT/MRI encouraged)
Refractory Ischemia: Inhosp*: recurrent ischemia on max
med Rx + ECG changes + intervention  1 day
After discharge: Rehosp for UA with ECG changes
Severe Ischemia*: Changes similar to in hospital Refractory
Ischema, but no intervention
Recurrent Angina*: All other ischemic CP in hospital
Outcome Definitions (2/2)
Major Bleeds: Significantly disabling, intraocular
(vision loss), or transfusion of  2 units
Classified as Life Threatening if:
Hb  > 5g/dl, hypotension needing IV inotropes,
surgery to stop bleeding, symptomatic ICH or
transfusion or  4 units of blood
Patient Schedule
Patients with
Acute Coronary
Syndrome
R
(UA or MI Without ST
elevation)
300 mg loading
+ 75 mg o.d.
dose
Aspirin 75-325mg
Clopidogrel
(~6,250 patients)
3 months  double-blind treatment  12 months
Aspirin 75-325mg
Placebo
1 tab o.d.
(~6,250 patients)
Baseline Characteristics (1)
Placebo
Clopidogrel
N=6303
%
61.7
N=6259
%
61.3
Female
38.3
38.7
Unstable Angina
74.9
74.9
MI w/o ST Elevation
Abnormal ECG
25.1
93.9
25.1
93.7
Elevated enzymes/marker
25.3
25.3
Male
Baseline Characteristics (2)
Placebo
Clopidogrel
Age
N=6303
Mean (SD)
64.2 (11.3)
N=6259
Mean (SD)
64.2 (11.3)
Heart rate
73.0 (14.6)
73.2 (14.8)
Systolic BP
134.1 (22.0)
134.4 (22.5)
14.1 (7.1)
14.2 (7.2)
Symptom onset to
randomization (hrs)
Medications After Randomization
in Hospital
Placebo
%
46.9
Clopidogrel
%
46.0
LMW Heparin
Beta-blocker
56.0
78.4
56.1
78.7
Any CCB
ACE-I
Lipid-lowering
36.0
49.9
47.0
36.0
50.9
46.3
IV Heparin
Outcomes 1 /2
Plac Clop
%
%
RR
# Patients
1st Co-Primary
CV Death
MI
Stroke
Non CV death
6303
11.41
5.47
6.65
1.38
0.71
6259
9.30
5.08
5.18
1.20
0.66
0.80
0.93
0.77
0.86
0.91
CI
p
0.72-0.90
0.79-1.08
0.67-0.89
0.63-1.18
0.60-1.39
< 0.001
0.03
0.04
0.05
Placebo
0.01
0.02
Clopidogrel
P = 0.003
0.0
Cumulative Hazard
Rates Rates
Hazard
Cumulative
0.06
Cumulative Hazard Rates for CV
Death/MI/Stroke up to 30 Days
00
10
10
No. Plac6303
Days of Follow- 20
6108 upDays of Follow-up 5998
5957
No. Clop6259
6103
5984
20
6035
30
30
Placebo
0.10
0.08
0.06
0.02
0.04
Clopidogrel
P < 0.001
0.0
Cumulative
Hazard Rates
Rates
Hazard
Cumulative
0.12
0.14
Cumulative Hazard Rates for
CV Death/MI/Stroke
00
3
3
66
99
12
12
No of
Pts
Plac 6303
5780
4664
3600
2388
Clop 6259
5866
4779
3644
2418
Months of Follow-up
Months
of Follow-up
Outcomes 2/2
# Patients
2nd Co-Primary
Refract.Ischemia
In hospital
After Discharge
Severe Ischemia
Plac Clop
%
% RR
CI
p
6303 6259
18.83 16.5 0.86 0.79-0.94 < 0.001
4
9.31 8.69 0.93 0.82-1.04
2.00 1.36 0.68 0.52-0.90
7.59 7.57 0.99 0.87-1.13
5.03 3.80 0.75 0.63-0.89 < 0.001
Bleeding Complications
Placebo Clopidogrel
RR
95% CI
p
# Patients
6303
6259
Major
Life
Threatening
2.7%
1.8%
3.7%
2.2%
1.38
1.21
1.13-1.67
0.95-1.56
0.001
0.13
0.9%
1.5%
1.70
1.22-2.35
< 0.002
2.4%
2.2%
5.1%
2.8%
2.12
1.30
1.75-2.56
1.04-1.62
< 0.001
0.02
Other
Major
Minor
Transfusion
(2+Units)
TIMI Major Bleeding / GUSTO Severe-LifeThreatening Bleeding Criteria
Plac
Clop
6303
6259
TIMI Criteria
73
(1.2%)
GUSTO Criteria
70
(1.1%)
# Patients
RR
(95% CI)
P
68
(1.1%)
0.94
0.70
78
(1.2%)
1.12
0.48
Major/Life-Threatening Bleeds within 7
Days of CABG Surgery
Plac
Clop
Stopped < 5 days prior N = 476
to CABG
Pts with Maj/LT
6.3%
Bleeds
N = 436
Stopped > 5 days prior N = 454
to CABG
Pts with Maj/LT
5.3%
Bleeds
N = 456
9.6%
4.4%
RR
p
1.53
0.06
0.83
0.53
Thrombocytopenia and
Neutropenia
Plac
# Rand
6303
Thrombocytopenia 28 (0.44%)
Neutropenia
5 (0.1%)
Clop
6259
26 (0.42%)
8 (0.13%)
Scenario

67 year old man, non-Q MI
 Diabetes, HTN, dyslipidemia, ex-smoker
– No previous MI or CAD, but GI bleed
– Was on ASA, other standard meds

Now 3 days post MI
– Rx ASA, clopidogrel, stop enoxaparin, other Rx
standard

Do you stop Clopidogrel?
Users’ Guides for an Article
about Harm

Are the results valid?
– Similarity of all known determinants of
outcome or adjustments for differences in
analysis?
– Were exposed patients equally identified?
– Outcome assessment similar?
– Was follow-up sufficiently complete?
Harm: Different Study Designs
Design
Starting
Point
Assessment
Strengths
Weaknesses
Cohort
Exposure
status
Outcome
event status
Feasible when
randomization
not possible
Susceptible
to bias;
limited
validity
CaseControl
Outcome
event
status
Exposure
status
Overcomes
temporal delays;
may only require
small sample size
Susceptible
to bias;
limited
validity
RCT
Exposure
status
Adverse
event status
Lower
susceptibility to
bias
Feasibility
and generalizability
Harm: Results and
Applicability

What are the results?
– How strong is the association between exposure and
outcome?
– How precise is the estimate of the risk?

How can I apply the results to patient care?
– Were the study patients similar to mine?
– Was f/u duration adequate?
– What is the magnitude of the risk?
– Should I attempt to stop the exposure?
Scenario

67 year old man, non-Q MI
 Diabetes, HTN, dyslipidemia, ex-smoker
– No previous MI or CAD, but GI bleed
– Was on ASA, other standard meds

Now 3 days post MI
– Rx ASA, clopidogrel, stop enoxaparin, other Rx
standard

Do you stop Clopidogrel?
Who would ….
1. Stop Clopidogrel?
2. Continue it?
3. Don’t know….
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Minor
Bleed
.024
.051
1.12
(.75-1.56)
.027
37
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Minor
Bleed
.024
.051
1.12
(.75-1.56)
.027
37
Our Patient
??
??
.20
(.10-.28)
??
??
TIMI Score for ACS
www.timi.tv or www.timi.org
1.
2.
3.
4.
5.
6.
7.
Age >= 65 years
3 CRF: (DM, HTN, Fam Hx, Lipid, smoker, )
Known CAD
Prior chronic ASA use
>= 2 episodes rest angina in 24h
Elevated Cardiac enzymes
ST deviation >= .5mm
TIMI Score for ACS
1.
2.
3.
4.
5.
6.
7.
Age >= 65 years
3 CRF: (DM, HTN, Fam Hx, Lipid, smoker, )
Known CAD
Prior chronic ASA use
>= 2 episodes rest angina in 24h
Elevated Cardiac enzymes
ST deviation >= .5mm
TIMI clinical prediction score
(14 days)
TIMI Score
Death/non-fatal MI Death/non-fatal
MI/revascularization
0/1
3%
5%
2
3%
8%
3
5%
13%
4
7%
20%
5
12
26%
6/7
19
41%
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
(31-87)
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Minor
Bleed
.024
.051
1.12
(.75-1.56)
.027
37
TIMI 4
.07
[.056]
[.20]
[.014]
[71]
WHAT ARE THE CONFIDENCE INTERVALS AROUND NNT?
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
(31-87)
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Minor
Bleed
.024
.051
1.12
(.75-1.56)
.027
37
Our Patient
TIMI 4
.07
.063
[.056]
.10
[.20]
.28
.007
[.014]
142
[71]
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
(31-87)
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Minor
Bleed
.024
.051
1.12
(.75-1.56)
.027
37
Our Patient
TIMI 4
.07
.063
[.056]
.05
.10
[.20]
.28
.007
[.014]
.02
142
[71]
51
Placebo
0.10
0.08
0.06
0.04
Clopidogrel
0.02
Initial benefit then 20% relative over 11 months
P < 0.001
0.0
Cumulative
HazardRates
Rates
Hazard
Cumulative
0.12
0.14
Cumulative Hazard Rates for
CV Death/MI/Stroke
00
3
3
66
99
12
12
No of
Pts
Plac 6303
5780
4664
3600
2388
Clop 6259
5866
4779
3644
2418
Months of Follow-up
Months of Follow-up
TIMI clinical prediction score
(14 days)
TIMI Score
Death/non-fatal MI Death/non-fatal
MI/revascularization
0/1
3%
5%
2
3%
8%
3
5%
13%
4
7%
20%
5
12
26%
6/7
19
41%
Clopidogrel: NNT and NNH
Outcome
ASA only
ASA and
Clopidogrel
RRR
ARR
NNT or
NNH
Primary
.114
.093
.20
(.10-.28)
.021
47
Major
Bleed
.027
.037
.38
(.13-.67)
.01
100
Minor
Bleed
.024
.051
1.12
(.75-1.56)
.027
37
Our Patient
TIMI 4
.07
.056
.20
(.10-.28)
.014
(.007-.02)
71
(51-142)
TIMI 6
.19
.15
.20
(.10-.28)
.04
(.019-.053)
25
(18-52)
TIMI in TACTICS (6mo)
TIMI
Conservative
Invasive
0-2
5%
5%
3-4
10%
7%
5-7
15%
12%
TIMI and PRISM-PLUS
TIMI
UFH
Tirofiban +
UFH
0-2
6%
5%
3-4
9%
7%
5-7
15%
9%
Non-ST Elevation ACS

When do you add Clopidogrel?
 When do you stop Clopidogrel?
 How do you place Clopidogrel in relation to other
expensive/potentially risky interventions:
– angiogram
– LMW heparin
– IV G2b3 inhibitors

Do you put Clopidogrel on formulary
Community GIM

My History
 Community vs Tertiary Clinical Practice
 Research
 Teaching
 Lifestyle
 Options / Electives
Tertiary vs Community GIM







Scut/hospitalist
Few offices
Few procedures
Onerous Call
Ponies and Horses
Looked down by
subspecialists
Access to journals


Consultant
Office at least 50%
Many choices
Paid call as consultant
Horses, Zebras and Gnus
Valued by subspecialists

Full access to journals




CLINICAL RESEARCH PROJECTS
Multicenter Studies:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Primary Site Investigator, ESSENCE study (completed). 1993-4.
Primary Site Investigator, GUSTO-III study (completed). 1994-5.
Primary Site Investigator, PAT study (completed). 1995-7.
Primary Site Investigator, OASIS-2 study (completed). 1995-7.
Primary Site Investigator, SYMPHONY 1 study (completed). 1997-8.
Primary Site Investigator, TAIS study (completed). 1995-8.
Primary Site Investigator, SYMPHONY 2 study (completed). 1998-9.
Primary Site Investigator, HOOD study (ongoing). 1993Primary Site Investigator, LITE/Home-LITE study (ongoing). 1995Primary Site Investigator, PEACE study (ongoing). 1996Primary Site Investigator, CURE study (completed). 1999-2001.
Primary Site Investigator, CHARM study (ongoing). 1999Primary Site Investigator, GUSTO-IV study (ongoing). 1999Primary Site Investigator, WAVE study (ongoing). 2000Primary Site Investigator, EPHESUS study (ongoing). 2000Primary Site Investigator, PREVENT study (ongoing). 2000Primary Site Investigator, HOPE-TOO study (ongoing). 2000Primary Site Investigator, DREAM study (ongoing). 2001Primary Site Investigator, POISE study (ongoing). 2001Primary Site Investigator, INTERACT study (ongoing). 2001Primary Site Investigator, COMPETE-CHIPP project, McMaster University (ongoing).
Primary Site Investigator, ONTARGET/TRANSCEND
Funded Local Studies:
 Principal Investigator, GHC polypharmacy audit (PSI funding, $4000).
 Principal Investigator, GHC Diabetic Continuity of Care Study (CHSRF funding,
$518,000 over three years).
 Principal Investigator, GHC/SAH applied research education grant (CHSRF funding,
$30,000).
 Co-director, GHC Health Promotion Initiative Programs (GHC $122,000).
 Principal Investigator, CHF discharge transition project (PSI funding, $5600).
 Principal Co-Investigator, Northern Health Research Grant for determinants of
cardiovascular disease in Sault Ste Marie 2000, (joint Lakehead, McMaster universities,
$5000).
 Principal Investigator, Validation of the Osteoporosis Risk Assessment Index. (Proctor
Gamble, $5000).
 Principal Investigator, Audit and Development of Atrial Fibrillation Risk Assessment
Index. (Dupont, $5000).
 Principal Investigator, Optimization of Secondary Prevention of Cardiac Events in CAD,
(Pfizer, $6000).
 Principal Investigator, Evidence Based Diabetes Lipids Management, (Merck, $5000).
 Co-Principal Investigator, Evaluating Teletriage in Northern Ontario. (Richard Ivey
Foundation, $162,000).
PUBLICATIONS:
1992, 1994
Chief Editor: Survival Guide, McMaster University ... (Still published, fourth edition).
1.
Heyland D., Cook D.J., Jaeschke R., Lee H.N., Griffith L., Guyatt G.G. Selective Decontamination of the Digestive Tract: An Overview. Chest 1994; 105:1221-9.
2.
Levine M, Walter S, Lee H, Haines T, Holbrook A, Moyer V. User’s Guides to the Medical Literature IV: How to use an article about harm. JAMA 271(20):16159;1994:May 25.
3.
User’s Guides Working Group, JAMA series 1993-1995.
4.
Lee HN, Cook DJ, Sarabia A, Hatala R, McCallum A, King D, Guyatt GH, Dobranowski J, Powers P. Inadequacy of intravenous heparin therapy in the initial
management of venous thromboembolism. Journal of General Internal Medicine. 10(6):342-5, 1995 Jun.
5.
Sauve H., Lee H.N. et al. The Critical Appraisal Topic: A Tool for Evidence Based Medicine. Ann R. College 1995.
6.
EBM Pocket Guide, Sault Ste Marie, 1997.
7.
EBM Workbook, Sault Ste Marie, 1997.
Presented/Published Abstracts
1.
Lee H.N., Cook D.J., Brill-Edwards P., Neville A. The Development of objective-linked behaviour-specific evaluation forms for residents on a clinical teaching unit.
Clinical Research 1993;41(2):560A.
2.
Lee H.N., Lang J.D., Cook D.J. Characterization of Patient Care in a Medical Clinical Teaching Unit. Clinical Research 1993; 41(2):560A.
3.
Lee H.N., Ganesan C., Hatala R., Sarabia, McCallum A., Cook D.J. The initial management of venous thromboembolism: A study of factors leading to inadequate
heparinization. Clinical Research 1993;41(2):543A.
4.
Lee H.N., Sauve J.S., Farkouh M.E., Sackett D.L. The Critically Appraised Topic: A standardized aid for the presentation and storage of evidence-based medicine.
Clinical Research 1993; 41(2): 543A.
5.
Lee H.N., Churchill D, Adachi R.D., Thorpe K. Change in Lumbar spine bone mineral content of hemodialysis patients after parathyroidectomy. Clinical Research
1993;41(2):358A.
6.
Hunt D.L., Lee H.N., Sauve J.S., Farkouh M.E., Sackett D.L., Neural Network diagnosis of iron-deficiency anemia in the elderly: Comparison with conventional
epidemiological methods. Clinical Research 1993;41(2):526A.
7.
Farkouh M.E., Sauve J.S., Kassam H., Lee H.N., Sackett D.L. Varying formats in which trial results are reported can affect clinical decision making. Clinical Research
1993;41(2):517A.
8.
Sauriol N, Lee HN. An audit of the acute management of myocardial infarction in a northern community. RCPSC Annual Meeting, Toronto, 1998.
9.
Catania A, Wallenius S, Lee HN. An audit of polypharmacy in a community health centre. Society of General Internal Medicine (SGIM) Annual Meeting, San Francisco, 1999.
10.
Olivier K, Lee HN. Utility of the Stress Test in a primary care setting. SGIM Annual Meeting, San Francisco, 1999.
11.
Shiau J, Wallenius S, Lee HN. A Randomized Controlled Trial of an Electronic Template to Improve Evidence Based Health Interventions in Patients with Diabetes.
(SGIM, Boston 2000, CDA Annual Meeting, Halifax 2000).
12.
Lee HN for the CHIC investigators. SF-36 Quality of Life and association with Continuity of Care and Quality of Care in Diabetes. (CDA Annual Meeting, Halifax
October 2000).
13.
Lee HN, Bragaglia P, Wetzl T, Apostolon C. A community-based registry of Adult Patients with Diabetes. (CDA Annual Meeting, Halifax, October 2000).
14.
Flintoft V, Lee HN, Sridhar F, Lee D. Systematic Review: Multidisciplinary Discharge Transition Programs decrease hospital readmission for heart failure patients.
(SGIM Annual Meeting, San Diego, 2001).
15.
Chau, J, Lee HN. Balancing the Risks and Benefits of Anticoagulation in Elderly Patients with Atrial Fibrillation. (SGIM Annual Meeting, San Diego, 2001).
16.
Lee HN, Garniss D, Oliver R, McCullogh C, Dulisse D. A Community Hospital-Based Heart Failure Program Decreases Readmission Rates. (SGIM Annual Meeting,
San Diego, 2001).
Lee HN, Wilson C, Ciaschini P, Hemy M, Mogharrabi V. Validation of the Osteoporosis Risk Assessment Index in the Community. (SGIM Annual Meeting, San Diego, 2001).
TEACHING

Med students
 Family Medicine students
 GIM / Core IM electives and …
 NEW Northern Community GIM program
starting July 2002
 NEW Northern Ontario & Rural Medical
School starting July 2004
Lifestyle
Family – commitments to work
 Renumeration / quality of life
 Location:
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Spousal employment
Climate
Safety
Recreation
Commuting
Electives and other options

Northern Specialty Electives
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Paid travel, accommodations
Other residents
Free Internet and eJournal access
Families considered also
Northern Community GIM Residency
– July 2002
– advice