CURE, HARM and GIM Academic

1
CURE, HARM and GIMAcademic ½ DayOctober 24th
2001

• Dr Hui N. Lee, MD, M.Sc., FRCPC
• Community GIM, Sault Ste Marie
• Clinical Assistant Professor McMaster University

2
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

3
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

4
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

5
CURE (OASIS-4)
Clopidogrel in Unstable Angina to
prevent Recurrent ischemic Events
6
Atherothrombosis a Generalized and Progressive
Process
Unstable angina
Plaquerupture/fissure thrombosis
ACS
Athero-scleroticplaque
Fattystreak
Fibrousplaque
MI
Normal
Ischemic stroke/TIA
Critical leg ischemia
Clinically silent
Stable angina Intermittent claudication
Cardiovasculardeath
Increasing age
ACS, acute coronary syndrome TIA, transient
ischemic attack
7
Efficacy of Antiplatelet TherapyAntiplatelet
Trialists Collaboration
MI, stroke, orvascular death
Odds ratio andconfidence interval(Antiplatelet
control)
No. oftrialswithdata
oddsreduction(SD)
Anti-platelet
Adjustedcontrols
Categoryof trial
Prior MI 11 1331/9677 1693/9914 25 (4) Acute
MI 9 992/9388 1348/9385 29 (4) Prior
stroke/ 18 1076/5837 1301/5870 22
(4)TIA Unstable angina 7 182/1991 285/2027
0
0.5
1.0
1.5
2.0
Antiplatelettherapybetter
Antiplatelettherapyworse
Antiplatelet Trialists Collaboration BMJ
199430881106
TIA, transient ischemic attack
8
Complementary Mode of Action between Clopidogrel
and ASA
COX, cyclooxygenase ADP, adenosine diphosphate
TxA2, thromboxane A2
Schafer AI Am J Med 1996101199209
9
Trials of ADP-receptor Antagonists vs Placebo in
Patients with Atherosclerosis
Trial, Year Setting Primary Outcome Primary Outcome Primary Outcome Odds Ratio 95 CI
Definition Thieno-pyridine (n/N) Comparator (n/N)
Thienopyridine versus Placebo or Control Thienopyridine versus Placebo or Control Thienopyridine versus Placebo or Control Thienopyridine versus Placebo or Control Thienopyridine versus Placebo or Control 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 Claudication Death, MI, Stroke 89/346 99/341 0.85 0.61-1.18
TOTAL 218/1185 279/1207 0.73 0.60-0.90
CURE Study Investigators Eur Heart J 2000 21
2033-41.
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Trials of ADP-receptor Antagonists vs ASA in
Patients with Atherosclerosis
Trial, Year Setting Setting Primary Outcome Primary Outcome Primary Outcome Odds Ratio 95 CI
Definition Thieno-pyridine (n/N) Comparator (n/N)
Thienopyridine versus ASA Thienopyridine versus ASA Thienopyridine versus ASA Thienopyridine versus ASA Thienopyridine versus ASA Thienopyridine versus ASA Thienopyridine versus ASA
TASS, 1989 (Ticlopidine vs 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) CAPRIE, 1996 (Clopidogrel vs ASA) Recent Stroke, Previous MI or PVD Death, MI, Stroke 939/9599 1021/9586 0.91 0.83-1.00
TOTAL TOTAL 1245/11128 1370/11126 0.90 0.83-0.97
CURE Study Investigators Eur Heart J 2000 21
2033-41.
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ASA Ticlopidine versus ASA after Coronary
Artery Stenting
Death or MI
Study
Odds Ratio
95 CI
HALL, 1996
0.17
0.01-0.72
0.25
0.10-0.63
STARS, 1998
TOTAL
0.23
0.11-0.49
P0.0001 Test for heterogeneity P0.66
0.1
1.0
10.0
Combination Better
ASA Alone Better
CURE Study Investigators Eur Heart J 2000
212033-41
Page 30 of 30
12
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

13
Study Objectives

• To evaluate if clopidogrel is superior to placebo
  in preventing
• CV death, MI, stroke (Primary at ? 0.045)
• Above and refractory ischemia (Co-primary at ?
  0.01)

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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 gt 60 yrs with normal
  ECG allowed

Revised July, 1999
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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
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Outcome Definitions (2/2)
Major Bleeds Significantly disabling,
intraocular (vision loss), or transfusion of ? 2
units Classified as Life Threatening if Hb ? gt
5g/dl, hypotension needing IV inotropes, surgery
to stop bleeding, symptomatic ICH or transfusion
or ? 4 units of blood
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Patient Schedule
300 mg loading 75 mg o.d. dose
Clopidogrel(6,250 patients)
Patients with Acute CoronarySyndrome
Aspirin 75-325mg
R
3 months double-blind treatment 12 months
(UA or MI Without STelevation)
Aspirin 75-325mg
Placebo 1 tab o.d.(6,250 patients)
Day 1
6 m. Visit
9 m. Visit
3 m. Visit
1 m. Visit
Discharge Visit
loading dose
12 m.or Final Visit
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Baseline Characteristics (1)
Placebo Clopidogrel
N6303 N6259
Male 61.7 61.3
Female 38.3 38.7
Unstable Angina 74.9 74.9
MI w/o ST Elevation 25.1 25.1
Abnormal ECG 93.9 93.7
Elevated enzymes/marker 25.3 25.3
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Baseline Characteristics (2)
Placebo Clopidogrel
N6303 Mean (SD) N6259 Mean (SD)
Age 64.2 (11.3) 64.2 (11.3)
Heart rate 73.0 (14.6) 73.2 (14.8)
Systolic BP 134.1 (22.0) 134.4 (22.5)
Symptom onset to randomization (hrs) 14.1 (7.1) 14.2 (7.2)
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Medications After Randomization in Hospital
Placebo Clopidogrel

IV Heparin 46.9 46.0
LMW Heparin 56.0 56.1
Beta-blocker 78.4 78.7
Any CCB 36.0 36.0
ACE-I 49.9 50.9
Lipid-lowering 47.0 46.3
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Outcomes 1 /2
Plac Clop
RR CI p
Patients 6303 6259
1st Co-Primary 11.41 9.30 0.80 0.72-0.90 lt 0.001
CV Death 5.47 5.08 0.93 0.79-1.08
MI 6.65 5.18 0.77 0.67-0.89
Stroke 1.38 1.20 0.86 0.63-1.18
Non CV death 0.71 0.66 0.91 0.60-1.39
22
Cumulative Hazard Rates for CV Death/MI/Stroke up
to 30 Days
Placebo
Cumulative Hazard Rates
Clopidogrel
P 0.003
0
10
20
30
Days of Follow-up
6303 6259
6108 6103
5998 6035
5957 5984
No. Plac No. Clop
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Cumulative Hazard Rates for CV Death/MI/Stroke
24
Outcomes 2/2
Plac Clop
RR CI p
Patients 6303 6259
2nd Co-Primary 18.83 16.54 0.86 0.79-0.94 lt 0.001
Refract.Ischemia 9.31 8.69 0.93 0.82-1.04
In hospital 2.00 1.36 0.68 0.52-0.90
After Discharge 7.59 7.57 0.99 0.87-1.13
Severe Ischemia 5.03 3.80 0.75 0.63-0.89 lt 0.001
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Bleeding Complications
Placebo Clopidogrel RR 95 CI p
Patients 6303 6259
Major 2.7 3.7 1.38 1.13-1.67 0.001
Life Threatening 1.8 2.2 1.21 0.95-1.56 0.13
Other Major 0.9 1.5 1.70 1.22-2.35 lt 0.002
Minor 2.4 5.1 2.12 1.75-2.56 lt 0.001
Transfusion (2Units) 2.2 2.8 1.30 1.04-1.62 0.02
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TIMI Major Bleeding / GUSTO Severe-Life-Threatenin
g Bleeding Criteria
Plac Clop RR (95 CI) P
Patients 6303 6259
TIMI Criteria 73 (1.2) 68 (1.1) 0.94 0.70
GUSTO Criteria 70 (1.1) 78 (1.2) 1.12 0.48
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Major/Life-Threatening Bleeds within 7 Days of
CABG Surgery
Plac Clop RR p
Stopped lt 5 days prior to CABG N 476 N 436
Pts with Maj/LT Bleeds 6.3 9.6 1.53 0.06

Stopped gt 5 days prior to CABG N 454 N 456
Pts with Maj/LT Bleeds 5.3 4.4 0.83 0.53
28
Thrombocytopenia and Neutropenia
Plac Clop
Rand 6303 6259
Thrombocytopenia 28 (0.44) 26 (0.42)
Neutropenia 5 (0.1) 8 (0.13)
29
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?

30
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?

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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
Case-Control 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 general-izability
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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?

33
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?

34

• Who would .
• Stop Clopidogrel?
• Continue it?
• Dont know.

35
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
36
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
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) ?? ??
38
TIMI Score for ACSwww.timi.tv or www.timi.org

1. Age gt 65 years
2. 3 CRF (DM, HTN, Fam Hx, Lipid, smoker, )
3. Known CAD
4. Prior chronic ASA use
5. gt 2 episodes rest angina in 24h
6. Elevated Cardiac enzymes
7. ST deviation gt .5mm

39
TIMI Score for ACS

1. Age gt 65 years
2. 3 CRF (DM, HTN, Fam Hx, Lipid, smoker, )
3. Known CAD
4. Prior chronic ASA use
5. gt 2 episodes rest angina in 24h
6. Elevated Cardiac enzymes
7. ST deviation gt .5mm

40
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
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?
42
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
43
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
44
Cumulative Hazard Rates for CV Death/MI/Stroke
Initial benefit then 20 relative over 11 months
45
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
46
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)
47
TIMI in TACTICS (6mo)
TIMI Conservative Invasive
0-2 5 5
3-4 10 7
5-7 15 12
48
TIMI and PRISM-PLUS
TIMI UFH Tirofiban UFH
0-2 6 5
3-4 9 7
5-7 15 9
49
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

50
QUESTIONS?
51
Community GIM

• My History
• Community vs Tertiary Clinical Practice
• Research
• Teaching
• Lifestyle
• Options / Electives

52
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

53
Research
CLINICAL RESEARCH PROJECTS   Multicenter
Studies   1. Primary Site Investigator, ESSENCE
study (completed). 1993-4. 2. Primary Site
Investigator, GUSTO-III study (completed).
1994-5. 3. Primary Site Investigator, PAT study
(completed). 1995-7. 4. Primary Site
Investigator, OASIS-2 study (completed).
1995-7. 5. Primary Site Investigator, SYMPHONY 1
study (completed). 1997-8. 6. Primary Site
Investigator, TAIS study (completed).
1995-8. 7. Primary Site Investigator, SYMPHONY 2
study (completed). 1998-9. 8. Primary Site
Investigator, HOOD study (ongoing). 1993-
9. Primary Site Investigator, LITE/Home-LITE
study (ongoing). 1995- 10. Primary Site
Investigator, PEACE study (ongoing).
1996- 11. Primary Site Investigator, CURE study
(completed). 1999-2001. 12. Primary Site
Investigator, CHARM study (ongoing).
1999- 13.               Primary Site
Investigator, GUSTO-IV study (ongoing).
1999- 14.               Primary Site
Investigator, WAVE study (ongoing).
2000- 15.               Primary Site
Investigator, EPHESUS study (ongoing).
2000- 16.               Primary Site
Investigator, PREVENT study (ongoing).
2000- 17.               Primary Site
Investigator, HOPE-TOO study (ongoing).
2000- 18.               Primary Site
Investigator, DREAM study (ongoing).
2001- 19.               Primary Site
Investigator, POISE study (ongoing).
2001- 20.               Primary Site
Investigator, INTERACT study (ongoing).
2001- 21.               Primary Site
Investigator, COMPETE-CHIPP project, McMaster
University (ongoing). 22.               Primary
Site Investigator, ONTARGET/TRANSCEND
54
  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).
55
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 1051221-9. 2. Levine
M, Walter S, Lee H, Haines T, Holbrook A, Moyer
V. Users Guides to the Medical Literature IV
How to use an article about harm. JAMA
271(20)1615-91994May 25. 3. Users 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 199341(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
199341(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 199341(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
199341(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 199341(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).
56
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

57
Lifestyle

• Family commitments to work
• Renumeration / quality of life
• Location
• Spousal employment
• Climate
• Safety
• Recreation
• Commuting

58
Electives and other options

• Northern Specialty Electives
• Paid travel, accommodations
• Other residents
• Free Internet and eJournal access
• Families considered also
• Northern Community GIM Residency
• July 2002
• advice