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Background: Prescription opioid use places a considerable economic burden on health care systems. Older patients undergoing surgical procedures for painful conditions commonly receive opioids pre- and postoperatively, and are susceptible to adverse reactions. This study explores predictors of prolonged postoperative opioid use among older patients after lumbar spine surgery and the consequences in terms of health care utilization and costs. Methods: We conducted a retrospective population-based cohort study using Ontario administrative data from older adults undergoing spine surgery between 2006 and 2017. Data were analyzed from 90 days preoperatively to 1 year after hospital discharge, with last postoperative opioid prescriptions stratified into 90-day increments. We used multivariable ordinal logistic regression to identify predictors of long-term opioid use and generalized linear modelling to examine resource utilization and health care costs (2021 Canadian dollars). Results: Of 15 109 patients included, 40.8% received preoperative opioid prescriptions. Preoperative opioid use strongly predicted prolonged postoperative use (odds ratio [OR] 4.47, 95% confidence interval [CI] 4.16–4.79), with 48.3% of patients who received preoperative opioids continuing to use opioids for longer than 9 months, relative to 12.7% of those without preoperative use. Several other risk factors for prolonged use were identified. Patients receiving long-term postoperative opioids incurred greater health care costs relative to those with opioids prescribed for fewer than 90 days (OR 1.49, 95% CI 1.44–1.54). Conclusion: Among older adults undergoing spine surgery, preoperative opioid use was a strong predictor of prolonged postoperative use, which was associated with increased health care costs. These results form an important baseline for future studies evaluating strategies to reduce opioid use targeting older surgical populations. [ABSTRACT FROM AUTHOR]

Background: Lung cancer (LC) care is resource and cost intensive. We launched a Multidisciplinary LC Clinic (MDC), where patients with a new LC diagnosis received concurrent oncology consultation, resulting in improved time to LC assessment and treatment. Here, we evaluate the impact of MDC on health resource utilization, patient and caregiver costs, and secondary patient benefits. Methods: We retrospectively analyzed patients in a rapid assessment clinic with a new LC diagnosis pre-MDC (September 2016–February 2017) and post-MDC implementation (February 2017–December 2018). Data are reported as means; unpaired t-tests and ANOVA were used to assess for significance. We also conducted a cost analysis. Resource utilization, out-of-pocket costs, procedure-related costs, and indirect costs were evaluated from the societal perspective and presented in 2019 Canadian dollars (CAD); multi-way worst/best case and threshold sensitivity analyses were conducted. Results: We reviewed 428 patients (78 traditional model, 350 MDC). Patients in the MDC model required significantly fewer oncology visits from LC diagnosis to first LC treatment (1.62 vs. 2.68, p < 0.001), which was significant for patients with stage 1, 3, and 4 disease. Compared with the traditional model, there was no change in mean biopsies/patient (1.32 traditional vs. 1.17 MDC, p = 0.18) or staging investigations/patient (2.24 traditional vs. 2.02 MDC, p = 0.20). Post-MDC, there was an increase in invasive mediastinal staging for patients with stage 2/3 LC (15.0% vs. 60.0%, p < 0.001). Over 22 months, MDC resulted in savings of CAD 48,389 including CAD 24,167 CAD in direct patient out-of-pocket expenses. For the threshold analyses, MDC was estimated to cost CAD 25,708 per quality-adjusted life year (QALY), considered to be below current willingness to pay thresholds (at CAD 80,000 per QALY). MDC also facilitated oncology assessment for 29 non-LC patients. Conclusions: An MDC led to a reduction in patient visits and direct patient and caregiver costs. [ABSTRACT FROM AUTHOR]

Objective. To describe factors associated with high clinic and emergency room (ER) use among individuals with chronic pain. Design. This study is part of a larger crosssectional survey on the epidemiology of chronic pain in Canada. The current analysis was guided by the Andersen-Newman Service Utilization Model. Methods. Respondents (N=702) were grouped into high (top 10%) and low (bottom 90%) users based on the number of visits made to clinics and ERs over the past year. The two groups were compared on predisposing (e.g., pain self-efficacy and sociodemographic characteristics), enabling (e.g., income and education), and need (e.g., pain characteristics and number of comorbidities) factors as well as personal health behaviors (e.g., use of medications). Binary logistic regression analysis was used to identify characteristics associated with high use in each setting. Results. High users were defined as 30 or more clinic visits or one or more ER visits. The factors associated with high clinic use in the adjusted analysis were low pain self-efficacy (odds ratio [OR]52.60, 95% confidence interval [CI]=1.50-4.51), two or more comorbidities (OR=2.13, 95% CI=1.23-3.69), five or more pain sites (OR=2.30, 95% CI=1.28-4.14), and having an "other" pain diagnosis (OR=1.78, 95% CI=1.01-3.20). Factors that increased ER use were low pain self-efficacy (OR=2.01, 95% CI=1.28-3.15) and two or more comorbidities (OR=2.31, 95% CI=1.48-3.59), while use of alternative pain management strategies reduced ER use (OR=0.42, 95% CI=0.21-0.84). Conclusions. Longitudinal studies are needed to confirm if modifiable factors such as pain selfefficacy and use of alternative therapies reduce health care use. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to explore the ten-year trends in utilization of bioequivalent doses of statin amongst elderly patients with diabetes according to sex/gender in Ontario, Canada.Methods: A cohort of patients with diabetes (>65 years) was constructed using the Ontario Diabetes Database Statin utilization data (2003-2012) was obtained from the Ontario Drug Benefit Program for both women and men. Bioequivalent doses for statins were calculated according to the dosing conversion factor in therapeutic interchange programs in clinical practice. Utilization pattern of high potency (Atorvastatin and Rosuvastatin) vs. low potency statins (Simvastatin, Lovastatin, Fluvastatin, Pravastatin) were also analyzed.Results: The average bioequivalent Simvastatin utilization in 2003 was 29.22 mg/day for women and 30.35 mg/day for men. By 2008, this gap in dosing was higher for both women and men and by 2013 it had increased to 47.75 mg/day for women and 52.98 mg/day for men. For average number of day supply per year, there was no significant trend of changes over the 10-year period, although the use of high potency statins increased significantly (P<0.001) for both women and men. No differences were seen for sex/gender; either for the 10-year period or for each year.Conclusions: There has been significant increase in bioequivalent statin utilization amongst elderly patients with diabetes in Ontario; for both men and women. In a publicly-funded healthcare system such as Ontario, there were no sex/gender differences in the utilization of high potency statin (Atorvastatin and Rosuvastatin) amongst elderly patient with diabetes. [ABSTRACT FROM AUTHOR]

Chronic non-cancer pain is a debilitating condition associated with high individual and societal costs. While opioid treatment for pain has been available for centuries, it is associated with high variability in outcome, and a considerable proportion of patients is unable to attain relief from symptoms while suffering adverse events and developing medication dependence. We performed a review of the efficacy of pharmacogenomic markers and their abilities to predict adverse events, dependence, and associated economic costs, focusing on two genes: OPRM1 and CYP2D6. Data sources were articles indexed by PubMed on or before August 6, 2013. Articles were first selected after review of their titles and abstracts, and full papers were read to confirm eligibility. Initially, fifty-two articles were identified. Of these, 17 were relevant to biological actions of pharmacogenomic markers and their effect on therapeutic efficacy, 16 to adverse events, 15 to opioid dependence, and eight to economic costs. In conclusion, increasing costs of opioid therapy have made the advances in pharmacogenomics an attractive solution to personalize care with unclear repercussions related to the impact on costs, morbidity, and outcomes. This intersection of pharmacoeconomics and pharmacogenomics presents a unique platform to further examine current advances in clinical medicine and their utility in cost-effective treatment of chronic pain. [ABSTRACT FROM AUTHOR]

The article presents a study that evaluated the effect of a procalcitonin-guided antibiotic strategy on clinical and economic results. The study involved qualitative and quantitative summaries of databases, published articles and personal files including results of randomized controlled trials conducted in an intensive care unit. Results revealed that procalcitonin-guided therapy may reduce antibiotic usage which in turn may reduce costs of health care.

The author discusses various studies related to the geographical variations responsible for difference in the role of cholinesterase inhibitors drugs in case of various disease. Topics discussed include effectiveness of cholinesterase inhibitors and memantine for treating dementia, variations in prescriptions of anti-dementia drug and a survey of Canadian family physicians prescribing patterns for Alzheimer disease.

Background: Some individuals with chronic pain do not seek care. This decision may be due to characteristics of the individual, pain, and/or their health professional(s). Aims: This study aimed to identify and compare features of individuals with chronic pain, their pain and general health, and their health care professional between community-dwelling adults who did and did not seek care. Methods: Randomly selected adults were mailed a study questionnaire that screened for chronic pain (pain persisting ≥3 months) and asked about their general well-being (Short Form [SF]-36), pain location (body diagram), pain intensity and characteristics (Leeds Assessment of Neuropathic Symptoms and Signs), experiences with health care professionals (Chronic Illness Resources Survey), and visits made to health professionals over the past year. Respondents were categorized as help-seeking (≥1 visit in the past year) and non-help-seeking (zero visits in the past year). Results: Six percent of respondents (44/696) were non-help-seeking. These respondents differed in individual, pain, and health care professional characteristics when compared to those who did seek care. Specifically, when other variables were controlled, non-help-seeking individuals were less likely to be male (relative risk [RR] = 0.39, 95% confidence interval [CI], 0.18–0.86), report comorbid conditions (RR = 0.46, 95% CI, 0.22–0.98), report being treated as an equal partner in decision making (RR = 0.40, 95% CI, 0.18–0.93), and rate their health care professional as important to their pain management (RR = 0.39, 95% CI, 0.18–0.85). They were more likely to use over-the-counter medication to manage their pain (RR = 2.52, 95% CI, 1.14–5.58). Conclusions: Experiences with health professionals play a role in determining whether an individual manages his or her pain independently. Future research should explore the safety of those who do not seek care. [ABSTRACT FROM AUTHOR]

Major bleeding is the most serious complication of oral anticoagulants (OACs). While consensus criteria to define major bleeding have been established by the International Society for Thrombosis and Haemostasis (ISTH), Bleeding Academic Research Consortium (BARC) and Thrombolysis in Myocardial Infarction (TIMI), significant variability exists across these definitions. We sought to evaluate the agreement of cases identified by the three definitions and to assess their effect on mortality and OAC resumption. We used a dataset of individuals ≥66 years in Ontario, Canada presenting with OAC-related bleeding from 2010 to 2015. For case agreement, we calculated Cohen's κ between the three major bleeding definitions. We used multivariate regression to determine differences in mortality and OAC resumption among ISTH, BARC and TIMI-defined major bleeds. Among 2002 cases of OAC-related bleeding, agreement in case identification between ISTH and BARC was substantial (Cohen's κ = 0.69); however, agreement between TIMI and other definitions were poor. Using 30-day mortality of clinically relevant non-major bleeds as comparator, ISTH-, BARC- and TIMI-defined major bleeds conferred 3.3-, 3.2- and 5.9-fold increased risk. Among survivors, 50% with ISTH- and BARC-defined major bleeds resumed OACs at 180 days, compared to 31% of TIMI-associated cases. Major bleeds identified by ISTH and BARC criteria showed good agreement and similar prognostic utility, whereas TIMI criteria identified patients at greater clinical risk. Our results highlight the need to revise major bleeding definitions based on criteria that are independently predictive of clinically relevant morbidity and mortality to more effectively reflect the risk associated with major bleeding and appropriately influence anticoagulant therapy decisions. [ABSTRACT FROM AUTHOR]

Objectives Surgical resection and adjuvant chemotherapy have become standard of care for treating resectable early stage non-small cell lung cancer (NSCLC). The purpose was to describe and compare the overall and regional resource utilization and costs of resected NSCLC treated with and without adjuvant chemotherapy. Materials & Methods A population-based retrospective cohort study of resected NSCLC patients, diagnosed between 2004 and 2006 (representing the cohort immediately affected by the change in clinical practice) was performed using administrative data. Patients were followed for four years from the date of surgery. The healthcare system perspective was used, and cost estimates (2012 US$) were derived from administrative data and the literature. Results 3354 patients were included. The average cost per patient treated with surgery and adjuvant chemotherapy was $37,860.88 and was significantly higher than the average cost per patient treated with surgery alone $32,221.45 ( p < 0.0001). Among regions, the costs of patients treated with surgery and chemotherapy ($32,672–$45,453) and the costs of those treated with surgery alone ($28,679–$36,845) varied significantly ( p < 0.0001). Rates of chemotherapy, the proportion of patients who received any imaging scans, hospitalizations, specialist visits, emergency room visits, mean number of imaging scans, general physician visits, and blood transfusions all varied significantly among geographic regions. Conclusions This population-based study demonstrates an average cost per patient similar to that shown in randomized controlled trials; however, costs for either treatment approach varied by geographic region. Understanding the regional variation in costs and resource utilization is important with respect to delivering optimal treatment in a cost-effective strategy. [ABSTRACT FROM AUTHOR]

The Canadian health care system is a publicly financed system administered by ten provincial and three territorial governments. The purpose of this article is to provide an overview of the universal health care system in Canada, including its history, the health status of Canadians, health care funding and spending, and health research and data collection. Health care spending in Canada amounts to 11.6% of the country's gross domestic product and is estimated to have been $200.5 billion Canadian dollars in 2011. Hospitals account for the largest source of health care spending (29%), followed by drugs (16%) and physician spending (14%). Of the total health care spending, 70% is paid for by the public system. Due to the Canadian population being covered by the universal health care system, health data are being collected and can be used to monitor the health care system and inform evidence-based medicine. [ABSTRACT FROM AUTHOR]

Background: Instrumented lumbar surgeries, such as lumbar fusion and lumbar disc replacement, are increasingly being used in the United States for low back pain, with utilization rates approaching those of total joint arthroplasty. It is unknown whether there is a similar pattern in Canada. We sought to determine utilization rates and total medical costs of instrumented lumbar surgeries in a single-payer system and to compare these with the rates and costs of total hip and knee replacements.Methods: We included Ontarians aged 20 years and older who underwent instrumented lumbar surgery or total knee or total hip replacement between April 1993 and March 2012. Utilization and medical cost of the procedures were evaluated and compared using linear regression in a time-series analysis. Instrumented lumbar surgical procedures were stratified by age and main indication for surgery.Results: Utilization of instrumented lumbar surgeries rose from 6.2 to 14.2 procedures per 100 000 population between 1993 and 2012 (p < 0.001), well below the utilization of knee and hip arthroplasties. Patients were younger than 50 years of age for 29.2% of all instrumented lumbar surgery cases; annual procedure rates among those older than 80 years of age rose 7.6-fold. Direct medical costs of instrumented lumbar surgeries from 2002 to 2012 totaled $176 million. Spinal stenosis and spondylolisthesis were the most common indications for instrumented lumbar surgeries.Conclusion: Use of instrumented lumbar surgeries in Ontario’s single-payer system has increased rapidly, especially among patients older than 80 years of age. In contrast to the situation in the United States, these rates were well below those of total joint arthroplasties. These data provide useful insights about resource allocation for surgical treatment of lumbar degenerative disorders. [ABSTRACT FROM AUTHOR]

Direct oral anticoagulants (DOACs) have expanded the options for antithrombotic therapy. DOAC-related major bleeds are associated with favorable outcomes compared to warfarin in clinical trials and routine practice. However, it is unclear whether management of DOAC-associated major bleeding incurs higher resource utilization and costs. We screened medical records of patients ≥ 66 years with atrial fibrillation admitted to one of five tertiary care hospitals in Ontario, Canada with a hemorrhage. We abstracted bleeds involving DOACs or warfarin and linked them to administrative databases to capture length of hospital stay, blood product use, procedural interventions, intensive care unit (ICU) utilization and related direct medical costs. To control for confounders, multivariate logistic and linear regressions were used for binary and linear outcomes respectively. Among 19,061 records screened, 1978 (10.4%) cases involving 1632 patients met criteria of oral anticoagulant-associated bleeding. Baseline characteristics between DOAC and warfarin groups were similar. Blood product costs were higher for DOACs (all comparisons DOACs vs. warfarin, $1456 vs. $1109, mean difference $347, 95% CI $185 to $509), but length of stay and ICU use were similar. Mean direct medical costs did not differ ($9217 vs. $10,790, adjusted relative ratio 0.94, 95% CI 0.84–1.05). Prior to introduction of DOAC-specific reversal agents, resource utilization and medical costs were comparable between DOAC- and warfarin-associated major bleeds, despite marginally higher blood product costs incurred by the former. Resource intensity associated with anticoagulant-related bleeding remains high, and our data provide measures for cost-effectiveness evaluation of emerging DOAC antidotes. • Costs of managing bleeds from direct oral anticoagulants (DOACs) are unknown. • We compared resource use and costs of 1978 major bleeds from DOACs and warfarin. • Blood product costs were higher for DOAC-associated bleeds compared to warfarin. • However, DOAC bleeds did not incur higher total costs compared to warfarin. • Major bleeds from dabigatran and factor Xa inhibitors had similar treatment costs. [ABSTRACT FROM AUTHOR]

Aims: Identify opportunities to improve knowledge translation for post-operative pain management in Rwanda by exploring clinician and environmental factors affecting this practice. Methods: The theory of planned behavior (TPB) guided development of a questionnaire to measure intent to assess and treat postoperative pain. Focus groups and individual interviews were used to contextualize the final questionnaire and generate questions related to pain management practice. Health care providers from two Rwandan teaching hospitals involved in postoperative pain management completed the TPB questionnaire in May 2015. TPB subscale scores were analyzed to identify demographic and practice characteristics associated with intention to treat pain. The general linear model was used to test effect of attitudes, subjective norms, and perceived control on behavioral intent to treat pain. Results: Forty-six percent of participants (N = 131) had training in acute pain management, 56% used a pain protocol, and 74% used pain scales. Tramadol (78%), morphine (79%), and paracetamol (75%) were used most often to treat pain. Drug availability was the most frequently reported barrier to treating pain. Though intention to treat pain was high, only attitudes and perceived control about assessing pain were associated with intention to treat pain. The theme of fear of the adverse effects of pain medications was consistent across focus groups and interviews in both sites. Conclusions: System and knowledge barriers exist: interventions to address these barriers may lead to improved postoperative pain care. Further validation of the TPB questionnaire is required to address cultural and language factors specific to the Rwandan context. [ABSTRACT FROM AUTHOR]

Introduction: Ankle sprains can have a significant impact on the short- and long-term well-being of patients. We conducted a study to describe the demographic characteristics of people with an ankle sprain/dislocation treated at physicians' offices and emergency departments in Ontario, by rurality status; describe the use of health care services and the associated costs in this population, by rurality status; and investigate the relation between health care costs and rurality status by sex, age, income quintile and season of injury. Methods: We obtained data on nonfracture injuries of the ankle, foot and toe (International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada diagnostic code S93) in Ontario between 2003 and 2011 from multiple databases linked through the Institute for Clinical Evaluative Sciences. We used the Rurality Index of Ontario (RIO) as a measure of the rurality level of communities. Demographic characteristics, use of health care services and physician billing costs were obtained and compared among 5 RIO categories. Results: Data were available for 1 787 866 injury encounters. Patients in the most rural RIO category saw specialists least often and had the greatest number of emergency department visits. The mean cost for specialist visits was $141 in the most urban category and $157 in the most rural category (p < 0.05), and the corresponding mean costs for general practitioner visits were $37 and $18, respectively (p < 0.001). Conclusion: The differences in use of health care resources between RIO categories may indicate a lack of access to specialist care in rural areas, thereby necessitating reliance on emergency care. These results may be useful in allocating future resources to better serve rural patients. [ABSTRACT FROM AUTHOR]

Background: Direct oral anticoagulants (DOACs) have expanded the armamentarium for antithrombotic therapy. Although DOAC-related major bleeding was associated with favorable outcomes compared with warfarin in clinical trials, warfarin effects were reversed in < 40% of cases, raising concerns about the generalizability of this finding.Methods: Consecutive patients ≥ 66 years presented to five tertiary care hospitals across three cities in Ontario, Canada from October 2010 to March 2015 with diagnoses that included hemorrhage. Charts were screened for association with DOAC or warfarin use; eligible cases were abstracted and linked to administrative databases.Results: Among 19,061 records screened, 2,002 (460 receiving DOAC, 1,542 receiving warfarin) were eligible. Reversal agents (72.9% vitamin K, 40.7% prothrombin complex concentrates) were frequently used in warfarin bleeding events. Red blood cell transfusions occurred more often in DOAC bleeding events than in warfarin events (52.0% vs 39.5%; adjusted relative risk [aRR], 1.32; 95% CI, 1.19-2.47). However, units of blood products transfused were not different between the two groups. Thirty-four DOAC cases (7.4%) received activated prothrombin complex concentrates or recombinant factor VIIa. In-hospital mortality was lower following DOAC bleeding events (9.8% vs 15.2%; aRR, 0.66; 95% CI, 0.49-0.89), although differences in 30-day mortality did not reach statistical significance (12.6% vs 16.3%; aRR, 0.79; 95% CI, 0.61-1.03).Conclusions: In this unselected cohort of patients with oral anticoagulant-related hemorrhage with high rates of warfarin reversal, in-hospital mortality was lower among DOAC-associated bleeding events. These findings support the safety of DOACs in routine care and present useful baseline measures for evaluations of DOAC-specific reversal agents. [ABSTRACT FROM AUTHOR]

The article offers information on a study which examines the predictors of home care services use and hospital stay of patients with metastatic gastric cancer in Ontario. It mentions that retrospective cohort study, chart review, and administrative healthcare data were used to identify patients with gastric cancer. It shows that the predictors of hospitalization and receipt of home care services are age, tumor location, and metastatic disease burden.

The authors discuss aspects of cost effectiveness analysis of gastric cancer treatment. They emphasize the clinical and financial burden of gastric cancer being the fourth most commonly diagnosed cancer. They argue on the lacks of economic evaluations for gastric cancer therapy, evidence-based understanding of how treatment costs are accumulated, and or a comparative ratio of costs to benefit of commonly used treatment options to guide decision making.

Ankle sprains are common soft-tissue injuries that are often treated in emergency departments. These injuries can have significant consequences for the patient, including long-term morbidity and loss of productivity. The objective of this study was to examine the direct and indirect health resource utilization associated with ankle sprains. 296 adult patients with acute ankle sprains participated in the study in Kingston, Ontario, Canada. Data were collected using a one-month productivity questionnaire. Overall, 11% (95% CI, 8-15%) of the participants visited a physician following the initial emergency department visit. Almost all (95%; 95% CI, 92-97%) of the participants used medications or supportive treatments and 55% (95% CI, 50-61%) reported taking time off from work, school, or housework. The use of unpaid assistance was indicated by 56% of the participants (95% CI, 50-62%). Findings from this analysis highlight the significant patient-related and health care system burden of acute ankle sprains. [ABSTRACT FROM AUTHOR]

The article presents a study on the reduction and prevention of obesity through active living in clinical settings. The researchers observed 10,349 patients who received personalized recruitment/information letters from December 1, 2004 to January 31, 2008. They also performed analyses on an intent-to-treat basis. They found that intensive behavioral counseling delivered by trained experts with the help of primary care physicians can effectively achieve modest reduction in abdominal obesity.

The article presents a literature review of studies concerning the estimated economic burden of sexually transmitted diseases (STD) in the U.S. It mentions that the authors have found three studies which estimated the overall economic burden of STD and included several STD such as chlamydia infections, gonorrhea and genital herpes. It also notes that the components of the economic burden of STD can be classified as direct medical costs, direct nonmedical costs and indirect costs.