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Introduction. Advance care planning (ACP) is an important part of cancer care. We determined the ACP practice patterns of medical oncologists at our academic cancer centre in Canada. Methods. Medical oncologists were invited to participate in a questionnaire in August 2019. Questions were validated by a local survey expert. Twelve multiple-choice questions were included. Results. Seventeen of the 23 eligible oncologists responded. 64% were male, and 76% were in practice for <16 years. Common tumour sites treated by respondents included breast (53%), lung (24%), gastrointestinal (24%), and genitourinary (24%) cancers. Oncologists responded that components of ACP included designating a substitute decision-maker (100%), determining goals of care (100%), making decisions about cardiopulmonary resuscitation (94%), and disposition of property/finances (88%). They discuss ACP with curable vs. incurable patients 6% vs. 93% of the time. While 88% of oncologists reported it would be desirable to initiate ACP discussions in the first 3 visits, in the incurable setting, only 29% reported doing so. Patient characteristics that prompt oncologists to discuss ACP in the first 3 visits in the curative vs. incurable settings include elderly age (23% vs. 59%), poor performance status (47% vs. 88%), and short prognosis (47% vs. 88%). Oncologists thought the most appropriate time to discuss ACP in the curative setting was at the time the patient initiates it (35%), and during visits 2-3 in the incurable setting (41%). The most common barriers to discussing ACP include insufficient time (71%) and too much information for the patient (71%). Conclusions. While medical oncologists believe that discussing ACP with cancer patients in the first few outpatient visits is important, this seldom occurs due to the presence of several barriers. [ABSTRACT FROM AUTHOR]

Rationale: Hearing loss is a common problem for older adults entering rehabilitation hospitals. Aims and Objectives: To pilot a hearing loss screening device to determine feasibility, usability, and impact on patient outcomes. Methods: We screened all patients newly admitted to a geriatric day hospital for hearing loss using the SHOEBOX® QuickTest (SHOEBOX Ltd.) app as part of a quality improvement programme. We measured the time it took for each patient to complete screening and recorded any issues they had using the app. We recorded the number of patients who screened positive who did not have a previous diagnosis and changes in physician behaviours after they received their patients' results. Results: Seventy‐four patients with a mean age of 83.4 years used the hearing screener. All patients were able to complete the screening with a mean time to completion of 10 min and 48 s. Ninety‐nine percent of patients screened positive for hearing loss. Of these positives 56% were in participants not already known to have hearing loss. Physicians often changed their behaviour after receiving results by using assistive devices during visits and referring to audiology for formal testing. Conclusions: Screening for hearing loss is feasible in a geriatric day hospital. The SHOEBOX QuickTest app is acceptable, usable, resulting in the identification of undiagnosed hearing loss and in changes to physician behaviour. [ABSTRACT FROM AUTHOR]

Objective The need for clinical staff to reliably identify patients with a shortened life expectancy is an obstacle to improving palliative and end-of-life care. We developed and evaluated the feasibility of an automated tool to identify patients with a high risk of death in the next year to prompt treating physicians to consider a palliative approach and reduce the identification burden faced by clinical staff. Methods Two-phase feasibility study conducted at two quaternary healthcare facilities in Toronto, Canada. We modified the Hospitalised-patient One-year Mortality Risk (HOMR) score, which identifies patients having an elevated 1-year mortality risk, to use only data available at the time of admission. An application prompted the admitting team when patients had an elevated mortality risk and suggested a palliative approach. The incidences of goals of care discussions and/or palliative care consultation were abstracted from medical records. Results Our model (C-statistic=0.89) was found to be similarly accurate to the original HOMR score and identified 15.8% and 12.2% of admitted patients at Sites 1 and 2, respectively. Of 400 patients included, the most common indications for admission included a frailty condition (219, 55%), chronic organ failure (91, 23%) and cancer (78, 20%). At Site 1 (integrated notification), patients with the notification were significantly more likely to have a discussion about goals of care and/or palliative care consultation (35% vs 20%, p = 0.016). At Site 2 (electronic mail), there was no significant difference (45% vs 53%, p = 0.322). Conclusions Our application is an accurate, feasible and timely identification tool for patients at elevated risk of death in the next year and may be effective for improving palliative and end-of-life care. [ABSTRACT FROM AUTHOR]

Objective: Renal replacement therapy (RRT) is the treatment of choice for severe acute kidney injury, but there are no firm guidelines as to the time of initiation of RRT in the critically ill. The primary objective of this study is to determine 1-month mortality rates of early versus late dialysis in critical care. As secondary end points, we provide a cost analysis of early versus late RRT initiation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and number of patients on dialysis at day 60 postrandomization. Data Sources: We identified all randomized controlled trials (RCTs) through EMLINE and MEDBASE that examined adult patients admitted to critical care who were randomized to receiving early dialysis versus standard of care. Study Selection: Inclusion criteria: (1) RCTs conducted after the year 2000, (2) the population evaluated had to be adults admitted to ICU, (3) the intervention had to be early RRT versus standard care, and (4) outcomes had to measure patient mortality. Data Extraction: Two independent investigators reviewed search results and identified appropriate studies. Information was extracted using standardized case report forms. Data Synthesis: Overall, 7 RCTs were included with a total of 1400 patients. Early RRT showed no survival benefit when compared to standard treatment (odds ratio [OR], 0.90 95% confidence interval [95% CI] 0.70-1.15, P = .39). There was no significant difference in length of hospital stay in patients with early RRT (−1.55 days [95% CI −4.75 to 1.65, P = .34]), in length of ICU stay (−0.79 days [95% CI −2.09 to 0.52], P = .24), or proportion of patients on dialysis at day 60 (OR 0.93 [95% CI 0.62 to 1.43], P = .79). Per patient, there is likely a small increase in costs (

Background: ICU care is costly, and there is a large variation in cost among patients.Methods: This is an observational study conducted at two ICUs in an academic centre. We compared the demographics, clinical data, and outcomes of the highest decile of patients by total costs, to the rest of the population.Results: A total of 7,849 patients were included. The high-cost group had a longer median ICU length of stay (26 versus 4 days, P < 0.001) and amounted to 49% of total costs. In-hospital mortality was lower in the high-cost group (21.1% versus 28.4%, P < 0.001). Fewer high-cost patients were discharged home (23.9% versus 45.2%, P < 0.001), and a large proportion were transferred to long-term care (35.1% versus 12.1%, P < 0.001). Patients with younger age or a diagnosis of subarachnoid hemorrhage, acute respiratory failure, or complications of procedures were more likely to be high cost.Conclusions: High-cost users utilized half of the total costs. While cost is associated with LOS, other drivers include younger age or admission for respiratory failure, subarachnoid hemorrhage, or after a procedural complication. Cost-reduction interventions should incorporate strategies to optimize critical care use among these patients. [ABSTRACT FROM AUTHOR]

Purpose: To use theoretical modelling exercises to determine the effect of reduced intensive care unit (ICU) length of stay (LOS) on total hospital costs at a Canadian centre.Methods: We conducted a retrospective cost analysis from the perspective of one tertiary teaching hospital in Canada. Cost, demographic, clinical, and LOS data were retrieved through case-costing, patient registry, and hospital abstract systems of The Ottawa Hospital Data Warehouse for all new in-patient ward (30,483) and ICU (2,239) encounters between April 2012 and March 2013. Aggregate mean daily variable direct (VD) costs for ICU vs ward encounters were summarized by admission day number, LOS, and cost centre.Results: The mean daily VD cost per ICU patient was $2,472 (CAD), accounting for 67.0% of total daily ICU costs per patient and $717 for patients admitted to the ward. Variable direct cost is greatest on the first day of ICU admission ($3,708), and then decreases by 39.8% to plateau by the fifth day of admission. Reducing LOS among patients with ICU stays ≥ four days could potentially result in an annual hospital cost saving of $852,146 which represents 0.3% of total in-patient hospital costs and 1.2% of ICU costs.Conclusion: Reducing ICU LOS has limited cost-saving potential given that ICU costs are greatest early in the course of admission, and this study does not support the notion of reducing ICU LOS as a sole cost-saving strategy. [ABSTRACT FROM AUTHOR]

Background: Like much of the developed world, healthcare costs in Canada are rising. A small proportion of patients account for a large proportion of healthcare spending and much of this spending occurs in acute care settings. The purpose of our study was to determine potentially modifiable factors related to care processes that contribute to high-cost admissions.Methods: Using a mixed-methods study design, factors contributing to high-cost admissions were identified from literature and case review. We defined pre- and post-admission factors contributing to high-cost admissions. Pre-admission factors included reason for admission (e.g. complex medical, elective surgery, trauma, etc.). Post-admission factors included medical complications, disposition delays, clinical services delays, and inefficient clinical decision-making. We selected a random sample of admissions in the top decile of inpatient cost from the Ottawa Hospital between January 1 and December 31, 2010. A single reviewer classified cases based on the pre- and post-admission factors. We combined this information with data derived from the Ottawa Hospital Data Warehouse to describe patient-level clinical and demographic characteristics and costs incurred.Results: We reviewed 200 charts which represents ~5% of all high cost admissions within the Ottawa Hospital in 2010. Post-admission factors contributing to high-cost admissions were: complications (60%), disposition delays (53%), clinical service delays (39%), and inefficient clinical decision-making (13%). Further, these factors varied substantially across service delivery lines. The mean (standard deviation (SD)) cost per admission was $49,923 CDN ($45,773). The most common reason for admission was "complex medical" (49%) and the overall median (IQR) length of stay was 27 (18-48) days. Approximately 1 in 3 high cost admissions (29%) included time in the intensive care unit (ICU).Conclusions: While high cost admissions often include time in ICU and have long lengths of stay, a substantial proportion of costs were attributable to complications and potentially preventable delays in care processes. These findings suggest opportunities exist to improve outcomes and reduce costs for this diverse patient population. [ABSTRACT FROM AUTHOR]

Background: Patients who are discharged from hospital after an acute medical illness often have impaired function that prevents them from returning to their previous place of residence. Assessing each patient's post-discharge needs takes time and resources but is important in order to reduce unplanned readmissions and adverse events post-discharge. Methods/design: We will conduct a systematic review to synthesize the evidence on prognostic models and their reported accuracy in predicting the location of discharge after a medical admission to an acute care hospital. We will perform searches in MEDLINE, EMBASE, CINAHL, and COCHRANE databases. Pre-defined study, population, and model characteristics will be reported. We will write a narrative summary of included studies. Methodological quality of the studies will be assessed using the QUIPS tool, and the quality of evidence will be evaluated using the GRADE tool. Discussion: Early and accurate assessment of patient needs for supportive services after discharge has the potential to improve patient outcomes and health system efficiency. This systematic review will identify factors that can accurately predict location of discharge using existing tools and identify priority knowledge gaps to inform future research. [ABSTRACT FROM AUTHOR]

Introduction: Older adults living in the community often have multiple, chronic conditions and functional impairments. A challenge for healthcare providers working in the community is the lack of a predictive tool that can be applied to the broad spectrum of mortality risks observed and may be used to inform care planning. Objective: To predict survival time for older adults in the home care setting. The final mortality risk algorithm will be implemented as a web-based calculator that can be used by older adults needing care and by their caregivers. Design: Open cohort study using the Resident Assessment Instrument for Home Care (RAI-HC) data in Ontario, Canada, from 1 January 2007 to 31 December 2013. Participants: The derivation cohort will consist of ~437 000 older adults who had an RAI-HC assessment between 1 January 2007 and 31 December 2012. A split sample validation cohort will include ~122 000 older adults with an RAI-HC assessment between 1 January and 31 December 2013. Main outcome measures: Predicted survival from the time of an RAI-HC assessment. All deaths (n≈245 000) will be ascertained through linkage to a population-based registry that is maintained by the Ministry of Health in Ontario. Statistical analysis: Proportional hazards regression will be estimated after assessment of assumptions. Predictors will include sociodemographic factors, social support, health conditions, functional status, cognition, symptoms of decline and prior healthcare use. Model performance will be evaluated for 6-month and 12-month predicted risks, including measures of calibration (eg, calibration plots) and discrimination (eg, c-statistics). The final algorithm will use combined development and validation data. Ethics and dissemination: Research ethics approval has been granted by the Sunnybrook Health Sciences Centre Review Board. Findings will be disseminated through presentations at conferences and in peer-reviewed journals. [ABSTRACT FROM AUTHOR]

Background: A small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital.Methods: We identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status.Results: During the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001).Conclusions: Within a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations. [ABSTRACT FROM AUTHOR]

Background: A small proportion of patients account for the majority of health care spending. We used detailed clinical and administrative data to explore clinical characteristics, patterns of health care use and changes in cost profiles over time among high-cost inpatients in an acute tertiary care hospital in Ottawa, Ontario. Methods: We identified all people who had 1 or more inpatient admissions to The Ottawa Hospital between Apr. 1, 2009, and Mar. 31, 2012. We calculated the direct inpatient costs using case-costing information to categorize patients into persistently high-cost, episodic high-cost and non-high-cost groups. Within each group, we used discharge abstracts to measure encounter-level characteristics and patterns of inpatient health care use over time. We also developed transition matrices to explore how inpatient costing states changed over time. Results: During the study period, 100 178 patients had 132 996 hospital admissions. Hospital spending was often limited to a single year for most of the patients (90.2%), with only a small proportion (7.4%) of patients remaining in the high-cost group in the subsequent year. Patients in the persistently (n = 236) and episodic (n = 5062) high-cost groups were often older, had medically complex conditions and generated most of the costs from nursing care and intensive care. Compared with patients in the other cost groups, those in the persistently high-cost group were more likely to have multiple readmissions (43.4%) and multiple placements in an alternate level of care (19.0%) and were high users of health care services outside of the hospital setting. Interpretation: Hospital spending was often limited to a single year for most patients, and only a small proportion of patients remained in the high-cost group in the subsequent year. These persistently high-cost patients had medically complex conditions and often required expensive care. A greater understanding of the circumstances that result in persistent hospital spending remains an area for future work, including an exploration of the potential barriers impeding efficient transition out of acute care for high-risk patients. [ABSTRACT FROM AUTHOR]

Rational, aims and objectives Many quality problems exist in health care. We aim to investigate the feasibility and acceptability of using e-learning (defined as computer-based learning modules) to address gaps in quality of care. Methods We performed a qualitative evaluation of participants in a pilot e-learning program. Physician members of six medical teaching units (MTUs) at a multi-site tertiary care teaching hospital were asked to complete two e-learning modules addressing hand hygiene practices and management of community-acquired pneumonia (CAP). An e-learning design team created online modules that were made available to members of the six MTUs for 4 weeks using a password secured website. Use of the modules was voluntary. Participants' perceptions of module content, mode of delivery, and suggestions for improvement were determined through focus groups. We then performed content analysis on the transcripts. We used system data to define patterns of module access. Results Out of 55 eligible users, 30 (55%) logged onto the system at least once. Residents (14/30, 47%) were less likely to use the system than medical students (9/14, 64%) and attending staff (7/11, 64%). Learners at all levels thought the modules were easy to use. Participants liked the knowledge-based material in the CAP module because it directly applied to their work. There were less favourable opinions of the hand hygiene module Conclusions Generating e-learning modules targeted at gaps in quality of care is feasible and acceptable to learners. Future studies should assess whether these approaches lead to desired changes in behavior. [ABSTRACT FROM AUTHOR]

1. Upon successful completion, participants will be able to outline key skills and strategies for communication with patients and their families during crisis settings. 2. Upon successful completion, participants will appreciate how the Serious Illness Conversation Guide may be adapted for crisis communication, for potential use in their clinical practice. There are limited tools to help physicians conduct serious illness conversations within a crisis situation, where there is a high probability of imminent death. The objective of our study was to identify the communication skills and strategies used by experts in crisis situations and to determine if and how the Serious Illness Conversation Guide (SICG) can be adapted for crisis. There are limited tools to help physicians conduct serious illness conversations within a crisis situation, where there is a high probability of imminent death. Ariadne Lab's Serious Illness Conversation Guide (SICG) offers physicians a framework to lead conversations with seriously ill patients in stable settings. Though the SICG was designed in outpatient oncology, the patient-tested language and structured framework may also be adaptable to crisis communication. To identify the communication skills and strategies used by expert clinicians in crisis situations and to examine whether the SICG can be adapted for use in crisis situations We conducted a qualitative analysis using semi-structured interviews. Data was analyzed by independent researchers via thematic analysis. We developed a preliminary adapted SICG based on the results. We interviewed general internists (n=8), intensive care physicians (n=3) and emergency medicine physicians (n=7) from Ottawa, Canada. All physicians worked at The Ottawa Hospital (a large tertiary care hospital). We identified four major themes : a) how crisis situations influence serious illness conversations, b) the key components required for crisis communication, c) the skills and strategies used to navigate difficult situations in crisis, and d) perceptions of adaptability of the SICG to crisis. All physicians felt the SICG could be adapted to crisis. The components of crisis communication that were identified to be absent from the existing SICG included: gathering information on the medical context and prior wishes, assessing capacity and establishing the substitute decision maker, gaining an understanding of the patient's quality of life and baseline function, and involving family. Our study outlines key skills and strategies of crisis communication and supports a role for adapting the SICG to acute care. Future studies should test the preliminary adapted guide, seeking feedback from patient-advocates from culturally diverse populations. Shared Decision Making / Advance Care PlanningCommunication [ABSTRACT FROM AUTHOR]

Abstract: The interactions of the antimicrobial peptides aurein 1.2, citropin 1.1 and maculatin 1.1 with dimyristoylphosphatidylcholine (DMPC), dimyristoylphosphatidylglycerol (DMPG) and dimyristoylphosphatidylethanolamine (DMPE) were studied by differential scanning calorimetry (DSC) and Fourier-transform infrared (FTIR) spectroscopy. The effects of these peptides on the thermotropic phase behavior of DMPC and DMPG are qualitatively similar and manifested by the suppression of the pretransition, and by peptide concentration-dependent decreases in the temperature, cooperativity and enthalpy of the gel/liquid–crystalline phase transition. However, at all peptide concentrations, anionic DMPG bilayers are more strongly perturbed than zwitterionic DMPC bilayers, consistent with membrane surface charge being an important aspect of the interactions of these peptides with phospholipids. However, at all peptide concentrations, the perturbation of the thermotropic phase behavior of zwitterionic DMPE bilayers is weak and discernable only when samples are exposed to high temperatures. FTIR spectroscopy indicates that these peptides are unstructured in aqueous solution and that they fold into α-helices when incorporated into lipid membranes. All three peptides undergo rapid and extensive H–D exchange when incorporated into D2O-hydrated phospholipid bilayers, suggesting that they are located in solvent-accessible environments, most probably in the polar/apolar interfacial regions of phospholipid bilayers. The perturbation of model lipid membranes by these peptides decreases in magnitude in the order maculatin 1.1>aurein 1.2>citropin 1.1, whereas the capacity to inhibit Acholeplasma laidlawii B growth decreases in the order maculatin 1.1>aurein 1.2≅citropin 1.1. The higher efficacy of maculatin 1.1 in disrupting model and biological membranes can be rationalized by its larger size and higher net charge. However, despite its smaller size and lower net charge, aurein 1.2 is more disruptive of model lipid membranes than citropin 1.1 and exhibits comparable antimicrobial activity, probably because aurein 1.2 has a higher propensity for partitioning into phospholipid membranes. [Copyright &y& Elsevier]