Search

Background Income disparities may affect patients’ care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited. Objective To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities. Design Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial. Participants Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals. Main Measures The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted. Key Results Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0–3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health. Conclusions There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

We implemented twice-weekly academic detailing rounds in 2015 as an antimicrobial stewardship (AMS) intervention in solid organ transplant (SOT) patients, led by an AMS pharmacist and a transplant infectious diseases physician. They reviewed SOT patients’ antimicrobials and made recommendations to prescribers on antimicrobial regimens, diagnostics investigations, and appropriate referrals for transplant infectious diseases consultation. To determine the impact of the intervention, we adjudicated antimicrobials prescriptions using established AMS principles, and compared the proportion of AMS-concordance regimens pre-intervention (2013) with post-intervention (2016) via 4-point-prevalence surveys conducted in each period. All admitted SOT patients who were receiving antimicrobial treatment on survey days were included. Primary outcome was the percentage of antimicrobial regimen adjudicated as AMS concordant. Secondary outcomes were percentage of AMS concordance in patients consulted by transplant infectious diseases; categories of AMS discordance; antimicrobial consumption in defined daily dose/100 patient-days (DDD/100PD); antimicrobial cost in CAD$/PD; and C. difficile infections. Balancing measures were length of stay, 30-day readmission, and in-hospital mortality. We compared outcomes using χ2 test or t-test; significant difference was defined as p

Objective: To estimate the bias associated with specific nonrandomized study attributes among studies comparing transcatheter aortic valve implantation with surgical aortic valve replacement for the treatment of severe aortic stenosis.Data sources and study selection: We searched 7 databases from inception to June 2017: Medline, Medline In-Process/ePubs, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included all RCTs and nonrandomized studies that reported outcomes of interest.Data extraction and synthesis: We categorized studies according to study design, and evaluated 41 nonrandomized study attributes as potential sources of bias. We calculated odds ratios (OR) and other effect measures with 95% confidence intervals (CI) using random effects models.Main outcomes: One month postoperative mortality, and length of stay. Bias was defined as the difference in estimates of treatment effects between nonrandomized studies and high quality (low risk of bias) RCTs, which were considered to provide “gold standard” estimates.Results: We included 6 RCTs and 87 nonrandomized studies. Surgical risk scores were similar for comparison groups in RCTs, but were higher for patients having transcatheter aortic valve implantation in nonrandomized studies. Nonrandomized studies underestimated the benefit of transcatheter aortic valve implantation compared with RCTs. For example, nonrandomized studies without adjustment estimated a higher risk of postoperative mortality for transcatheter aortic valve implantation compared with surgical aortic valve replacement (OR 1.43 [95% CI, 1.26 to 1.62]) than high quality RCTs (OR 0.78 [95% CI, 0.54 to 1.11). Nonrandomized studies using propensity score matching (OR 1.13 [95% CI, 0.85 to 1.52]) and regression modelling (OR 0.68 [95% CI, 0.57 to 0.81]) to adjust results estimated treatment effects closer to high quality RCTs. Nonrandomized studies describing losses to follow-up estimated treatment effects that were significantly closer to high quality RCT than nonrandomized studies that did not.Conclusion: Studies with different attributes produce different estimates of treatment effects. Study design attributes related to the completeness of follow-up may explain biased treatment estimates in nonrandomized studies, as in the case of aortic valve replacement where high-risk patients were preferentially selected for the newer (transcatheter) procedure.

Laparoscopic adjustable gastric band (LAGB) placement remains a common bariatric procedure. While LAGB procedure is performed within private clinics in most Canadian provinces, public health care is often utilized for LAGB-related reoperations. We identified 642 gastric band removal procedures performed in Ontario from 2011 to 2014 using population-level administrative data. The number of procedures performed increased annually from 101 in 2011 to 220 in 2014. Notably, 54.7% of the patients required laparotomy, and 17.6% of patients underwent a subsequent bariatric surgery. Our findings demonstrated that LAGB placement in private clinics resulted in a large number of band removal procedures performed within the public system. This represents a significant public health concern that may result in significant health care utilization and patient morbidity.

Staphylococcus aureus bacteremia (SAB) causes significant morbidity and mortality. We assessed the disease severity and clinical outcomes of SAB in patients with pre-existing immunosuppression, compared with immunocompetent patients. A retrospective cohort investigation studied consecutive patients with SAB hospitalized across six hospitals in Toronto, Canada from 2007 to 2010. Patients were divided into immunosuppressed (IS) and immunocompetent (IC) cohorts; the IS cohort was subdivided into presence of one and two or more immunosuppressive conditions. Clinical parameters were compared between cohorts and between IS subgroups. A competing risk model compared in-hospital mortality and time to discharge. A total of 907 patients were included, 716 (79%) were IC and 191 (21%) were IS. Within the IS cohort, 111 (58%) had one immunosuppressive condition and 80 (42%) had two or more conditions. The overall in-hospital mortality was 29%, with no differences between groups (IS 32%, IC 28%, p = 0.4211). There were no differences in in-hospital mortality (sub-distribution hazard ratio [sHR] 1.17, 95% confidence interval [CI] 0.88–1.56, p = 0.2827) or time to discharge (sHR 0.94, 95% CI 0.78–1.15, p = 0.5570). Independent mortality predictors for both cohorts included hypotension at 72 h (IS: p

Background Isolation precautions have negative effects on patient safety, psychological well-being, and healthcare worker contact. However, it is not known whether isolation precautions affect certain hospital-related outcomes.

Infectious diseases specialists often use diagnostic tests to assess the probability of a disease based on knowledge of the diagnostic properties. It has become standard for published studies on diagnostic tests to report sensitivity, specificity and predictive values. Likelihood ratios are often omitted. We compared published clinical prediction rules in Staphylococcus aureus bacteremia to illustrate the importance of likelihood ratios. We performed a narrative review comparing published clinical prediction rules used for excluding endocarditis in S. aureus bacteremia. Of nine published clinical prediction rules, only three studies reported likelihood ratios. Many studies concluded that the clinical prediction rule could safely exclude endocarditis based on high sensitivity and high negative predictive value. Of the studies with similar high sensitivity and high negative predictive value, calculated negative likelihood ratios were able to differentiate and identify the best clinical prediction rule for excluding endocarditis. Compared to sensitivity, specificity and predictive values, likelihood ratios can be more directly used to interpret diagnostic test results to assist in ruling in or ruling out a disease. Therefore, a new standard should be set to include likelihood ratios in reporting of diagnostic tests in infectious diseases research.

Intravenous administration of vascular endothelial growth factor (VEGF)-inhibiting drugs is associated with adverse gastrointestinal (GI) events. Clinical trials of VEGF inhibitors used for the treatment of retinal diseases have suggested higher risks of adverse GI events among patients treated with bevacizumab. However, population-based studies have been lacking.Our objective was to assess risks for GI adverse events associated with intravitreal injections of VEGF-inhibiting drugs.We conducted a population-based, nested case-control study of 114,427 older adults in Ontario, Canada, with retinal disease identified between 1 November 2005 and 30 April 2011. Of these, 3,582 cases were admitted to hospital or assessed in an emergency department for GI adverse events. Controls were matched to cases on the basis of age, sex, and outcome history.Patients experiencing adverse events were equally as likely as matched controls to have been exposed to bevacizumab or ranibizumab. Adjusted odds ratios for bevacizumab were 1.05 (95 % confidence interval [CI] 0.69-1.61) for upper GI ulceration, 1.29 (95 % CI 0.86-1.96) for diverticular disease, 1.49 (95 % CI 0.84-2.63) for pancreatitis, 0.82 (95 % CI 0.53-1.29) for cholelithiasis, and 1.45 (95 % CI 0.67-3.12) for cholecystitis. For ranibizumab they were 1.25 (95 % CI 0.88-1.77) for upper GI ulceration, 1.12 (95 % CI 0.83-1.52) for diverticular disease, 0.85 (95 % CI 0.51-1.40) for pancreatitis, 0.77 (95 % CI 0.53-1.11) for cholelithiasis, and 0.83 (95 % CI 0.44-1.56) for cholecystitis. Results were similar when the analysis was restricted to patients only exposed to a single type of VEGF inhibitor.In this population-based study, intravitreal injections of bevacizumab and ranibizumab were not associated with increased risks of adverse GI events.

Previous studies discussing the risk of medical misconduct amongst anesthesiologists differ in their conclusions. In Canada, there is a paucity of data regarding demographic information, disciplinary findings, and penalties received by anesthesiologists. The aim of this study was to identify potential characteristics for discipline within the specialty of anesthesiology by ascertaining disciplinary findings and types of penalties received by anesthesiologists and comparing these with cases of disciplinary action against other Canadian physicians.Using a retrospective cohort design, we constructed a database of all Canadian physicians disciplined by their respective provincial and territorial regulatory colleges between 2000-2011. We collected and compared physician demographic information, types of disciplinary findings, and penalties received by anesthesiologists and other physicians during that time period.Between 2000-2011, various physicians were disciplined 721 times in Canada. Nine anesthesiologists were found guilty of 11 (1.5%) disciplinary findings. One anesthesiologist was disciplined three separate times. All anesthesiologists subject to discipline were males, ten (90.9%) were independent practitioners, and almost two-thirds (63.6%) were international medical graduates. The most common types of disciplinary findings were related to standard of care issues, inappropriate prescribing, and fraudulent behaviour. Anesthesiologists appeared less likely than other physicians to be disciplined for sexual misconduct and unprofessional behaviour.Anesthesiologists in Canada have been subject to low rates of disciplinary action. Specifically, there have been low rates of sexual misconduct and unprofessional behaviour. Interventions to reduce disciplinary findings in anesthesiology could be directed toward bolstering education relating to standard of care issues, prescribing practices, and fraudulent behaviour.

Background Patients undergoing orthopaedic procedures experience major changes in function and daily routines upon their return home. Discharge summaries are an important communication tool that may play a role in optimizing a safe transition from hospital. Current care gaps and key elements of an ideal discharge summary specific for orthopaedic population are unknown. We sought to identify the challenges of current orthopaedic discharge summaries and to determine key elements of an ideal document. Methods Qualitative study survey using semi-structured interviews with a sample of 17 patients and clinicians representing diverse professions, backgrounds, and practice settings. We used the constant comparative method of qualitative analysis to define the experiences and perceptions of quality gaps and strategies to improve orthopaedic-specific discharge summaries. Results We identified 3 major themes describing factors perceived to be limiting the quality of current discharge summaries: 1) physician-centric documentation and the absence of a comprehensive, inter-professional perspective; 2) access to resources and health informatics; and 3) process variations in document creation and dissemination. Conclusions Clinicians and patients identified several factors limiting the quality of discharge summaries among orthopaedic inpatients. Incorporating these elements could improve hospital transitions.

Background: The rapid rise in the availability and use of pharmaceutical agents, and particularly polypharmacy, directly increases the risk for patients to experience adverse drug reactions (ADRs). There are few studies on the overall incidence and costs of ADRs.

Opinions on the use of research abstracts in policy decision making are conflicting. We sought to evaluate the influence of research abstracts in guiding decisions of the Joint Oncology Drug Review of Canada (JODR), which conducts clinical and economic reviews of new cancer treatment drugs for formulary listing. The minutes of the monthly meetings of the JODR between 2005 and 2007 were reviewed. One submission per drug indication was included. Elements evaluated included the level of evidence supporting each decision, the year the study was published and subsequent publication of any abstracts. There were 73 recommendations reviewed over the 36 months. Ten recommendations were deferred and eight recommendations were resubmissions, thus 55 recommendations underwent analysis. There were 31 recommendations based to some extent on abstracts, of which 14 (45%) were in favour of formulary listing and 17 (55%) were opposed. Twelve recommendations were based exclusively on abstracts, seven (58%) of which were in favour of formulary listing. As a comparison, published randomized controlled trials were part of the evidentiary base in 30 committee recommendations (55%). Of these, 17 (57%) were in favour of formulary listing, while 13 (43%) were opposed. Research abstracts are commonly involved in evidence-based decision making for formulary listing. The rates of approving cancer drugs for funding by the JODR were similar among recommendations based on abstracts and other levels of evidence. Abstracts can play an important role in guiding decision making.

Patient care transitions are periods of enhanced risk. Discharge summaries have been used to communicate essential information between hospital-based physicians and primary care physicians (PCPs), and may reduce rates of adverse events after discharge.To assess PCP satisfaction with an electronic discharge summary (EDS) program as compared to conventional dictated discharge summaries.Cluster randomized trial.Four medical teams of an academic general medical service.The primary endpoint was overall discharge summary quality, as assessed by PCPs using a 100-point visual analogue scale. Other endpoints included housestaff satisfaction (using a 100-point scale), adverse outcomes after discharge (combined endpoint of emergency department visits, readmission, and death), and patient understanding of discharge details as measured by the Care Transition Model (CTM-3) score (ranging from 0 to 100).209 patient discharges were included over a 2-month period encompassing 1 housestaff rotation. Surveys were sent out for 188 of these patient discharges, and 119 were returned (63% response rate). No difference in PCP-reported overall quality was observed between the 2 methods (86.4 for EDS vs. 84.3 for dictation; P = 0.53). Housestaff found the EDS significantly easier to use than conventional dictation (86.5 for EDS vs. 49.2 for dictation; P = 0.03), but there was no difference in overall housestaff satisfaction. There was no difference between discharge methods for the combined endpoint for adverse outcomes (22 for EDS [21%] vs. 21 for dictation [20%]; P = 0.89), or for patient understanding of discharge details (CTM-3 score 80.3 for EDS vs. 81.3 for dictation; P = 0.81)An EDS program can be used by housestaff to more easily create hospital discharge summaries, and there was no difference in PCP satisfaction.

Background Statistical models developed using administrative databases are powerful and inexpensive tools for predicting survival. Conversely, data abstraction from chart review is time-consuming and costly. Our aim was to determine the incremental value of pathological data obtained from chart abstraction in addition to information acquired from administrative databases in predicting all-cause and prostate cancer (PC)-specific mortality. Methods We identified a cohort of men with diabetes and PC utilizing population-based data from Ontario. We used the c-statistic and net-reclassification improvement (NRI) to compare two Cox- proportional hazard models to predict all-cause and PC-specific mortality. The first model consisted of covariates from administrative databases: age, co-morbidity, year of cohort entry, socioeconomic status and rural residence. The second model included Gleason grade and cancer volume in addition to all aforementioned variables. Results The cohort consisted of 4001 patients. The accuracy of the admin-data only model (c-statistic) to predict 5-year all-cause mortality was 0.7 (95% CI 0.69-0.71). For the extended model (including pathology information) it was 0.74 (95% CI 0.73-0.75). This corresponded to a change in category of predicted probability of survival among 14.8% in the NRI analysis. The accuracy of the admin-data model to predict 5-year PC specific mortality was 0.76 (95% CI 0.74-0.78). The accuracy of the extended model was 0.85 (95% CI 0.83-0.87). Corresponding to a 28% change in the NRI analysis. Conclusions Pathology chart abstraction, improved the accuracy in predicting all-cause and PC-specific mortality. The benefit is smaller for all-cause mortality, and larger for PC-specific mortality.

Background Impairment in activities of daily living (ADL) is an important predictor of outcomes although many administrative databases lack information on ADL function. We evaluated the impact of ADL function on predicting postoperative mortality among older adults with hip fractures in Ontario, Canada. Methods Sociodemographic and medical correlates of ADL impairment were first identified in a population of older adults with hip fractures who had ADL information available prior to hip fracture. A logistic regression model was developed to predict 360-day postoperative mortality and the predictive ability of this model were compared when ADL impairment was included or omitted from the model. Results The study sample (N = 1,329) had a mean age of 85.2 years, were 72.8% female and the majority resided in long-term care (78.5%). Overall, 36.4% of individuals died within 360 days of surgery. After controlling for age, sex, medical comorbidity and medical conditions correlated with ADL impairment, addition of ADL measures improved the logistic regression model for predicting 360 day mortality (AIC = 1706.9 vs. 1695.0; c -statistic = 0.65 vs 0.67; difference in - 2 log likelihood ratios: χ2 = 16.9, p = 0.002). Conclusions Direct measures of ADL impairment provides additional prognostic information on mortality for older adults with hip fractures even after controlling for medical comorbidity. Observational studies using administrative databases without measures of ADLs may be potentially prone to confounding and bias and case-mix adjustment for hip fracture outcomes should include ADL measures where these are available.

To evaluate a bedside clinical prediction rule for detecting moderate or severe aortic stenosis.Cross-sectional study with independent comparison to a diagnostic reference standard, doppler echocardiography.Urban university hospital.Consecutive hospital inpatients (n = 124) who had been referred for echocardiography.Participants were examined by a third-year general internal medicine resident and a staff general internist. We hypothesized in advance that absence of a murmur over the right clavicle would rule out aortic stenosis, while the presence of three or four associated findings (slow carotid artery upstroke, reduced carotid artery volume, maximal murmur intensity at the second right intercostal space, and reduced intensity of the second heart sound) would rule in aortic stenosis. Study physicians were unaware of echocardiographic findings. The outcome was echocardiographic moderate or severe aortic stenosis, defined as a valve area of 1.2 cm2 or less, or a peak instantaneous gradient of 25 mm Hg or greater. Absence of a murmur over the right clavicle ruled out aortic stenosis (likelihood ratio [LR] 0.10; 95% confidence interval [CI] 0.01, 0.44). The presence of three or four associated findings ruled in aortic stenosis (LR 40; 95% CI 6.6, 240). If a murmur was present over the right clavicle, but no more than two associated findings were present, then the examination was indeterminate (LR 1.8; 95% CI 0.93, 2.9).A clinical prediction rule, using simple bedside maneuvers, accurately ruled in and ruled out aortic stenosis.

Background It is uncertain whether patients with renal vascular disease will have renal or mortality benefit from re-establishing renal blood flow with renal revascularization procedures. The RAVE study will compare renal revascularization to medical management for people with atherosclerotic renal vascular disease (ARVD) and the indication for revascularization. Patients will be assessed for the standard nephrology research outcomes of progression to doubling of creatinine, need for dialysis, and death, as well as other cardiovascular outcomes. We will also establish whether the use of a new inexpensive, simple and available ultrasound test, the renal resistance index (RRI), can identify patients with renal vascular disease who will not benefit from renal revascularization procedures1. Methods/design This single center randomized, parallel group, pilot study comparing renal revascularization with medical therapy alone will help establish an infrastructure and test the feasibility of answering this important question in clinical nephrology. The main outcome will be a composite of death, dialysis and doubling of creatinine. Knowledge from this study will be used to better understand the natural history of patients diagnosed with renal vascular disease in anticipation of a Canadian multicenter trial. Data collected from this study will also inform the Canadian Hypertension Education Program (CHEP) Clinical Practice Guidelines for the management of Renal and Renal Vascular Disease. The expectation is that this program for ARVD, will enable community based programs to implement a comprehensive guidelines based diagnostic and treatment program, help create an evidence based approach for the management of patients with this condition, and possibly reduce or halt the progression of kidney disease in these patients. Discussion Results from this study will determine the feasibility of a multicentered study for the management of renovascular disease.

Background and Objectives There have been no contemporary studies assessing abstract publication rates and the factors associated with full publication within the field of nephrology. As such, it is unclear whether a publication bias exists for abstracts presented at nephrology meetings, which may hinder the dissemination of potentially important results. Our objective was to review a selection of abstracts presented at 3 major nephrology meetings to determine the proportion that reach full publication and factors associated with full publication. Methods 300 randomly selected abstracts presented as posters at three annual nephrology meetings in 2006 [American Society of Nephrology (ASN), European Renal Association (ERA), and National Kidney Foundation (NKF)] were reviewed. Accepted methods of literature search were performed to determine subsequent journal publication. Univariate and multivariate analyses were performed to determine the association between abstract characteristics and subsequent full publication. Results 127 (42%) abstracts were published in peer-reviewed journals at 4.5 years. On multivariable analysis, basic science research (OR 2.84, 95% CI 1.44-5.61 as compared to clinical research) and the scientific meeting [OR 2.87, 95% CI 1.60-5.15 (ASN); OR 1.92, 95% CI 1.07-3.45(ERA) as compared to NKF] were significantly associated with full publication. Conclusions Almost two-fifths of abstracts presented at three major nephrology meetings are subsequently published in peer-reviewed journals. Basic science content and the meeting at which the abstract was presented are associated with publication. Further research is needed to ascertain the impact of other important factors on abstract publication rates to address publication bias in the renal literature.