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Background: The World Health Organization (WHO) has set hepatitis C (HCV) elimination targets for 2030. Understanding existing gaps in the "HCV care-cascade" is essential for meeting these targets. We aimed to identify the level of service scale-up needed along the "HCV care-cascade" to achieve the WHO's HCV elimination targets in Ontario, Canada. Methods: By employing a decision analytic model, we projected the quality-adjusted life years (QALYs) and healthcare costs for individuals with HCV in Ontario. We increased RNA testing and treatment rates to 98%, followed by increasing antibody testing uptake until we achieved the WHO's mortality target (i.e., a 65% reduction in liver-related mortality by 2030 vs. 2015). Results: Without scaling up by 2030, the expected QALYs and costs per person were 9.156 and CAD 48,996, respectively. Improved RNA testing and treatment rates reduced liver-related deaths to 3.3/100,000, a 57% reduction from 2015. Further doubling the antibody testing rates can achieve the WHO's mortality target in 2035, but not in 2030. Compared to the status quo, such program would be cost-effective considering a 50,000 CAD/QALY gained threshold if annual implementation costs stayed under 2.3 M CAD/100,000 people. Conclusions: Doubling the antibody testing rates, along with increased RNA testing and treatment rates, showed promise in meeting the WHO's goals by 2035. [ABSTRACT FROM AUTHOR]

Background Frailty and multimorbidity among older cancer patients affect treatment tolerance and efficacy. Comprehensive geriatric assessment and management is recommended to optimize cancer treatment, but its effect on various outcomes remains uncertain. Objective Our objective was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) and cost-effectiveness studies comparing comprehensive geriatric assessment (with or without implementation of recommendations) to usual care in older cancer patients. Methods We searched MEDLINE, EMBASE, CINAHL, and Cochrane trials from inception to January 27, 2023, for RCTs and cost-effectiveness studies. Pooled estimates for outcomes were calculated using random-effects models. Results A total of 19 full-text articles representing 17 RCTs were included. Average participant age was 72-80 years, and 31%-62% were female. Comprehensive geriatric assessment type, mode of delivery, and evaluated outcomes varied across studies. Meta-analysis revealed no difference in risk of mortality (risk ratio [RR] = 1.08. 95% confidence interval [CI] = 0.91 to 1.29), hospitalization (RR = 0.92, 95% CI = 0.77 to 1.10), early treatment discontinuation (RR = 0.89, 95% CI = 0.67 to 1.19), initial dose reduction (RR = 0.99, 95% CI = 0.99 to 1.26), and subsequent dose reduction (RR = 0.87, 95% CI = 0.70 to 1.09). However, the risk of treatment toxicity was statistically significantly lower in the comprehensive geriatric assessment group (RR = 0.78, 95% CI = 0.70 to 0.86). No cost-effectiveness studies were identified. Conclusion Compared with usual care, comprehensive geriatric assessment was not associated with a difference in risk of mortality, hospitalization, treatment discontinuation, and dose reduction but was associated with a lower risk of treatment toxicity indicating its potential to optimize cancer treatment in this population. Further research is needed to evaluate cost-effectiveness. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Recently, minimally invasive surgical therapies (MISTs) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH). This study evaluated the cost-utility of water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH. METHODS: In this model-based economic evaluation, we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the Canadian healthcare payer perspective) per qualityadjusted life year (QALY), discounted at 1.5% annually. In the model, men could receive up to three lines of therapy: 1) initial pharmacotherapy with MIST as second-line, and TURP or pharmacotherapy as third-line; 2) initial MIST (WVTT or PUL) with MIST again, TURP, or pharmacotherapy as second-line, and TURP as third-line. The model was populated using data from the published literature. RESULTS: The expected lifetime QALYs and costs were 15.50 QALYs and $14 626 for initial treatment with WVTT, 15.35 QALYs and $11 795 for pharmacotherapy followed by WVTT, 15.29 QALYs and $13 582 for pharmacotherapy followed by PUL, and 15.29 QALYs and $19 151 for initial treatment with PUL. Strategies involving PUL procedures were dominated by strategies involving WVTT. The incremental cost per QALY gained was $18 873 for initial WVTT compared to initial pharmacotherapy followed by WVTT. CONCLUSIONS: WVTT appears to be a cost-effective procedure and may be an appropriate first-line alternative to pharmacotherapy for patients with BPH and prostate volume less than 80 cm3 who seek faster improvement and no lifelong commitment to daily medications. [ABSTRACT FROM AUTHOR]

The long‐term effects of direct‐acting antiviral therapies (DAAs) for chronic hepatitis C (CHC) remain uncertain. The objective of this systematic review and meta‐analysis was to assess the impact of DAAs on CHC progression and mortality. We searched Ovid MEDLINE, Ovid EMBASE and PubMed databases (January 2011 to March 2020) for studies that compared the efficacy of DAAs to a non‐DAA control in patients with CHC. Main outcomes were the adjusted hazard ratios (HRs) for mortality, liver decompensation, HCC occurrence and recurrence. Pooled estimates of HRs were determined using random‐effects meta‐analyses with inverse variance weighting, with sensitivity analyses and meta‐regression to explore the effects of clinical factors. We identified 39 articles for the primary analysis. Compared with unexposed individuals, patients treated with DAA had a reduced risk of death (HR; CI = 0.44; 0.38‐0.52), decompensation (HR; CI = 0.54; 0.38‐ 0.76) and HCC occurrence (HR; CI = 0.72; 0.61‐ 0.86). The protective effect of DAA on HCC recurrence was less clear (HR; CI = 0.72; 0.44‐1.16). Sustained virologic response (SVR) attainment was a significant predictor of reduced mortality (HR; CI = 0.33; 0.23‐0.46), decompensation (HR; CI = 0.11; 0.05‐0.24), HCC occurrence (HR; CI = 0.31; 0.27‐0.37) and HCC recurrence (HR; CI = 0.32; 0.20‐0.51). Meta‐regression showed no evidence of effect modification by patient age, sex, presence of cirrhosis or length of follow‐up. In conclusion, our findings show protective effects of DAA treatment and DAA‐related SVR on CHC progression and mortality. [ABSTRACT FROM AUTHOR]

Background: Few prognostic tools are currently available to predict hospital mortality in patients with acute type A aortic dissection. The aim of this study was to validate the performance of two existing risk-assessment tools, the original and the adjusted Leipzig-Halifax scorecards, to predict hospital mortality among Armenian patients with acute type A aortic dissection. Methods: This retrospective cohort study included all consecutive patients with acute type A aortic dissection who were admitted to two tertiary cardiac centers in Armenia and underwent surgery from January 2008 to April 2018. We evaluated the predictive power of the original and adjusted Leipzig-Halifax scorecards using logistic regression analysis. Results: Overall, 211 patients (76% males, mean age 57 ± 9 years) were included in the study, of whom 37 (17.5%) died during hospitalization. The adjusted Leipzig-Halifax score, but not the original Leipzig-Halifax score, was a significant predictor of hospital mortality. Patients with medium and high adjusted Leipzig-Halifax scores had a significantly higher odds of death compared to patients with low scores (odds ratio = 3.0 vs. 3.9, 95% confidence interval: 1.3–6.9 vs. 1.0–14.9, respectively). The areas under the receiver operating characteristic curves were 0.58 and 0.63, respectively, p > 0.05. Conclusion: The adjusted Leipzig-Halifax score performed slightly better than the original Leipzig-Halifax score in the Armenian acute type A aortic dissection population. The adjusted Leipzig-Halifax score should now be applied prospectively to generate more data for further validation and potential improvement. [ABSTRACT FROM AUTHOR]

The Federal Government of Canada established a $1.1 billion compensation programme in 1999 to support individuals who acquired hepatitis C virus (HCV) through blood products between January 1986 and July 1990. We aimed to describe the morbidity and mortality of this unique post‐transfusion cohort (n = 4550) followed for over 15 years from 2000 to 2016. The age‐standardized mortality rates were compared with that of the Canadian general population and HCV cohorts from other countries. We evaluated all‐cause mortality using Kaplan‐Meier survival curves and HCV‐related and unrelated mortality using competing risk models. The age‐standardized all‐cause and HCV‐related mortality rates per 10 000 person‐years were 127 (95% CI: 117‐138) and 76 (95% CI: 69‐85) for males, and 77 (95% CI: 69‐87) and 43 (95% CI: 37‐51) for females, respectively. The risk of death of the post‐transfusion cohort was almost twice as high as the Canadian general population (rate ratio = 1.8; 95% CI: 1.7‐1.9). All‐cause, HCV‐related and HCV‐unrelated mortality were 20%, 12% and 8%, respectively at 15 years of follow‐up. By comparison, HCV‐related mortality rates per 10 000 person‐years for population‐based HCV cohorts varied from 18 and 11 in Australia to 65 and 43 in Scotland for males and females, respectively. We reported long‐term follow‐up data for the largest post‐transfusion cohort in the literature. The all‐cause mortality rates were markedly higher than that of the Canadian general population. We also showed that HCV‐related mortality were greater compared to other HCV cohorts. This suggests that continued efforts to identify and treat post‐transfusion HCV are warranted. [ABSTRACT FROM AUTHOR]

Purpose: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. In-laboratory, overnight type I polysomnography (PSG) is the current “gold standard” for diagnosing OSA. Home sleep apnea testing (HSAT) using portable monitors (PMs) is an alternative testing method offering better comfort and lower costs. We aimed to systematically review the evidence on diagnostic ability of type IV PMs compared to PSG in diagnosing OSA.Methods: Participants: patients ≥16 years old with symptoms suggestive of OSA;intervention: type IV PMs (devices with < 2 respiratory channels); comparator: in-laboratory PSG; outcomes: diagnostic accuracy measures;studies: cross-sectional, prospective observational/experimental/quasi-experimental studies; information sources: MEDLINE and Cochrane Library from January 1, 2010 to May 10, 2016. All stages of review were conducted independently by two investigators.Results: We screened 6054 abstracts and 117 full-text articles to select 24 full-text articles for final review. These 24 studies enrolled a total of 2068 patients with suspected OSA and evaluated 10 different PMs with one to six channels. Only seven (29%) studies tested PMs in the home setting. The mean difference (bias) between PSG-measured and PM-measured apnea-hypopnea index (AHI) ranged from − 14.8 to 10.6 events/h. At AHI ≥ 5 events/h, the sensitivity of type IV PMs ranged from 67.5-100% and specificity ranged from 25 to 100%.Conclusion: While current evidence is not very strong for the stand-alone use of level IV PMs in clinical practice, they can potentially widen access to diagnosis and treatment of OSA. Policy recommendations regarding HSAT use should also consider the health and broader social implications of false positive and false negative diagnoses. [ABSTRACT FROM AUTHOR]

Background The objective of this study was to investigate the changes in blood pressure among patients enrolled in the Telehomecare programme in Ontario, Canada. Methods This observational study utilised a prospective longitudinal cohort design, including patients with heart failure and chronic obstructive pulmonary disease enrolled in the Ontario Telehomecare programme from July 2012 to July 2015. The outcome of interest was change in mean (biweekly) systolic and diastolic blood pressure levels over a six-month period. Patient data were extracted from the Ontario Telemedicine Network database, and analysed using generalised linear mixed model procedures. Results Overall, we analysed data for 3513 patients. Patients were on average 74.1 ± 11.4 years of age; almost half were men, 62% had heart failure, 55% chronic obstructive pulmonary disease and 29% diabetes. At baseline, the mean systolic and diastolic blood pressure levels were 130.4 ± 19.1 mmHg and 72.2 ± 12.5 mmHg for the total sample. At six months, the adjusted reduction in systolic and diastolic blood pressure values were 4.0 mmHg (95% confidence interval: -4.5 to -3.5) and 2.7 mmHg (95% confidence interval: -3.1 to -2.4), respectively. In a subgroup of 1220 patients with uncontrolled blood pressure at baseline (systolic/diastolic blood pressure of 150.7 ± 10.2 mmHg/80.2 ± 13.5 mmHg) the adjusted reduction in systolic blood pressure was 12.5 mmHg (95% confidence interval: -13.4 to -11.6) and in diastolic blood pressure was 7.1 mmHg (95% confidence interval: -7.8 to -6.5) over the six-month period. Conclusions Blood pressure levels were significantly reduced in patients enrolled in the Telehomecare programme, with changes being more pronounced in patients with uncontrolled blood pressure. The sustainability of decreased blood pressure on other clinical outcomes needs further evaluation. [ABSTRACT FROM AUTHOR]

Background: Although heart failure (HF) prevalence is equally high among men and women, observed differences in the provision of care are still not fully understood. We sought to evaluate gender differences in patient profiles, diagnostic testing, medication prescription, and referrals in specialized multidisciplinary ambulatory HF clinics in Ontario. Materials and Methods: Medical chart abstraction was conducted first by randomly selecting 9 (out of 34) HF clinics in Ontario, and then by randomly selecting 100 patient records in each clinic. Data on patient demographics, comorbidities, diagnostic tests, medication use, and referrals were abstracted, covering a period from the first clinic visit up to 1 year. Descriptive statistics and regression analysis were used to assess gender differences. Results: Of the 884 patients, only 314 were women (35.5%). At the first clinic visit, women were older, had better systolic function but worse functional status, and had a lower prevalence of hyperlipidemia, diabetes, and smoking than men. There were more women with non-ischemic HF etiology than men (63.9% vs. 43.3%, p < 0.001). Adjusted analysis did not reveal gender differences in the average number of echocardiographic assessments and in the prescription rates of evidence-based medications. Men were twice more likely to be referred to electrophysiology studies than women (18.6% vs. 7.8%, p < 0.001). The rates of dietary counseling and cardiac rehabilitation referrals were similarly low in both groups. Conclusions: More men than women are treated in specialized ambulatory HF clinics. Although women differ from men in selected clinical characteristics, no major differences were observed in patient management. The reasons for low enrollment rates of women into the HF ambulatory clinics need further investigation. [ABSTRACT FROM AUTHOR]

Background: Despite the high prevalence of osteoarthritis and the prominence of primary care in managing this condition, there is no systematic summary of quality indicators applicable for osteoarthritis care in primary care settings.Objectives: This systematic review aimed to identify evidence-based quality indicators for monitoring, evaluating and improving the quality of care for adults with osteoarthritis in primary care settings.Methods: Ovid MEDLINE and Ovid EMBASE databases and grey literature, including relevant organizational websites, were searched from 2000 to 2015. Two reviewers independently selected studies if (i) the study methodology combined a systematic literature search with assessment of quality indicators by an expert panel and (ii) quality indicators were applicable to assessment of care for adults with osteoarthritis in primary care settings. Included studies were appraised using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. A narrative synthesis was used to combine the indicators within themes. Applicable quality indicators were categorized according to Donabedian's 'structure-process-outcome' framework.Results: The search revealed 4526 studies, of which 32 studies were reviewed in detail and 4 studies met the inclusion criteria. According to the AIRE domains, all studies were clear on purpose and stakeholder involvement, while formal endorsement and use of indicators in practice were scarcely described. A total of 20 quality indicators were identified from the included studies, many of which overlapped conceptually or in content.Conclusions: The process of developing quality indicators was methodologically suboptimal in most cases. There is a need to develop specific process, structure and outcome measures for adults with osteoarthritis using appropriate methodology. [ABSTRACT FROM AUTHOR]

Background: Despite the growing interest in assessing the quality of care for depression, there is little evidence to support measurement of the quality of primary care for depression. This study identified evidence-based quality indicators for monitoring, evaluating and improving the quality of care for depression in primary care settings. Methods: Ovid MEDLINE and Ovid PsycINFO databases, and grey literature, including relevant organizational websites, were searched from 2000 to 2015. Two reviewers independently selected studies if (1) the study methodology combined a systematic literature search with assessment of quality indicators by an expert panel and (2) quality indicators were applicable to assessment of care for adults with depression in primary care settings. Included studies were appraised using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument, which contains four domains and 20 items. A narrative synthesis was used to combine the indicators within themes. Quality indicators applicable to care for adults with depression in primary care settings were extracted using a structured form. The extracted quality indicators were categorized according to Donabedian's 'structure-process-outcome' framework. Results: The search revealed 3838 studies. Four additional publications were identified through grey literature searching. Thirty-nine articles were reviewed in detail and seven met the inclusion criteria. According to the AIRE domains, all studies were clear on purpose and stakeholder involvement, while formal endorsement and usage of indicators in practice were scarcely described. A total of 53 quality indicators were identified from the included studies, many of which overlap conceptually or in content: 15 structure, 33 process and four outcome indicators. This study identified quality indicators for evaluating primary care for depression among adult patients. Conclusions: The identified set of indicators address multiple dimensions of depression care and provide an excellent starting point for further development and use in primary care settings. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated that organized, multidisciplinary care is the cornerstone of current strategies to reduce the death and disability caused by stroke. Identification of stroke units and an understanding of their composition and operation would provide insight for the further actions required to improve stroke care. The objective of this study was to identify and survey stroke units in Canada's largest province, Ontario (population of 13 million) in order to describe availability, structure, staffing, processes of care, and type of population stroke units serve.Methods: The Ontario Stroke Network (2011) list of stroke units and snowball sampling was used to identify all stroke units. During 2013 - 2014 an interviewer conducted telephone surveys with the stroke unit managers using closed and semi-open ended questions. Descriptive statistics were used to summarize survey responses.Results: The survey identified 32 stroke units, and a respondent from every stroke unit (100% response rate) was interviewed. Twenty one were acute stroke units, 10 were integrated stroke units and one was classified as a rehabilitation stroke unit. Stroke units were available in all 14 Local Health Integration Networks except Central West. The estimated average number of stroke patients served per stroke unit was 604 with six-fold variation (242 to 1480) across the province. The typical population served in stroke units were patients with either ischemic or hemorrhagic stroke. Data consistently reported on the processes of stroke care, including the availability of multidisciplinary staff, specific diagnostic imaging, use of validated assessment tools, and the delivery of patient education. Details about the core components of stoke care were provided by 16 stroke units (50%).Conclusions: This study demonstrates the heterogeneous structure of stroke units in Ontario and signaled potential disparity in access to stroke units. Many core components are in place, but half of the stroke units in Ontario do not meet all criteria. Areas for potential improvement include stroke care training for the multidisciplinary team, provision of individualized rehabilitation plans, and early discharge assessment. [ABSTRACT FROM AUTHOR]

Background: Despite research demonstrating the potential effectiveness of Telehomecare for people with Chronic Obstructive Pulmonary Disease and Heart Failure, broad-scale comprehensive evaluations are lacking. This article discusses the qualitative component of a mixed-method program evaluation of Telehomecare in Ontario, Canada. The objective of the qualitative component was to explore the multi-level factors and processes which facilitate or impede the implementation and adoption of the program across three regions where it was first implemented.Methods: The study employs a multi-level framework as a conceptual guide to explore the facilitators and barriers to Telehomecare implementation and adoption across five levels: technology, patients, providers, organizations, and structures. In-depth semi-structured interviews and ethnographic observations with program stakeholders, as well as a Telehomecare document review were used to elicit key themes. Study participants (n = 89) included patients and/or informal caregivers (n = 39), health care providers (n = 23), technicians (n = 2), administrators (n = 12), and decision makers (n = 13) across three different Local Health Integration Networks in Ontario.Results: Key facilitators to Telehomecare implementation and adoption at each level of the multi-level framework included: user-friendliness of Telehomecare technology, patient motivation to participate in the program, support for Telehomecare providers, the integration of Telehomecare into broader health service provision, and comprehensive program evaluation. Key barriers included: access-related issues to using the technology, patient language (if not English or French), Telehomecare provider time limitations, gaps in health care provision for patients, and structural barriers to patient participation related to geography and social location.Conclusions: Though Telehomecare has the potential to positively impact patient lives and strengthen models of health care provision, a number of key challenges remain. As such, further implementation and expansion of Telehomecare must involve continuous assessments of what is working and not working with all stakeholders. Increased dialogue, evaluation, and knowledge translation within and across regions to understand the contextual factors influencing Telehomecare implementation and adoption is required. This can inform decision-making that better reflects and addresses the needs of all program stakeholders. [ABSTRACT FROM AUTHOR]

Abstract: Calcium-regulating system is important for the functional activity of myocardium. However, little is known about the role of this system in the pathogenesis of cardiovascular diseases. Blood samples from the patients with chronic heart failure (CHF) caused by ischaemic disease (coronary artery disease) (NYHA class I–IV) were used to analyze the levels of calcium, inorganic phosphate, sodium, potassium, parathyroid hormone (PTH) and parathyroid hormone-related protein (PTHrP). The heart beat rate and arterial blood pressure were chosen as additional tests for the functional status of cardiovascular system. The alteration of electrolytes homeostasis was found dependent on the severity of the pathology being maximally expressed in the NYHA class IV patients. Similar tendency was demonstrated for circulating PTH and PTHrP with the highest blood concentrations observed in patients of the NYHA class III and IV. The extent of these changes was found more pronounced in the female patients. It is suggested that the calcium-regulating hormonal system is involved in the pathogenesis of the ischaemic heart disease; however the sharp increase of PTH and PTHrP at the severe stages of pathology may play a compensatory role in maintaining the heart function. [Copyright &y& Elsevier]

Human Papillomavirus (HPV) is a common sexually transmitted disease and causes cervical cancer. Although the HPV vaccine is available in Armenia, the coverage is low, attributed to the lack of parental knowledge and awareness about HPV and vaccine safety. The study aimed to evaluate changes in knowledge, belief and intent to vaccinate their daughters against HPV among parents of school-going girls after a video intervention in Yerevan, Armenia. The study followed a pre- and post-test design with a 10-minute multimedia intervention created using constructs of health belief model and theory of planned behavior. Parents from two randomly selected primary schools who had a daughter(s) not vaccinated against HPV and aged between 9 and 14 years participated in the study. The study used a paired t-test to analyze differences in composite knowledge and beliefs scores, and Wilcoxon signed-rank tests to compare paired responses for intention to vaccinate between the pre-test and post-test measurements. All 39 participants were mothers with a mean age of 38 years (SD = 5.90). The knowledge scores [M1 = 4.51 (SD = 2.92); M2 = 9.31 (SD = 3.15)] and belief scores [M1 = 20.54 (SD = 3.79); M2 = 23.56 (SD = 4.51)] of the participants improved significantly (p < 0.001) after the intervention [by 4.80 (SD = 2.92) and 3.03 (SD = 4.58), respectively]; 34.2% of participants improved their intent to vaccinate their daughter against HPV . In conclusion, multimedia education was well received by parents and could be an efficient tool in HPV education. [ABSTRACT FROM AUTHOR]