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The objective of this study was to examine the presence of small-area-level effects on children's dental caries in Alberta, Canada, where dental public health programming is targeted in nature, based on an area-level measure of socio-economic circumstances.This cross-sectional study included data on tooth decay (from an intra-oral examination conducted by dental hygienists at school) and socio-demographic and behavioural information (from a parent questionnaire) from 5677 grade 1 and 2 schoolchildren attending schools in public or Catholic school systems in Calgary and Edmonton in 2013/2014. Area-level socio-economic circumstances were quantified using the Pampalon Material Deprivation Index derived from census data, applied to the dissemination area (DA) of the child's school. The outcome variable was presence (vs. absence) of tooth decay (cavitation). Data were analyzed using multilevel modeling with two levels: individual level (level 1) and school dissemination area (DA) (level 2).We observed a small but statistically significant area-level effect on children's caries experience, above and beyond individual-level characteristics.Study findings are relevant to dental public health programming in Alberta and other jurisdictions that use targeted strategies. Multilevel interventions, including universal approaches, are necessary to reduce inequities in children's dental caries.RéSUMé: OBJECTIFS: Examiner la présence d’effets de petite région sur les caries dentaires des enfants en Alberta, au Canada, où les programmes publics de santé dentaire sont ciblés de nature, d’après un indicateur régional de la situation socioéconomique. MéTHODE: Cette étude transversale a inclus des données sur la carie dentaire (venant d’un examen intra-buccal mené par des hygiénistes dentaires dans les écoles) et des informations sociodémographiques et comportementales (venant d’un questionnaire auprès des parents) concernant 5 677 enfants d’âge scolaire de 1

Background Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care. Methods We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department. Results We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access. Interpretation Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.

Summary Background Although opioid analgesics are not generally recommended for treatment of knee osteoarthritis (OA), they are frequently used. We sought to determine the association between medical comorbidities and self-reported opioid analgesic use in these patients. Methods This cross-sectional study recruited patients referred to two provincial hip and knee clinics in Alberta, Canada for consideration of total knee arthroplasty. Standardized questionnaires assessed demographic (age, gender, income, education, social support, smoking status) and clinical (pain, function, total number of troublesome joints) characteristics, comorbid medical conditions, and non-surgical OA management participants had ever used or were currently using. Multivariable Poisson regression with robust estimate of the standard errors assessed the association between comorbid medical conditions and current opioid use, controlling for potential confounders. Results 2,127 patients were included: mean age 65.4 (SD 9.1) years and 59.2% female. Currently used treatments for knee OA were: 57.6% exercise and/or physiotherapy, 61.1% NSAIDs, and 29.8% opioid analgesics. In multivariable regression, controlling for potential confounders, comorbid hypertension (RR 1.18, 95% CI 1.02–1.37), gastrointestinal disease (RR 1.31, 95% CI 1.07–1.60), depressed mood (RR 1.25, 95% CI 1.05–1.48) and a higher number of troublesome joints (RR 1.04 per joint, 95% CI 1.00–1.09) were associated with opioid use, with no association found with having ever used recommended non-opioid pharmacological or non-pharmacological treatments. Conclusions In a large cohort of patients with knee OA, of 12 comorbidities assessed, comorbid hypertension, gastrointestinal disease, and depressed mood were associated with current use of opioid analgesics, in addition to total burden of troublesome joints. Improved guidance on the management of painful OA in the setting of common comorbidities is warranted.

Background Health care payers are interested in policy-level interventions to increase peritoneal dialysis use in end-stage renal disease. We examined whether increases in physician remuneration for peritoneal dialysis were associated with greater peritoneal dialysis use. Methods We studied a cohort of patients in Alberta who started long-term dialysis with at least 90 days of preceding nephrologist care between Jan. 1, 2001, and Dec. 31, 2014. We compared peritoneal dialysis use 90 days after dialysis initiation in patients cared for by fee-for-service nephrologists and those cared for by salaried nephrologists before and after weekly peritoneal dialysis remuneration increased from $0 to $32 (fee change 1, Apr. 1, 2002), $49 to $71 (fee change 2, Apr. 1, 2007), and $71 to $135 (fee change 3, Apr. 1, 2009). Remuneration for peritoneal dialysis remained less than hemodialysis until fee change 3. We performed a patient-level differences-in-differences logistic regression, adjusted for demographic characteristics and comorbidities, as well as an unadjusted interrupted time-series analysis of monthly outcome data. Results Our cohort included 4262 patients. There was no statistical evidence of a difference in the adjusted differences-indifferences estimator following fee change 1 (0.89, 95% confidence interval [CI] 0.44-1.81), 2 (1.15, 95% CI 0.73-1.83), or 3 (1.52, 95% CI 0.96-2.40). There was no significant difference in the immediate change or the trend over time in peritoneal dialysis use between fee-for-service and salaried groups following any of the fee changes in the interrupted time-series analysis. Interpretation We identified no statistical evidence of an increase in peritoneal dialysis use following increased fee-for-service remuneration for peritoneal dialysis. It remains unclear what role, if any, physician payment plays in selection of dialysis modality.

Background Recurrent vasovagal syncope is common, responds poorly to treatment, and causes physical trauma and poor quality of life. Midodrine prevents hypotension and syncope during tilt tests in patients with vasovagal syncope. Objective To determine whether midodrine can prevent vasovagal syncope in usual clinical conditions. Design Randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT01456481). Setting 25 university hospitals in Canada, the United States, Mexico, and the United Kingdom. Patients Patients with recurrent vasovagal syncope and no serious comorbid conditions. Intervention Patients were randomly assigned 1:1 to placebo or midodrine and followed for 12 months. Measurements The primary outcome measure was the proportion of patients with at least 1 syncope episode during follow-up. Results The study included 133 patients who had had a median of 6 syncope episodes in the prior year (median age, 32 years; 73% female). Compared with patients receiving placebo, fewer patients receiving midodrine had at least 1 syncope episode (28 of 66 [42%] vs. 41 of 67 [61%]). The relative risk was 0.69 (95% CI, 0.49 to 0.97; P = 0.035). The absolute risk reduction was 19 percentage points (CI, 2 to 36 percentage points), and the number needed to treat to prevent 1 patient from having syncope was 5.3 (CI, 2.8 to 47.6). The time to first syncope was longer with midodrine (hazard ratio, 0.59 [CI, 0.37 to 0.96]; P = 0.035; log-rank P = 0.031). Adverse effects were similar in both groups. Limitation Small study size, young and healthy patients, relatively short observation period, and high proportion of patients from 1 center. Conclusion Midodrine can reduce the recurrence of syncope in healthy, younger patients with a high syncope burden. Primary funding source The Canadian Institutes of Health Research.

BACKGROUND Degenerative lumbar spinal stenosis is a common condition, predominantly affecting middle-aged and elderly people. This study focused on patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity. PURPOSE To determine whether the addition of fusion to decompression resulted in improved clinical outcomes at 3, 12, and 24 months postsurgery. STUDY DESIGN/SETTING The Canadian Spine Outcomes and Research Network (CSORN) prospective database that includes pre- and postoperative data from tertiary care hospitals. PATIENT SAMPLE The CSORN database was queried for consecutive spine surgery cases of degenerative lumbar stenosis receiving surgical decompression for neurogenic claudication or radiculopathy. Neurogenic claudication patients with baseline and 2-year follow-up data, from four sites, formed the study sample (n=306). The sample was categorized into two groups: (1) those that had decompression alone, and (2) those that underwent decompression plus fusion. OUTCOME MEASURES Change in modified Oswestry Disability Index (ODI), numerical rating scale for back/leg pain, the EuroQol EQ5D, the SF-12 physical, and mental component scores. The primary outcome measure was the ODI at 2 years postoperative. METHODS We conducted a multicenter, ambispective review of consecutive spine surgery patients enrolled between October 2012 and January 2018. RESULTS Baseline characteristics were comparable between groups except for female sex and multilevel pathology (both with greater proportion in the decompression plus fusion group). The decompression plus fusion group had clinically meaningfully more operative time, blood loss, rate of perioperative complication, and length of hospital stay (p Both decompression and decompression plus fusion had a large clinically meaningful impact on generic and disease-specific patient-reported outcome measures within 3 months of surgery which was maintained out to 24-month follow-up. At any follow-up time point, there was no statistical evidence of a difference in these effects favoring decompression plus fusion over decompression alone. CONCLUSIONS The addition of fusion to decompression did not result in improved outcomes at 3-, 12-, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity.

Background and objectives:The landscape of antimicrobial resistance (AMR) surveillance is changing rapidly. The primary objective of this study was to assess the benefit of linking population-based infection prevention and control surveillance data on methicillin-resistant Staphylococcus aureus (MRSA) to hospital discharge abstract data (DAD). We assessed the value of this novel data linkage for the characterization of hospital-acquired (HA) and community-acquired MRSA (CA-MRSA) cases.Methods:Incident inpatient MRSA surveillance data for all adults (≥18 years) from 4 acute-care facilities in Calgary, Alberta, between April 1, 2011, and March 31, 2017, were linked to DAD. Personal health number (PHN) and gender were used to identify specific individuals, and specimen collection time-points were used to identify specific hospitalization records. A third common variable on admission date between these databases was used to validate the linkage process. Descriptive statistics were used to characterize HA-MRSA and CA-MRSA cases identified through the linkage process.Results:A total of 2,430 surveillance records (94.6%) were successfully linked to the correct hospitalization period. By linking surveillance and administrative data, we were able to identify key differences between patients with HA- and CA-MRSA. These differences are consistent with previously reported findings in the literature. Data linkage to DAD may be a novel tool to enhance and augment the details of base surveillance data.Conclusion and recommendations:This is the first Canadian study linking a frontline healthcare-associated infection AMR surveillance database to an administrative population database. This work represents an important methodological step toward complementing traditional AMR surveillance data practices. Data linkage to other data types, such as primary care, emergency, social, and biological data, may be the basis of achieving more precise data focused around AMR.

Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term.We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars.The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated.These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.L’initiative de récupération améliorée après la chirurgie (RAAC) est un projet international d’amélioration de la qualité en chirurgie. On en sait peu sur les retombées économiques, tant à court qu’à long terme, de la mise en œuvre de multiples lignes directrices de RAAC.Nous avons réalisé une analyse du rendement sur l’investissement (RSI) visant la mise en œuvre de multiples lignes directrices de RAAC (pour les opérations colorectales, pancréatiques, hépatiques ou d’oncologie gynécologique et la cystectomie) dans 9 hôpitaux albertains sur un horizon temporel de 30, 180 et 365 jours. L’incidence de la RAAC sur l’utilisation des services de santé (durée du séjour à l’hospitalisation initiale, nombre de réadmissions, durée du séjour à la réhospitalisation et nombre de visites à l’urgence, en consultation externe, chez un spécialiste et chez un omnipraticien) a été évaluée à l’aide d’un modèle multiniveau de régressions binomiales négatives à effets mixtes multivariés. Les bénéfices nets et le RSI ont été estimés à l’aide d’un processus de modélisation analytique décisionnelle. Tous les coûts ont été rapportés en dollars canadiens de 2019.Les économies nettes du système de santé allaient de 26,35 $ à 3606,44 $ par patient, et le RSI variait de 1,05 à 7,31; chaque dollar investi dans l’initiative de RAAC a donc généré un retour sur l’investissement de 1,05 $ à 7,31 $. Les probabilités d’économie grâce au RAAC allaient de 86,5% à 99,9%. Les retombées générées augmentaient avec un horizon temporel à plus long terme, ce qui suggère que l’utilisation unique d’un horizon temporel de 30 jours aurait mené à une sousestimation des bénéfices.Les résultats montrent que la mise en œuvre de multiples lignes directrices de RAAC a permis des économies en Alberta. En vue d’obtenir un RSI optimal, il est important de tenir compte d’une grande variété d’utilisations des services de santé, des retombées à long terme, des économies d’échelle, de l’efficacité productive et de l’efficience des allocations pour la pérennité, la mise à l’échelle et la diffusion des projets de mise en œuvre de RAAC.

Background Patients in the intensive care unit (ICU) are known to be at increased risk of developing delirium, but the risk of subsequent neuropsychiatric disorders is unclear. We therefore sought to examine the association between the presence of delirium in the ICU and incident neuropsychiatric disorders (including depressive, anxiety, trauma-and-stressor-related, and neurocognitive disorders) post-ICU stay among adult medical-surgical ICU patients. Methods Retrospective cohort study utilizing clinical and administrative data from both inpatient and outpatient healthcare visits to identify the ICU cohort and diagnostic information 5 years prior to and 1 year post-ICU stay. Patients ≥ 18 years of age admitted to one of 14 medical-surgical ICUs across Alberta, Canada, January 1, 2014–June 30, 2016, and survived to hospital discharge were included. The main outcome of interest was a new diagnosis of any neuropsychiatric disorder 1 year post-ICU stay. The exposure variable was delirium during the ICU stay identified through any positive delirium screen by the Intensive Care Unit Delirium Screening Checklist (ICDSC) during the ICU stay. Results Of 16,005 unique patients with at least one ICU admission, 4033 patients were included in the study of which 1792 (44%) experienced delirium during their ICU stay. The overall cumulative incidence of any neuropsychiatric disorder during the subsequent year was 19.7% for ICU patients. After adjusting for hospital characteristics using log-binomial regression, patients with delirium during the ICU stay had a risk ratio (RR) of 1.14 (95% confidence interval [CI] 0.98–1.33) of developing any neuropsychiatric disorder within 1 year post-ICU compared to those who did not experience delirium. Delirium was significantly associated with neurocognitive disorders (RR 1.59, 95% CI 1.08–2.35), but not depressive disorders (RR 1.16, 95% CI 0.92–1.45), anxiety (RR 1.16, 95% CI 0.92–1.47), and trauma-and-stressor-related (RR 0.82, 95% CI 0.53–1.28) disorders. Conclusions The diagnosis of new onset of neurocognitive disorders is associated with ICU-acquired delirium. In this study, significant associations were not observed for depressive, anxiety, and trauma-and-stressor-related disorders.

Key Points Question Does the implementation of multiple Enhanced Recovery After Surgery (ERAS) pathways across 1 health care system affect ERAS guideline adherence, length of stay, complications, readmissions, and mortality? Findings In this quality improvement study, comparison of pre-post–ERAS cohorts found that pathway implementation was associated with increased guideline adherence, from 52% to 76%; decreased unadjusted length of stay, from a mean of 9.4 to 7.8 days; and decreased adjusted length of stay by 0.71 days, with no differences in serious complications or 30-day mortality. Meaning These results suggest that implementation of multiple ERAS pathways could provide system-level improvement in ERAS guidelines adherence and length of stay., Importance Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. Objective To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. Design, Setting, and Participants This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Interventions Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Main Outcomes and Measures Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post–ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. Results A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P, This quality improvement study evaluates the implementation of Enhanced Recovery After Surgery pathways to examine the association with guideline adherence, length of stay, complications, readmissions, and mortality.

Background Vascular dementia (VaD) is the second most common form of dementia. However, there were mixed evidences about the association between blood pressure (BP) and risk of VaD in midlife and late life and limited evidence on the association between pulse pressure and VaD. Methods This is a population-based observational study. 265,897 individuals with at least one BP measurement between the ages of 60 to 65 years and 211,116 individuals with at least one BP measurement between the ages of 70 to 75 years were extracted from The Health Improvement Network in United Kingdom. Blood pressures were categorized into four groups: normal, prehypertension, stage 1 hypertension, and stage 2 hypertension. Cases of VaD were identified from the recorded clinical diagnoses. Multivariable survival analysis was used to adjust other confounders and competing risk of death. All the analysis were stratified based on antihypertensive drug use status. Multiple imputation was used to fill in missing values. Results After accounting for the competing risk of death and adjustment for potential confounders, there was an association between higher BP levels in the age 60–65 cohort with the risk of developing VaD (hazard ratio [HR] 1.53 (95% confidence interval: 1.04, 2.25) for prehypertension, 1.90 (1.30, 2.78) for stage 1 hypertension, and 2.19 (1.48, 3.26) for stage 2 hypertension) in the untreated group. There was no statistically significant association between BP levels and VaD in the treated group in the age 60–65 cohort and age 70–75 cohort. Analysis on Pulse Pressure (PP) stratified by blood pressure level showed that PP was not independently associated with VaD. Conclusion High BP between the ages of 60 to 65 years is a significant risk for VaD in late midlife. Greater efforts should be placed on early diagnosis of hypertension and tight control of BP for hypertensive patients for the prevention of VaD. Electronic supplementary material The online version of this article (10.1186/s12877-017-0649-3) contains supplementary material, which is available to authorized users.

Objective:To examine the frequency and type of adverse events (AEs) experienced by neurologic patients in hospital.Methods:This population-based, retrospective cohort study used hospital discharge abstract data for children and adults admitted to hospital from 2009 to 2015 with 1 of 9 neurologic conditions (Alzheimer disease and related dementia, brain tumor, epilepsy, motor neuron disease, multiple sclerosis, parkinsonism/Parkinson disease, spinal cord injury, traumatic brain injury, and stroke). Neurologic conditions were identified with ICD-10-CA codes. Eighteen AEs were examined with ICD-10-CA codes. The proportion of AEs was calculated, and regression analysis was used to examine factors and outcomes associated with AEs (age, sex, comorbidity, length of stay, and mortality).Results:The overall proportion of admissions associated with an AE among those with a neurologic condition was 11 per 100 admissions. Those with a spinal cord injury had the highest proportion of AEs (39.4 per 100 admissions). The most common AEs were infections and respiratory complications (32.0% and 16.7%, respectively). Age and the presence of comorbidities were associated with higher odds of an AE, while readmission was associated with lower odds of an AE. Having an AE was associated with increased length of stay and higher odds of mortality.Conclusions:This study demonstrates that neurologic patients have a high proportion of AEs in hospital. The findings provide information on the quality and safety of care for people with neurologic conditions in hospital, which can help inform future quality improvement initiatives.

ObjectivesThe purpose of this study is to estimate the prevalence of comorbidities among people with osteoarthritis (OA) using administrative health data.DesignRetrospective cohort analysis.SettingAll residents in the province of Alberta, Canada registered with the Alberta Health Care Insurance Plan population registry.Participants497 362 people with OA as defined by ‘having at least one OA-related hospitalization, or at least two OA-related physician visits or two ambulatory care visits within two years’.Primary outcome measuresWe selected eight comorbidities based on literature review, clinical consultation and the availability of validated case definitions to estimate their frequencies at the time of diagnosis of OA. Sex-stratified age-standardised prevalence rates per 1000 population of eight clinically relevant comorbidities were calculated using direct standardisation with 95% CIs. We applied χ2 tests of independence with a Bonferroni correction to compare the percentage of comorbid conditions in each age group.Results54.6% (n=2 71 794) of people meeting the OA case definition had at least one of the eight selected comorbidities. Females had a significantly higher rate of comorbidities compared with males (standardised rates ratio=1.26, 95% CI 1.25 to 1.28). Depression, chronic obstructive pulmonary disease (COPD) and hypertension were the most prevalent in both females and males after age-standardisation, with 40% of all cases having any combination of these comorbidities. We observed a significant difference in the percentage of comorbidities among age groups, illustrated by the youngest age group (65 years.ConclusionsOur findings highlight the high frequency of comorbidity in people with OA, with depression having the highest age-standardised prevalence rate. Comorbidities differentially affect females, and vary by age. These factors should inform healthcare programme and delivery.

Key Points Question Is a specialist physician payment model associated with visit frequency, quality of care, and costs for people with chronic disease? Findings In this population-based cohort study that included a propensity-score matched cohort of 31 898 adults with diabetes or chronic kidney disease seen by 489 physicians, there was no statistical evidence of a difference in follow-up outpatient visit rates, quality, and costs between patients seeing salaried and fee-for-services physicians. The median association of physician clustering and the outcomes was greater than the association with the physician payment model. Meaning Specialist physician payment does not appear to be associated with variation in use of chronic disease care, quality, and costs; however, these findings suggest large variation in outcomes between physicians., Importance Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases. Objective To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists. Design, Setting, and Participants A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics. Exposures Specialist physician payment model (salary-based or FFS). Main Outcomes and Measures Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs. Results A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care–sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13). Conclusions and Relevance Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases., This population-based cohort study examines the visit frequency, quality of care, and cost for patients with chronic diseases seen by fee-for-service vs salaried specialist physicians.

Objective.Our aim was to assess prior use of core recommended non-surgical treatment among patients with knee osteoarthritis (OA) scheduled for total knee arthroplasty (TKA), and to assess potential patient-level correlates of underuse, if found.Methods.This was a cross-sectional study of patients undergoing TKA for primary knee OA at 2 provincial central intake hip and knee clinics in Alberta, Canada. Standardized questionnaires assessed sociodemographic characteristics, social support, coexisting medical conditions, OA symptoms and coping, and previous non-surgical management. Multivariable logistic regression was used to assess the patient-level variables independently associated with receipt of recommended non-surgical knee OA treatment, defined as prior use of pharmacotherapy for pain, rehabilitation strategies (exercise or physiotherapy), and weight loss if overweight or obese (body mass index ≥ 25 kg/m2).Results.There were 1273 patients included: mean age 66.9 years (SD 8.7), 39.9% male, and 44.1% had less than post-secondary education. Recommended non-surgical knee OA treatment had been used by 59.7% of patients. In multivariable modeling, the odds of having received recommended non-surgical knee OA treatment were significantly and independently lower among individuals who were older (OR 0.97, 95% CI 0.95–0.99), male (OR 0.33, 0.25–0.45), and who lacked post-secondary education (OR 0.70, 0.53–0.93).Conclusion.In a large cross-sectional analysis of knee OA patients scheduled for TKA, 40% of individuals reported having not received core recommended non-surgical treatments. Older individuals, men, and those with less education had lower odds of having used recommended non-surgical OA treatments.

Background Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes of care and clinical outcomes. Methods The Contrast-Reducing Injury Sustained by Kidneys (Contrast RISK) study will implement an evidence-based multifaceted intervention designed to reduce the incidence of CI-AKI, encompassing automated identification of patients at increased risk for CI-AKI, point-of-care information on safe contrast volume targets, personalized recommendations for hemodynamic optimization of intravenous fluids, and follow-up information for patients at risk. Implementation will use cardiologist academic detailing, computerized clinical decision support, and audit and feedback. All 31 physicians practicing in all 3 of Alberta’s cardiac catheterization laboratories will participate using a cluster-randomized stepped-wedge design. The order in which they are introduced to this intervention will be randomized within 8 clusters. The primary outcome is CI-AKI incidence, with secondary outcomes of CI-AKI avoidance strategies and downstream adverse major kidney and cardiovascular events. An economic evaluation will accompany the main trial. Conclusions The Contrast RISK study leverages information technology systems to identify patient risk combined with evidence-based protocols, audit, and feedback to reduce CI-AKI in cardiac catheterization laboratories across Alberta. If effective, this intervention can be broadly scaled and sustained to improve the safety of cardiac catheterization.

Cancer patients often experience poor quality of life (QoL) during chemotherapy (CT) treatments due to side effects including fatigue, insomnia, pain and nausea/vomiting. Mindfulness-based cancer recovery (MBCR) is an evidence-based intervention for treating such symptoms, but has not been investigated as an adjunctive treatment during CT. This study aims to determine the efficacy of an online group MBCR programme delivered during CT in 12 real-time interactive weekly sessions for managing fatigue (primary outcome). Secondary outcomes include sleep disturbance, pain, nausea/vomiting, mood, stress and QoL. Exploratory outcomes include cognitive function, white blood cell counts and return to work. The study is a two-armed randomised controlled waitlist trial with 2:1 allocation to treatment (online group MBCR during CT) or control (waitlist usual care; online MBCR following CT completion) with a target sample size of N = 178. Participants are breast or colorectal cancer patients undergoing common CT regimens in Calgary, Canada. Online assessments using validated self-reported instruments will take place at baseline, post-MBCR, post-CT and 12 months' post-baseline. If online MBCR delivered during CT significantly reduces fatigue in cancer patients' post-CT and also impacts secondary symptoms, this would provide evidence for including mindfulness training as an adjunctive symptom management therapy during CT.

BACKGROUND Although published studies report that screening for distress (SFD) improves the quality of care for patients with cancer, little is known about how SFD impacts healthcare professionals (HCPs). OBJECTIVES This quality improvement project examined the impact of implementing the SFD intervention on HCPs' confidence in addressing patient distress and awareness of person-centered care. PATIENTS AND METHODS This project involved pre-evaluation and post-evaluation of the impact of implementing SFD. A total of 254 HCPs (cohort 1) were recruited from 17 facilities across the province to complete questionnaires. SFD was then implemented at all cancer care facilities over a 10-month implementation period, after which 157 HCPs (cohort 2) completed post-implementation questionnaires. At regional and community care centers, navigators supported the integration of SFD into routine practice; therefore, the impact of navigators was examined. RESULTS HCPs in cohort 2 reported significantly greater confidence in managing patients' distress and greater awareness about person-centered care relative to HCPs in cohort 1. HCPs at regional and community sites reported greater awareness in person-centeredness before and after the intervention, and reported fewer negative impacts of SFD relative to HCPs at tertiary sites. Caring for single or multiple tumor types was an effect modifier, with effects observed only in the HCPs treating multiple tumors. CONCLUSIONS Implementation of SFD was beneficial for HCPs' confidence and awareness of person-centeredness. Factors comprising different models of care, such as having site-based navigators and caring for single or multiple tumors, influenced outcomes.

Background Vasovagal syncope (VVS) is a common problem associated with a poor quality of life, which improves when syncope frequency is reduced. Effective pharmacological therapies for VVS are lacking. Metoprolol is a β-adrenergic receptor antagonist that is ineffective in younger patients, but may benefit older (≥40 years) VVS patients. Given the limited therapeutic options, a placebo-controlled clinical trial of metoprolol for the prevention of VVS in older patients is needed. Structure of study The POST5 is a multicenter, international, randomized, placebo-controlled study of metoprolol in the prevention of VVS in patients ≥40 years old. The primary endpoint is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive metoprolol 25 to 100 mg BID or matching placebo, and followed up for 1 year. Secondary end points include syncope frequency, presyncope, quality of life, and cost analysis. Primary analysis will be intention to treat, with a secondary on-treatment analysis. Power calculations A sample size of 222, split equally between the groups achieves 85% power to detect a hazard rate of 0.3561 when the event rates are 50% and 30% in the placebo and metoprolol arms. Allowing for 10% dropout, we propose to enroll 248 patients. Implications This study will be the first adequately powered trial to determine whether metoprolol is effective in preventing VVS in patients ≥40 years. If effective, metoprolol may become the first line pharmacological therapy for these patients.

Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system. We compared pre- and post-guideline implementation in consecutive elective colorectal patients, ≥18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts. A total of 1333 patients (350 pre- and 983 post-ERAS) were analysed. Of this number, 55 % were males. Median overall guideline compliance was 39 % in pre- and 60 % in post-ERAS patients. Median LOS was 6 days for pre-ERAS compared to 4.5 days in post-ERAS patients with the longest implementation (p value

Objective.Cardiovascular disease (CVD) is a major comorbidity for patients with rheumatoid arthritis (RA). This study sought to determine the performance of 11 recently developed CVD quality indicators (QI) for RA in clinical practice.Methods.Medical charts for patients with RA (early disease or biologic-treated) followed at 1 center were retrospectively reviewed. A systematic assessment of adherence to 11 QI over a 2-year period was completed. Performance on the QI was reported as a percentage pass rate.Results.There were 170 charts reviewed (107 early disease and 63 biologic-treated). The most frequent CVD risk factors present at diagnosis (early disease) and biologic start (biologic-treated) included hypertension (26%), obesity (25%), smoking (21%), and dyslipidemia (15%). Performance on the CVD QI was highly variable. Areas of low performance (< 10% pass rates) included documentation of a formal CVD risk assessment, communication to the primary care physician (PCP) that patients with RA were at increased risk of CVD, body mass index documentation and counseling if overweight, communication to a PCP about an elevated blood pressure, and discussion of risks and benefits of antiinflammatories in patients at CVD risk. Rates of diabetes screening and lipid screening were 67% and 69%, respectively. The area of highest performance was observed for documentation of intent to taper corticosteroids (98%–100% for yrs 1 and 2, respectively).Conclusion.Gaps in CVD risk management were found and highlight the need for quality improvements. Key targets for improvement include coordination of CVD care between rheumatology and primary care, and communication of increased CVD risk in RA.

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources. Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only. ClinicalTrials.gov , NCT03163095 .

To evaluate the associations between strained ICU capacity and patient outcomes.Multi-center population-based cohort study of nine integrated ICUs in Alberta, Canada. Path-analysis modeling was adopted to investigate direct and indirect associations between strain (available beds ≤1; occupancy ≥95%) and outcomes. Mixed-effects multivariate regression was used to measure the association between strain and acuity (APACHE II score), and both acuity and strain measures on ICU mortality and length of stay.12,265 admissions comprise the study cohort. Available beds ≤1 and occupancy ≥95% occurred for 22.3% and 17.0% of admissions. Lower bed availability was associated with higher APACHE II score (p0.0001). The direct effect of ≤1 available beds at ICU admission on ICU mortality was 11.6% (OR 1.116; 95% CI, 0.995-1.252). Integrating direct and indirect effects resulted in a 16.5% increased risk of ICU mortality (OR 1.165; 95% CI, 1.036-1.310), which exceeded the direct effect by 4.9%. Findings were similar with strain defined as occupancy ≥95%. Strain was associated with shorter ICU stay, primarily mediated by greater acuity.Strained capacity was associated with increased ICU mortality, partly mediated through greater illness acuity. Future work should consider both the direct and indirect relationships of strain on outcomes.

Purpose A growing number of cancer survivors suffer high levels of distress, depression and stress, as well as sleep disturbance, pain and fatigue. Two different mind-body interventions helpful for treating these problems are Mindfulness-Based Cancer Recovery (MBCR) and Tai Chi/Qigong (TCQ). However, while both interventions show efficacy compared to usual care, they have never been evaluated in the same study or directly compared. This study will be the first to incorporate innovative design features including patient choice while evaluating two interventions to treat distressed cancer survivors. It will also allow for secondary analyses of which program best targets specific symptoms in particular groups of survivors, based on preferences and baseline characteristics. Methods and significance The design is a preference-based multi-site randomized comparative effectiveness trial. Participants (N = 600) with a preference for either MBCR or TCQ will receive their preferred intervention; while those without a preference will be randomized into either intervention. Further, within the preference and non-preference groups, participants will be randomized into immediate intervention or wait-list control. Total mood disturbance on the Profile of mood states (POMS) post-intervention is the primary outcome. Other measures taken pre- and post-intervention and at 6-month follow-up include quality of life, psychological functioning, cancer-related symptoms and physical functioning. Exploratory analyses investigate biomarkers (cortisol, cytokines, blood pressure/Heart Rate Variability, telomere length, gene expression), which may uncover potentially important effects on key biological regulatory and antineoplastic functions. Health economic measures will determine potential savings to the health system.

Background Although the nature and frequency of postoperative complications after intestinal resection in patients with inflammatory bowel disease have been previously described, short-term readmission has not been characterized in population-based studies. We therefore assessed the risk of postoperative complications and emergent readmissions after discharge from an intestinal resection. Methods We used a Canadian provincial-wide inpatient hospitalization database to identify 2638 Crohn's disease (CD) and 559 ulcerative colitis (UC) admissions with intestinal resection from 2002 to 2011. We identified the cumulative risk of in-hospital complication and emergent readmission within 90 days after discharge along with predictors for both outcomes using a Poisson regression for binary outcomes. Results The cumulative risks of in-hospital postoperative complications and 90-day emergent readmission were 23.8% and 12.6%, respectively in CD and 33.3% and 11.1%, respectively in UC. The predictors for in-hospital postoperative complications for CD and UC included older age, comorbidities, and open laparatomy for CD, additional predictors included emergent admission, stoma surgery, and concurrent resection of both small and large bowel. The predictors for 90-day readmission for CD included a postoperative complication (risk ratio, 1.61; 95% confidence interval, 1.30-2.01), emergent admission (risk ratio, 1.39; 95% confidence interval, 1.12-1.73), and stoma formation (risk ratio, 1.49; 95% confidence interval, 1.15-1.93) at the hospitalization requiring surgery. Conclusions Readmission and postoperative complications are common after intestinal resection in CD and UC. Clinicians should closely monitor surgical patients who required emergent admission, undergo surgery with stoma formation, or develop in-hospital postoperative complications to anticipate need for readmission or interventions to prevent readmission.

Aim We assessed the value of cardiovascular magnetic resonance (CMR) criteria (‘Lake Louise Criteria’) for predicting left ventricular (LV) functional improvement in patients with acute myocarditis. Methods and results We studied 37 patients who referred for acute myocarditis during clinically acute myocarditis and after a 12-month follow-up. CMR sequences sensitive for oedema, hyperaemia, and irreversible injury were applied. Global and regional oedema were defined using published quantitative signal intensity (SI) cut-off values (area with an SI of >2 SD above visually normal myocardium). LV function was analysed using six long-axis views, with an increase of at least 5% of left ventricular ejection fraction considered as improvement. Out of a total of 37 patients, 29 met the CMR Lake Louise criteria (LL+) and eight did not (LL−). Baseline and 12-month ejection fraction (EF) were significantly lower in LL+ (53.2 ± 8 vs. 62.2 ± 5, P = 0.007 and 58.9 ± 4 vs. 62.9 ± 5, P = 0.045, respectively). At follow-up, EF increased in LL+ but remained unchanged within normal limits in LL− groups (delta EF: 5.7 ± 9.8 vs. 0.7 ± 2.0). The presence of global or regional myocardial oedema was strongly associated with an increase of EF ≥5%. In a multivariate analysis, the presence of global and/or regional oedema on admission was the only independent predictor of an increase of EF ( P = 0.046). Conclusion In patients with clinically suspected acute myocarditis, the presence of positive CMR criteria is associated with LV function recovery. Myocardial oedema as defined by CMR was the strongest parameter, indicating that the observed increase of EF may be due to the recovery of reversibly injured (oedematous) myocardium.

Background Modifications to the Model for End-Stage Liver Disease (MELD) have been proposed to improve prioritization of liver transplant (LT) candidates. Using a U.S. database, we derived a revised MELD including sodium and albumin [5-variable MELD (5vMELD)] that improved prediction of waiting list mortality. Our objectives were to confirm the association between hypoalbuminaemia and mortality and to externally validate 5vMELD in Canadian LT candidates. Methods Among adults registered on the LT waiting list at the University of Alberta (01/2000-10/2009), Cox regression determined the association between albumin and 1-year waiting list mortality. The discrimination of MELD, MELDNa and 5vMELD for predicting 1-year mortality were compared using c-statistics. Results Among 677 patients, 17% died and 51% underwent LT within 1 year of listing. Median serum albumin was 3.1 g/dl (IQR 2.6–3.6) and 70% of patients were hypoalbuminaemic (albumin

The importance of dose, frequency and duration of vitamin D supplementation for plasma 25(OH)D levels is not well described and rarely reported for supplementation that exceeds 2000 IU per day. The objective is to examine dose, frequency and duration of supplementation in relation to plasma 25(OH)D in a large population-based sample. We accessed data on 2714 volunteers that contributed to 4224 visits and applied multilevel regression. Compared to not using supplements, a minimum regimen of 1000–2000 IU once or twice per week for one month was not effective in raising 25(OH)D. Compared to this minimum regimen, higher doses of 2000–3000, 3000–4000, and 5000 IU or more were associated with a 7.49, 13.19 and 30.22 nmol/L 25(OH)D increase, respectively; frequencies of three to four, five to six and seven times/week were associated with a 5.44, 16.52 and 30.69 nmol/L increase, respectively; and supplementation of five months or longer was associated with an increase of 6.68 nmol/L (p < 0.01 for all). Age, body weight, physical activity, smoking, and self-rated health were significantly associated with 25(OH)D. Whereas dose, frequency and duration of supplementation are important to healthy subjects committed to optimizing their nutritional status, to the design of clinical trials, individual characteristics and lifestyle contribute substantially to 25(OH)D.

To determine the incidence of gastrointestinal (GI) bleeding in patients after cardiac surgery, assess the perioperative risk factors, and determine the type of GI tract pathology associated with bleeding events.At a tertiary referral hospital, all cardiac surgery patients having a postoperative GI bleed from April 2002 to March 2012 were identified. To determine bleeding etiology, only patients requiring endoscopy were included in the analysis. By retrospective review of 3 prospectively maintained databases, the incidence and independent predictors of GI bleeding, as well as endoscopic findings, were determined.Ninety-one GI bleeding events that required endoscopy were identified in 9017 patients. Those that bled were aged 71 ± 12 years, and 76% were men. Sixty-three percent of these patients had valve surgery and 37% had an isolated coronary artery bypass grafting. The overall incidence of GI bleeding was 1.01%, with an upper GI source accounting for 78%. Endoscopy data found a duodenal ulcer as the bleeding source in 71%, whereas stress gastritis accounted for 8%. Preoperative risk factors for bleeding included age ≥70 years, ejection fraction35%, congestive heart failure, cerebrovascular disease, chronic kidney disease, and gastrointestinal disease. A preoperative history of atrial fibrillation and anticoagulation with Coumadin also was associated with bleeding. Patients that bled had a 30-day mortality rate of 8.8%, which was significantly greater than patients who did not bleed (4.3%; P = .03).Clinical variables can be used to identify patients at high risk for GI bleeding after cardiac surgery. When GI bleeding occurs, the most common cause is duodenal ulceration, which has an association with Helicobacter pylori infection. These findings may provide an opportunity to initiate preoperative preventative strategies.

Background One of the main arguments made in favor of community water fluoridation is that it is equitable in its impact on dental caries (i.e., helps to offset inequities in dental caries). Although an equitable effect of fluoridation has been demonstrated in cross-sectional studies, it has not been studied in the context of cessation of community water fluoridation (CWF). The objective of this study was to compare the socio-economic patterns of children’s dental caries (tooth decay) in Calgary, Canada, in 2009/10 when CWF was in place, and in 2013/14, after it had been discontinued. Methods We analyzed data from population-based samples of schoolchildren (grade 2) in 2009/10 and 2013/14. Data on dental caries (decayed, missing, and filled primary and permanent teeth) were gathered via open mouth exams conducted in schools by registered dental hygienists. We examined the association between dental caries and 1) presence/absence of dental insurance and 2) small area index of material deprivation, using Poisson (zero-inflated) and logistic regression, for both time points separately. For small-area material deprivation at each time point, we also computed the concentration index of inequality for each outcome variable. Results Statistically significant inequities by dental insurance status and by small area material deprivation were more apparent in 2013/14 than in 2009/10. Conclusions Results are consistent with increasing inequities in dental caries following cessation of CWF. However, further research is needed to 1) confirm the effects in a study that includes a comparison community, and 2) explore possible alternative reasons for the findings, including changes in treatment and preventive programming.

Background Although a number of accreditation agencies and professional societies recommend routine screening for distress (SFD) for patients with cancer, it has been integrated very slowly into clinical practice. Objectives This evaluation investigated the impact of a large-scale SFD intervention on patients' quality of life, symptom reports, and psychosocial well-being. The SFD intervention involved (1) completion of the SFD tool by patients, (2) discussion between patient and provider about the concerns indicated, and (3) provision of appropriate assessments/interventions based on priority concerns. Patients and methods This quality improvement work included a pre-evaluation and postevaluation of the impact of implementation on patients' well-being. Patients in cohort 1 (N=740) were surveyed before implementation, whereas patients in cohort 2 (N=534) were surveyed 10 months after the implementation at 17 clinics province-wide. As part of the implementation, providers received training on assessing and responding to patient priority concerns with the standardized tool. Results No differences were seen in total score of quality of life between the cohorts. Fewer patients in cohort 2 than in cohort 1 reported health problems, including tiredness, drowsiness, poor appetite, nausea, anxiety, and poor well-being. Similarly, significantly fewer patients in cohort 2 endorsed problems relating to emotional, practical, informational, spiritual, social, and physical aspects of well-being. Conclusions Results showed significantly improved psychological and physical symptoms and psychosocial well-being after routine SFD was implemented, suggesting that a large-scale SFD intervention is beneficial for patients when it is integrated into existing clinical practice and community resources.

Summary Objective Total hip replacement (THR) and total knee replacement (TKR) (arthroplasty) surgery for end-stage osteoarthritis (OA) are ideal candidates for optimization through an algorithmic care pathway. Using a comparative effectiveness study design, we compared the effectiveness of a new clinical pathway (NCP) featuring central intake clinics, dedicated inpatient resources, care guidelines and efficiency benchmarks vs the standard of care (SOC) for THR or TKR. Methods We compared patients undergoing primary THR and TKR who received surgery in NCP vs SOC in a randomised controlled trial within the trial timeframe. 1,570 patients (1,066 SOC and 504 NCP patients) that underwent surgery within the study timeframe from urban and rural practice settings were included. The primary endpoint was improvement in Western Ontario and McMaster University Osteoarthritis Index (WOMAC) overall score over 12months post-surgery. Secondary endpoints were improvements in the Physical Function (PF) and Bodily Pain (BP) domains of the Short Form 36 (SF-36). Results NCP patients had significantly greater improvements from baseline WOMAC scores compared to SOC patients after adjusting for covariates (treatment effect=2.56; 95% confidence interval (CI) [1.10–4.01]). SF-36 BP scores were significantly improved for both hip and knee patients in the NCP (treatment effect=3.01, 95% CI [0.70–5.32]), but SF-36 PF scores were not. Effects of the NCP were more pronounced in knee patients. Conclusion While effect sizes were small compared with major effects of the surgery itself, an evidence-informed clinical pathway can improve health related quality of life (HRQoL) of hip and knee arthroplasty patients with degenerative joint disorder in routine clinical practice for up to 12months post-operatively. Clinicaltrials.gov identifier NCT00277186.

STUDY OBJECTIVES Excessive daytime sleepiness is an important public health concern associated with increased morbidity and mortality. However, in the absence of sleep diagnostic testing, it is difficult to separate the independent effects of sleepiness from those of intrinsic sleep disorders such as obstructive sleep apnea (OSA). The objective of this study was to determine if excessive daytime sleepiness was independently associated with increased health care utilization among patients referred for assessment of OSA. DESIGN Cross-sectional study. SETTING/PARTICIPANTS 2149 adults referred for sleep diagnostic testing between July 2005 and August 2007. INTERVENTIONS N/A. MEASUREMENTS Subjective daytime sleepiness was defined as an Epworth Sleepiness Scale score ≥10. Health care use (outpatient physician visits, all-cause hospitalizations, and emergency department visits) was determined from Alberta Health and Wellness administrative databases for the 18-month period preceding their sleep study. Rates of health resource use were analyzed using negative binomial regression, with predictors of increased health care use determined using logistic regression. RESULTS excessive daytime sleepiness was associated with an increased rate of outpatient physician visits after adjustment for demographic variables, sleep medication use, hypertension, diabetes, depression, and OSA severity (rate ratio [RR]: 1.09 (95% confidence interval [CI]: 1.01, 1.18, P = 0.02) compared to non-sleepy subjects. There was an interaction between severe OSA and sleepiness (RR: 1.22 [95% CI: 1.06, 1.41]), although OSA was not an independent predictor of health care use. Also, sleepy patients with treated depression had a lower likelihood of outpatient visits (RR: 0.95 [95% CI: 0.86, 1.05]). Finally, sleepiness was an independent predictor of increased health care use for outpatient physician visits (odds ratio [OR]: 1.25 [95% CI: 1.00, 1.57; P = 0.048]) and all-cause hospitalizations (OR: 3.94 [95% CI: 1.03, 15.04; P = 0.046]). CONCLUSIONS Excessive daytime sleepiness is associated with increased health care utilization among patients referred for assessment of OSA. Further investigation is required to determine whether the findings are related to direct effects of sleepiness, or in part, to interactions with other comorbidity such as OSA.

Background and Purpose— Neurocognitive dysfunction complicates coronary artery bypass surgery. Erythropoietin may be neuroprotective. We sought to determine whether human recombinant erythropoietin would reduce the incidence of neurocognitive dysfunction after surgery. Methods— We randomly assigned 32 elective first-time coronary artery bypass graft patients to receive placebo or 375 U/kg, 750 U/kg, or 1500 U/kg of recombinant human erythropoietin divided in 3 daily doses, starting the day before surgery. Primary outcomes were feasibility and safety, and secondary outcomes were neurocognitive dysfunction at discharge and 2 months. Results— All subjects were male, mean age 60 years (range 46 to 73). No significant differences were found in pump time, cross-clamp time, or hospital length of stay. Mortality and pure red cell aplasia were not observed. One patient in the 375 U/kg group had ST changes compatible with myocardial injury immediately postoperative, but no other thrombotic complications were observed. Neurocognitive dysfunction occurred in 21/32 (66%) of patients at discharge and 5/32 (16%) at 2 months. Neurocognitive dysfunction at discharge by group was: placebo 6/8 (75%), 375 U/kg 4/8 (50%), 750 U/kg 6/8 (75%), and 1500 U/kg 5/8 (63%). Neurocognitive dysfunction at 2 months by group was: placebo 3/8 (38%), 375 U/kg 1/8 (13%), 750 U/kg 1/8 (13%), and 1500 U/kg 0/8 (0%). Neurocognitive dysfunction at 2 months for erythropoietin at any dose was 2/24 (8.3%) versus 3/8 (38%) for placebo ( P =0.085). Conclusions— This study demonstrates feasibility and safety for the use of human recombinant erythropoietin as a neuroprotectant in coronary artery bypass graft surgery. A trend in the reduction of neurocognitive dysfunction at 2 months was associated with erythropoietin use. A multicenter randomized controlled trial is warranted.

Prostate cancer patients receiving androgen deprivation therapy (ADT) are vulnerable to a number of potentially debilitating side effects, which can significantly impact quality of life. The role of alternate therapies, such as physical activity (PA), in attenuating these side effects is largely understudied for such a large population. Thus, the purpose of this study was to investigate the effects of PA intervention for men receiving ADT on PA behavior, quality of life, and fitness measures.One hundred participants were randomized into an intervention (n = 53) or a wait-list control group (n = 47), with 11 dropping out of the intervention group and 23 dropping out of the wait-list control group prior to post-testing. The intervention consisted of both an individually tailored home-based aerobic and light resistant training program and weekly group sessions. PA, quality of life, fitness, and physiological outcomes were assessed pre and post the 16-week intervention.Significant increases in PA, supported by changes in girth measures and blood pressure, support the beneficial impact of the intervention. Positive trends were also evident for depression and fatigue. However, due to the high dropout rate, these results must be interpreted with caution.PA effectively attenuates many of the side effects of ADT and should be recommended to prostate survivors as an alternate therapy. Determining the maintenance of this behavior change will be important for understanding how the long-term benefits of increased activity levels may alleviate the late effects of ADT.

Background The effects of kidney disease on the risk of hospitalization or death from specific noncardiovascular causes, including pneumonia, are unclear. The objective of this study is to determine the associations between estimated glomerular filtration rate (eGFR) and hospitalization or death with pneumonia. Study Design Retrospective cohort study. Setting & Participants Community-based study from a Canadian health region of 252,516 participants with 1 or more outpatient serum creatinine measurements from July 1, 2003, to June 30, 2004, who were not receiving dialysis or kidney transplantation. Predictor eGFR calculated by using the 4-variable Modification of Diet in Renal Disease Study equation. Outcomes Hospitalization with pneumonia or death within 30 days after pneumonia hospitalization. Measurements Cox proportional hazards models adjusted for age, sex, socioeconomic status, and comorbidities with censoring at death, initiation of renal replacement therapy, or emigration. Results Lower eGFR was associated with increased risk of hospitalization with pneumonia, although the magnitude of effect varied with age. The risk associated with decreased eGFR was greatest in participants 18 to 54 years old; compared with participants with an eGFR of 60 to 104 mL/min/1.73 m 2 , adjusted hazard ratios for hospitalization with pneumonia were 3.23 (95% confidence interval, 2.40 to 4.36) in those with eGFR of 45 to 59 mL/min/1.73 m 2 , 9.67 (95% confidence interval, 6.36 to 14.69) for eGFR of 30 to 44 mL/min/1.73 m 2 , and 15.04 (95% confidence interval, 9.64 to 23.47) for eGFR less than 30 mL/min/1.73 m 2 . Associations became weaker with increasing age, although the graded inverse association between lower eGFR and risk remained for older participants. An age-dependent inverse relationship also was observed between eGFR and risk of death within 30 days of hospitalization with pneumonia. Limitations Residual confounding caused by severity of illness or unmeasured comorbidities may be present. Conclusion The risk of hospitalization and death with pneumonia is greater at lower eGFRs, especially in younger adults. This association may contribute to excess mortality in people with chronic kidney disease.

Summary Purpose: Epilepsy imposes a significant burden on society. The objective of this study was to estimate health resource utilization (HRU) over a 1-year period in epilepsy patients, using administrative databases. Methods: Three administrative databases (inpatient, emergency, and physician claims) were used to identify epilepsy cases. HRU variables included general physician (GP) and emergency (ER) visits, physician billings, hospitalizations, and length of stay (LOS). Logistic regression was used to determine the association between demographic variables and HRU variations. Results: Among the 1,431 patients with a mean age of 37.5 ± 17.3 years, 56 (4%) were aboriginal. Ninety-six percent of patients saw a GP or a specialist (outpatient visit), 12% were hospitalized, and 8% visited the ER. Younger patients were more likely to see a neurologist (OR = 1.7, 95% CI 1.3–2.3), visit the ER (OR = 4.9, 95% CI 3.2–7.4), or be hospitalized (OR = 2.9, 95% CI 2.0–4.3). Females were less likely to see a GP but more likely to see a neurologist. Aboriginals were more likely than nonaboriginals to visit the ER (OR = 2.3, 95% CI 1.1–5.0) or be hospitalized (OR = 2.8, 95% CI 1.5–5.1) but less likely to see a neurologist (OR = 0.3, 95% CI 0.2–0.6). Welfare status and residence location (urban vs. rural) were not associated with HRU level. Discussion: We demonstrated the feasibility of using administrative databases to assess HRU in epilepsy. We also uncovered disparities in HRU by age, gender, and by aboriginal status, suggesting possible internal or external barriers to specialized care in some groups.

Rationale: The use of “pro re nata” (PRN) medication in patients with behavioral and psychological symptoms of dementia (BPSD) is common but may be a source of inappropriate medication administration. Objective: To identify trends in the administration of PRN medications to inpatients with BPSD. Methods: Retrospective chart audits were completed on inpatients with dementia who had PRN medications prescribed for aggression, agitation, or insomnia. Data collected included age, sex, time of day, day of week, medication used, and dementia diagnosis. Additionally, data regarding administration of ranged doses and concurrent use with regularly prescribed medications of the same class were collected. Results: A total of 170 inpatients with dementia were included. Over 50 346 bed days, 4000 PRNs were administered. Individuals were more likely to receive a PRN if they were younger, shortly after shift change, in the evening, or during the weekend. If a ranged dose is provided they are more likely to receive the higher dose. If they are receiving regularly scheduled medication from the same class, there is risk of double dosing.

Objective Ordinal scales often generate scores with skewed data distributions. The optimal method of analyzing such data is not entirely clear. The objective was to compare four statistical multivariable strategies for analyzing skewed health-related quality of life (HRQOL) outcome data. HRQOL data were collected at 1 year following catheterization using the Seattle Angina Questionnaire (SAQ), a disease-specific quality of life and symptom rating scale. Study Design and Setting In this methodological study, four regression models were constructed. The first model used linear regression. The second and third models used logistic regression with two different cutpoints and the fourth model used ordinal regression. To compare the results of these four models, odds ratios, 95% confidence intervals, and 95% confidence interval widths (i.e., ratios of upper to lower confidence interval endpoints) were assessed. Results Relative to the two logistic regression analysis, the linear regression model and the ordinal regression model produced more stable parameter estimates with smaller confidence interval widths. Conclusion A combination of analysis results from both of these models (adjusted SAQ scores and odds ratios) provides the most comprehensive interpretation of the data.

Surnames have the potential to accurately identify ancestral origins as they are passed on from generation to generation. In this study, we developed and validated a Chinese surname list to define Chinese ethnicity.We conducted a literature review, a panel review, and a telephone survey in a randomly selected sample from a Canadian city in 2003 to develop a Chinese surname list. The list was then validated to data from the Canadian Community Health Survey. Both surveys collected information on self-reported ethnicity and surname.Of the 112,452 people analyzed in the Canadian Community Health Survey, 1.6% were self-reported as Chinese. This was similar to the 1.5% identified by the surname list. Compared with self-reported Chinese ethnicity (reference standard), the surname list had 77.7% sensitivity, 80.5% positive predictive value, 99.7% specificity, and 99.6% negative predictive value. When stratifying by sex and marital status, the positive predictive value was 78.9% for married women and 83.6% for never married women.The Chinese surname list appears to be valid in identifying Chinese ethnicity. The validity may depend on the geographic origins and Chinese dialects in given populations.

Background: The optimal population rate of cardiac catheterization is unknown. One potential way to determine it would be to examine whether there is a population rate beyond which the yield of high-risk coronary artery disease (CAD) does not rise. Methods: Using a detailed clinical registry that captures all patients undergoing cardiac catheterization in Alberta, we determined annual population rates of cardiac catheterization and the corresponding yield of cases of high-risk CAD in each of Alberta9s 17 health regions from 1995 to 2002. Least squares linear regression analysis and hierarchical modelling methods were then used to assess the linear relation between catheterization rates and rates of high-risk CAD. Results: The age-adjusted average rate of cardiac catheterization among men ranged from 404.9 to 638.1 per 100 000 population aged over 20 years. Among women, the average rate ranged from 171.8 to 314.0 per 100 000. For both sexes, increased regional rates of catheterization were associated with a linearly increasing yield of high-risk CAD, with no evidence of a plateau in yield when more procedures were performed. One additional case of high-risk CAD was identified for every 2.5 additional cardiac catheterization procedures performed among men, and for every 3.7 additional procedures performed among women. Interpretation: The increasing yield of patients with high-risk CAD associated with increased regional population rates of cardiac catheterization, together with the absence of a plateau in yield, suggests that Alberta9s population rates of cardiac catheterization are suboptimal to detect people with high-risk CAD.

Objective. Many consider smoking to be a personal choice for which individuals should be held accountable. We assessed whether there is any evidence of bias against smokers in cardiac care decision-making by determining whether smokers were as likely as non-smokers to undergo revascularization procedures after cardiac catheterization. Design. Prospective cohort study. Subjects and setting. All patients undergoing cardiac catheterization in Alberta, Canada. Main measures. Patients were categorized as current smokers, former smokers, or never smokers, and then compared for their risk-adjusted likelihood of undergoing revascularization procedures (percutaneous coronary intervention or coronary artery bypass grafting) after cardiac catheterization. Results. Among 20406 patients undergoing catheterization, 25.4% were current smokers at the time of catheterization, 36.6% were former smokers, and 38.0% had never smoked. When compared with never smokers (reference group), the hazard ratio for undergoing any revascularization procedure after catheterization was 0.98 (95% CI 0.93–1.03) for current smokers and 0.98 (0.94–1.03) for former smokers. The hazard ratio for undergoing coronary artery bypass grafting was 1.09 (1.00–1.19) for current smokers and 1.00 (0.93–1.08) for former smokers. For percutaneous coronary intervention, the hazard ratios were 0.93 (0.87–0.99) for current smokers and 1.00 (0.94–1.06) for former smokers. Conclusion. Despite potential for discrimination on the basis of smoking status, current and former smokers undergoing cardiac catheterization in Alberta, Canada were as likely to undergo revascularization procedures as catheterization patients who had never smoked.

OBJECTIVE—Women with ischemic heart disease have poorer outcomes than men and are suggested to have greater risk associated with diabetes. We evaluated the prognosis associated with diabetes, in analyses stratified by sex, to determine whether similar differences are seen in a large unselected cohort of patients. RESEARCH DESIGN AND METHODS—Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and follow-up initiative capturing all patients undergoing cardiac catheterization in Alberta, Canada, the relative significance of diabetes on long-term survival in 13,152 men and 4,249 women was evaluated in patients presenting with or without myocardial infarction and according to first treatment received. RESULTS—The 1-year mortality rates were 4.7% and 6.8% in men and women (P < 0.001), 4.1% and 7.4% in nondiabetic and diabetic men (P < 0.001), and 5.8% and 9.6% in nondiabetic and diabetic women, respectively (P < 0.001). The risk-adjusted Cox proportional hazard ratios associated with diabetes in myocardial infarction were 1.03 in men and 1.20 in women. The diabetes hazard ratios for percutaneous coronary intervention were 1.28 in men and 1.40 in women, 1.23 in men and 1.32 in women for bypass surgery, and 1.26 in men and 1.31 in women for medical therapy (P = NS for all diabetes hazard ratio comparisons between men and women). CONCLUSIONS—Hazard ratios quantifying the adverse prognosis associated with diabetes in patients undergoing angiography are consistently higher among women than men, but the differences across sexes are not statistically significant. These slight sex differences noted in the APPROACH registry are similar to previously reported findings and may be clinically important.

Health researchers commonly use logistic regression when profiling health providers. Data from the patients treated by the providers are used to construct models predicting the expected number of outcomes for providers and the ratio of observed to expected outcomes (O/E ratio) used as a risk-adjusted measure of provider performance. Typically, when calculating the standard deviation (SD) of O/E ratios, only O is treated as a random variable. We used the propagation of errors (Pe) to derive a SD estimate that accounted for variability in O and the estimate of E. Using data previously used to profile Canadian cardiac surgery providers, we compared Pe-SD estimates with typical SD (SDT) estimates. The SDT estimates and confidence intervals were always larger than the Pe estimates, most notably when one or more providers treated a large proportion of the patients. This was confirmed using computer simulations. SDT estimates should be abandoned in favor of more sophisticated estimates.

This waitlist-controlled study examined the timing of changes during Mindfulness-Based Cancer Recovery (MBCR), and explored sequential mediated effects through enhanced mindfulness and emotion regulation (ER) in a cancer population.Patients were recruited from the MBCR program waitlist and were either registered for immediate participation (n = 135) or waiting for the next program to begin (n = 76). Participants completed self-report measures of stress symptoms, mood disturbance, mindfulness, and ER (rumination, worry, and experiential avoidance) pre-, mid- and post-MBCR or waiting period.There was a relatively early effect of MBCR on observing, nonjudging, rumination, and worry. All other measures changed later. Early changes in present-focused nonjudgmental awareness, rumination, and worry mediated the effect of MBCR on mindfulness skills such as nonreactivity later on.The constructs of mindfulness and ER may overlap and changes may be mutually facilitative during MBCR. The study informs our understanding of mindfulness and ER as mechanisms of mindfulness-based interventions.

Cardiovascular disease (CVD) is a leading cause of mortality in rheumatoid arthritis (RA). This study systematically reviewed and appraised guidelines and quality indicators (QIs) pertaining to CVD risk management in patients with RA.Four electronic medical databases (Medline, Embase, CINAHL, and Web of Science) and gray literature publications were searched using terms and keywords pertaining to guidelines, QIs, RA, and CVD (RA and general population literature searched). Abstracts were screened for inclusion and rated using the Appraisal of Guidelines for Research and Evaluation II instrument independently by 2 of 3 reviewers.In total, 16,064 abstracts were screened and 808 underwent full-text review. A total of 17 guidelines and 3 QI sets published between 2008 and 2013 were included. A number of consistent themes emerged, including the increased CV risk faced by RA patients and the need to address modifiable risk factors on a regular basis. The role of the multidisciplinary team in risk optimization was also highlighted. Ten guidelines provided recommendations for CVD prevention in patients with RA. Unfortunately, most recommendations lacked the specificity required to determine adherence to the recommendation. Only 4 RA-specific CVD QIs were identified (1 general comorbidity screening, formal CVD risk estimation, exercise, and minimizing steroid use).Regular screening for CVD risk factors is an important part of care in patients with RA. Unfortunately, existing RA-specific CVD QIs do not adequately address risk factor management, and existing guideline recommendations lack specificity for measurement and use in quality improvement initiatives.

The quantity of subarachnoid (SAH) and intraventricular hemorrhage (IVH) occurring in the setting of a ruptured cerebral aneurysm is strongly associated with subsequent complications and poor outcomes. We randomly allocated aneurysmal SAH patients with a modified Fisher score of 4, who had been treated with endovascular coil embolization and ventricular drainage, to receive either 2 mg intraventricular tissue plasminogen activator (TPA) every 12 h (maximum 10 mg) or placebo. Computed tomography scans were performed 12, 48, and 72 h after administration. Primary outcomes included feasibility (enrollment and consent rates), safety (assessed by prospectively screening for complications), and rate of intracranial blood clearance (measured using sequential IVH, modified Graeb, and SAH sum scores). Secondary outcomes included angiographic vasospasm, delayed cerebral ischemia, need for ventriculoperitoneal shunting, and 6-month neurological outcomes. Seventy-seven patients were screened, 17 were eligible, and 12 were randomized. The consent rate was 87 %. There were no cases of new intracranial hemorrhage complicating use of TPA. Models fit using generalized estimating equations demonstrated more rapid reduction in IVH volume (p = 0.009), modified Graeb score (p

Objective To derive a clinical decision guide (CDG) to identify patients best suited for cervical diagnostic facet joint blocks. Design Prospective cohort study. Setting Pain management center. Participants Consecutive patients with neck pain (N=125) referred to an interventional pain management center were approached to participate. Interventions Subjects underwent a standardized testing protocol, performed by a physiotherapist, prior to receiving diagnostic facet joint blocks. All subjects received the reference standard diagnostic facet joint block protocol, namely controlled medial branch blocks (MBBs). The physicians performing the MBBs were blinded to the local anesthetic used and findings of the clinical tests. Main Outcome Measures Multivariate regression analyses were performed in the derivation of the CDGs. Sensitivity, specificity, positive and negative likelihood ratios, and 95% confidence intervals (CIs) were calculated for the index tests and CDGs. Results A CDG involving the findings of the manual spinal examination (MSE), palpation for segmental tenderness (PST), and extension-rotation (ER) test demonstrated a specificity of 84% (95% CI, 77–90) and a positive likelihood ratio of 4.94 (95% CI, 2.8–8.2). Sensitivity of the PST and MSE were 94% (95% CI, 90–98) and 92% (95% CI, 88–97), respectively. Negative findings on the PST were associated with a negative likelihood ratio of .08 (95% CI, .03–.24). Conclusions MSE, PST, and ER may be useful tests in identifying patients suitable for diagnostic facet joint blocks. Further research is needed to validate the CDGs prior to their routine use in clinical practice.

Background Studies of survival of patients with multivessel coronary artery disease (MVD) in the prestent era suggested that outcomes after coronary artery bypass surgery (CABG) are similar to those after percutaneous coronary intervention (PCI) in subsets of coronary severity. The purpose of this study of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) was to examine the association between treatment and survival up to 5 years in patients with MVD enrolled from 1995 through 1998. Methods and Results Data on patient characteristics were obtained at the time of the initial coronary angiography. Survival was determined through data linkage to the provincial Bureau of Vital Statistics. Risk-adjusted hazard ratios were calculated to compare different treatments. In the 11,661 patients with MVD, CABG was the initial therapy in 3782, PCI in 3540, and medical therapy in 4339. Cumulative 5-year survival was 91.4% with CABG, 91.9% with PCI, and 82.9% with medical therapy (P