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Redelmeier DA, Najeeb U, Etchells EE. Understanding Patient Personality in Medical Care: Five-Factor Model. J Gen Intern Med 2021; 36:2111-2114. [PMID: 33506393 PMCID: PMC7840072 DOI: 10.1007/s11606-021-06598-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/01/2021] [Indexed: 12/27/2022]
Abstract
Personality is the description of an individual's tendencies when acting or reacting to others. Clinicians spontaneously form impressions of a patient's apparent personality yet such unstructured impressions might lead to snap judgments or unhelpful labels. Here we review the evidence-based five-factor model from psychology science for understanding personalities (OCEAN taxonomy). Openness to experience is defined as the general appreciation for a variety of experiences. Conscientiousness is the tendency to exhibit self-discipline. Extraversion is the degree of engagement with the external world. Agreeableness is the general concern for social harmony. Neuroticism is the tendency to experience negative emotions. An awareness of these five dimensions might help clinicians avoid faulty judgments from casual contact. Expert assessment of personality requires extensive training and data, thereby suggesting that clinicians should take a humble view of their own unsophisticated impressions of a patient's personality.
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Redelmeier DA, Ng K, Thiruchelvam D, Shafir E. Association of socioeconomic status with medical assistance in dying: a case-control analysis. BMJ Open 2021; 11:e043547. [PMID: 34035092 PMCID: PMC8154947 DOI: 10.1136/bmjopen-2020-043547] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints. DESIGN Population-based case-control study of adults who died. SETTING Ontario, Canada, between 1 June 2016 and 1 June 2019. PATIENTS Patients receiving palliative care under universal insurance with no user fees. EXPOSURE Patient's socioeconomic status identified using standardised quintiles. MAIN OUTCOME MEASURE Whether the patient received medical assistance in dying. RESULTS A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design. CONCLUSIONS Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.
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Fralick M, Colacci M, Thiruchelvam D, Gomes T, Redelmeier DA. Sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors and the risk of heart failure: A nationwide cohort study of older adults with diabetes mellitus. Diabetes Obes Metab 2021; 23:950-960. [PMID: 33336894 DOI: 10.1111/dom.14300] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/30/2020] [Accepted: 12/13/2020] [Indexed: 12/20/2022]
Abstract
AIMS To analyse the rate of heart failure hospitalization for older adults prescribed a sodium-glucose co-transporter-2 (SGLT2) inhibitor. MATERIALS AND METHODS The study cohort included adults aged 66 years and older diagnosed with diabetes mellitus in Ontario, Canada, between July 2015 and March 2019, who received either an SGLT2 inhibitor or a dipeptidyl peptidase-4 (DPP-4) inhibitor. The primary outcome was a composite of heart failure hospitalization and all-cause mortality. Secondary outcomes included diabetic ketoacidosis and hypoglycaemia. RESULTS A total of 29 916 adults prescribed an SGLT2 inhibitor were compared with 29 916 adults prescribed a DPP-4 inhibitor. The mean age was 72 years, 60% were men, the baseline glycated haemoglobin concentration was 8.2% and the baseline creatinine was 89 μmol/L. The incidence rate of the primary outcome was 19/1000 person-years for adults prescribed an SGLT2 inhibitor compared to 38/1000 person-years in those prescribed a DPP-4 inhibitor. This resulted in a hazard ratio (HR) of 0.49 (95% confidence interval [CI] 0.45, 0.54) and a rate difference (RD) of 19 fewer events per 1000 person-years (RD -19 [95% CI -22, -17]). Patients prescribed an SGLT2 inhibitor also had a lower rate of hypoglycaemia (HR 0.61 [95% CI 0.46, 0.81); RD -1.6 [95% CI -2.4, -0.8]), but a higher rate of diabetic ketoacidosis (HR 1.84 [95% CI 1.26, 2.70]; RD 1.0 [95% CI 0.4, 1.6]). CONCLUSIONS Older adults prescribed an SGLT2 inhibitor had a lower rate of heart failure hospitalization or death, and a lower rate of hypoglycaemia, but an increased rate of diabetic ketoacidosis compared to older adults prescribed a DPP-4 inhibitor.
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Redelmeier DA, Thiruchelvam D. Hand hygiene sprayed into eye. IDCases 2021; 24:e01092. [PMID: 33912387 PMCID: PMC8065190 DOI: 10.1016/j.idcr.2021.e01092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/15/2022] Open
Abstract
Hand hygiene is a practical, affordable, acceptable, reliable, and effective strategy to mitigate nosocomial infection risks in hospitals. Here we provide an image of clinical medicine that documents a potential error related to hand sanitizer dispenser malfunction. An awareness of this adverse event can lead to immediate modifiable changes in healthcare settings to reduce the risks of nosocomial infections.
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Sinyor M, Williams M, Zaheer R, Loureiro R, Pirkis J, Heisel MJ, Schaffer A, Redelmeier DA, Cheung AH, Niederkrotenthaler T. The association between Twitter content and suicide. Aust N Z J Psychiatry 2021; 55:268-276. [PMID: 33153274 DOI: 10.1177/0004867420969805] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE A growing body of research has established that specific elements of suicide-related news reporting can be associated with increased or decreased subsequent suicide rates. This has not been systematically investigated for social media. The aim of this study was to identify associations between specific social media content and suicide deaths. METHODS Suicide-related tweets (n = 787) geolocated to Toronto, Canada and originating from the highest level influencers over a 1-year period (July 2015 to June 2016) were coded for general, putatively harmful and putatively protective content. Multivariable logistic regression was used to examine whether tweet characteristics were associated with increases or decreases in suicide deaths in Toronto in the 7 days after posting, compared with a 7-day control window. RESULTS Elements independently associated with increased subsequent suicide counts were tweets about the suicide of a local newspaper reporter (OR = 5.27, 95% CI = [1.27, 21.99]), 'other' social causes of suicide (e.g. cultural, relational, legal problems; OR = 2.39, 95% CI = [1.17, 4.86]), advocacy efforts (OR = 2.34, 95% CI = [1.48, 3.70]) and suicide death (OR = 1.52, 95% CI = [1.07, 2.15]). Elements most strongly independently associated with decreased subsequent suicides were tweets about murder suicides (OR = 0.02, 95% CI = [0.002, 0.17]) and suicide in first responders (OR = 0.17, 95% CI = [0.05, 0.52]). CONCLUSIONS These findings largely comport with the theory of suicide contagion and associations observed with traditional news media. They specifically suggest that tweets describing suicide deaths and/or sensationalized news stories may be harmful while those that present suicide as undesirable, tragic and/or preventable may be helpful. These results suggest that social media is both an important exposure and potential avenue for intervention.
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Redelmeier DA, Kao MM. Harnessing choice architecture to improve medical care. BMJ Qual Saf 2021; 30:bmjqs-2020-012598. [PMID: 33452140 DOI: 10.1136/bmjqs-2020-012598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 11/04/2022]
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Redelmeier DA, Detsky AS. Economic Theory and Medical Assistance in Dying. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:5-8. [PMID: 32372250 DOI: 10.1007/s40258-020-00587-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Ma T, Chee JN, Hanna J, Al Jenabi N, Ilari F, Redelmeier DA, Elzohairy Y. Impact of medical fitness to drive policies in preventing property damage, injury, and death from motor vehicle collisions in Ontario, Canada. JOURNAL OF SAFETY RESEARCH 2020; 75:251-261. [PMID: 33334484 DOI: 10.1016/j.jsr.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/12/2019] [Accepted: 09/03/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Drivers with medical conditions and functional impairments are at increased collision risk. A challenge lies in identifying the point at which such risk becomes unacceptable to society and requires mitigating measures. This study models the road safety impact of medical fitness-to-drive policy in Ontario. METHOD Using data from 2005 to 2014, we estimated the losses to road safety incurred during the time medically-at-risk drivers were under review, as well as the savings to road safety accrued as a result of licensing decisions made after the review process. RESULTS While under review, drivers with medical conditions had an age- and sex-standardized collision rate no different from the general driver population, suggesting no road safety losses occurred (RR = 1.02; 95% CI: 0.93-1.12). Licensing decisions were estimated to have subsequently prevented 1,211 (95% CI: 780-1,730) collisions, indicating net road safety savings resulting from medical fitness to drive policies. However, more collisions occurred than were prevented for drivers with musculoskeletal disorders, sleep apnea, and diabetes. We theorize on these findings and discuss its multiple implications. CONCLUSIONS Minimizing the impact of medical conditions on collision occurrence requires robust policies that balance fairness and safety. It is dependent on efforts by academic researchers (who study fitness to drive); policymakers (who set driver medical standards); licensing authorities (who make licensing decisions under such standards); and clinicians (who counsel patients on their driving risk and liaise with licensing authorities). Practical Applications: Further efforts are needed to improve understanding of the effects of medical conditions on collision risk, especially for the identified conditions and combinations of conditions. Results reinforce the value of optimizing the processes by which information is solicited from physicians in order to better assess the functional impact of drivers' medical conditions on driving and to take suitable licensing action.
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Sinyor M, Kiss A, Williams M, Zaheer R, Pirkis J, Heisel MJ, Schaffer A, Redelmeier DA, Cheung AH, Niederkrotenthaler T. Changes in Suicide Reporting Quality and Deaths in Ontario Following Publication of National Media Guidelines. CRISIS 2020; 42:378-385. [PMID: 33241743 DOI: 10.1027/0227-5910/a000737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Media guidelines can influence suicide-related reporting quality and may impact suicide rates. Aim: Our study aimed to investigate the quality of suicide-related reporting after the release of the 2009 Canadian Psychiatric Association (CPA) guidelines and their impact on suicides. Method: A random sample of suicide-related articles (n = 988) were retrieved from 12 major Canadian print/online publications (2002-2015). Articles were coded for quality of content before and after guidelines release. Suicide mortality data were obtained from Ontario coroner records. Time series analyses were used to identify associations between guideline publication and subsequent suicides. Results: The CPA guidelines were associated with improvements in reporting quality with 10 putatively harmful elements being less frequent after their publication. These included less frequent front-page articles, monocausal (simplistic) explanations for suicide, and depictions of suicide methods. Two putatively protective factors, alternatives to suicide and messages of hope, were twice and four times as common, respectively, after the guidelines. The guidelines were not associated with a change in suicide counts. Limitations: This study could not prove exposure to suicide reporting. Conclusion: Publication of Canadian media guidelines was associated with significant, moderate-sized improvements in reporting quality but not with decreased suicides. The latter finding may reflect only modest dissemination and implementation of the guidelines.
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Zipursky JS, Redelmeier DA. Mobility and Mortality During the COVID-19 Pandemic. J Gen Intern Med 2020; 35:3100-3101. [PMID: 32779139 PMCID: PMC7417107 DOI: 10.1007/s11606-020-05943-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/21/2020] [Indexed: 10/27/2022]
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Redelmeier DA, Ross LD. Pitfalls from Psychology Science that Worsen with Practice. J Gen Intern Med 2020; 35:3050-3052. [PMID: 32378011 PMCID: PMC7573066 DOI: 10.1007/s11606-020-05864-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
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Manzoor F, Redelmeier DA. Sexism in medical care: "Nurse, can you get me another blanket?". CMAJ 2020; 192:E119-E120. [PMID: 32015082 DOI: 10.1503/cmaj.191181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
BACKGROUND Gun injury accounts for substantial acute mortality worldwide and many others survive with lingering disabilities. We investigated whether additional health losses beyond mortality can also arise for patients who survive with long-term disability. METHODS We conducted a population-based individual patient analysis of adults injured by firearms who had received emergency medical care in Ontario, Canada, from Apr. 1, 2002, to Apr. 1, 2019. Longitudinal cohort analyses were evaluated through deterministic linkages of individual electronic patient files. The primary outcome was death or subsequent application for long-term disability in the years after hospital discharge. RESULTS In total, 8313 patients were injured from firearms, of which 3020 were injured from intentional incidents and 5293 were injured from unintentional incidents. A total of 2657 (88.0%) patients with intentional gun injury and 5089 (96.1%) patients with unintentional gun injury survived initial injuries. After a mean 7.75 years of follow-up, patients surviving intentional injuries had a disability rate twice as high as patients surviving unintentional injuries (19.7% v. 10.1%, p < 0.001), equivalent to a hazard ratio of 2.01 (95% confidence interval 1.80-2.25). The higher risk of long-term disability for survivors after intentional gun injury was not explained by demographic characteristics, extended to survivors treated and released from the emergency department, and was observed regardless of whether the incident was self-inflicted or from interpersonal assault. Half of the disability cases were identified after the first year. Additional predictors of long-term disability included a lower socioeconomic status, an urban home location, arrival by ambulance transport, a history of mental illness and a diagnosis of substance use disorder. INTERPRETATION Our study shows that gun death statistics underestimate the extent of health losses from long-term disability, particularly for those with intentional injuries. Additional and sustainable follow-up medical care might improve patient outcomes.
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Sinyor M, Williams M, Zaheer R, Loureiro R, Pirkis J, Heisel MJ, Schaffer A, Cheung AH, Redelmeier DA, Niederkrotenthaler T. The Relationship Between Suicide-Related Twitter Events and Suicides in Ontario From 2015 to 2016. CRISIS 2020; 42:40-47. [PMID: 32366171 DOI: 10.1027/0227-5910/a000684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background: Many studies have demonstrated suicide contagion through mainstream journalism; however, few have explored suicide-related social media events and their potential relationship to suicide deaths. Aims: To determine whether Twitter events were associated with changes in subsequent suicides. Methods: Suicide-related Twitter events that garnered at least 100 tweets originating in Ontario, Canada (July 1, 2015 to June 30, 2016) were identified and characterized as putatively "harmful" or "innocuous" based on recommendations for responsible media reporting. The number of suicides in Ontario during the peak of each Twitter event and the subsequent 6 days ("exposure window") was compared with suicides occurring during a pre-event period of the same length ("control window"). Results: There were 17 suicide-related Twitter events during the period of study (12 putatively harmful and five putatively innocuous). The number of tweets per event ranged from 121 for "physician-assisted suicide law in Quebec" to 6,202 for the "Attawapiskat suicide crisis." No significant relationship was detected between Twitter events and actual suicides. Notably, a comprehensive examination of the details of Twitter events showed that even the putatively harmful events lacked many of the characteristics commonly associated with contagion. Limitations: This was an uncontrolled experiment in only one epoch and a single Canadian province. Discussion: This study found no evidence of suicide contagion associated with Twitter events. This finding must be interpreted with caution given the relatively innocuous content of suicide-related Tweets in Ontario during 2015-2016.
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Mazereeuw G, Gomes T, Macdonald EM, Greaves S, Li P, Mamdani MM, Redelmeier DA, Juurlink DN. Oxycodone, Hydromorphone, and the Risk of Suicide: A Retrospective Population-Based Case-Control Study. Drug Saf 2020; 43:737-743. [PMID: 32328907 DOI: 10.1007/s40264-020-00924-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Opioids have been increasingly associated with suicide, but whether they are independent contributors is unclear. Oxycodone and hydromorphone are commonly prescribed high-potency opioids that can differentially affect mood. OBJECTIVE The objective of this study was to explore whether oxycodone and hydromorphone are differentially associated with suicide. METHODS We conducted a retrospective population-based case-control study in Ontario, Canada, from 1992 to 2014. Using coronial data, we defined case subjects as individuals who died by suicide involving an opioid overdose. Each of these was matched with up to four controls who died of accidental opioid overdose. We ascertained exposure to oxycodone, hydromorphone, and other opioids from postmortem toxicology testing. We used odds ratios and 95% confidence intervals to examine whether opioid-related suicide was disproportionately associated with oxycodone relative to hydromorphone. RESULTS We identified 438 suicides and 1212 accidental deaths, each of which involved either oxycodone or hydromorphone but not both. The median age at death was 49 years and 51% were men. After adjusting for a history of self-harm, psychiatric illness, and exposure to other opioids, we found that oxycodone was more strongly associated with suicide than hydromorphone (adjusted odds ratio 1.59; 95% confidence interval 1.20-2.11). In a secondary analysis, we observed a trend of similar magnitude in which combined exposure to oxycodone and hydromorphone was more strongly associated with suicide than hydromorphone alone (adjusted odds ratio 1.68; 95% confidence interval 0.92-3.09). CONCLUSIONS While preliminary, these findings support the possibility that some high-potency opioids might independently influence the risk of suicide in susceptible individuals.
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Redelmeier DA, Shafir E. Pitfalls of judgment during the COVID-19 pandemic. LANCET PUBLIC HEALTH 2020; 5:e306-e308. [PMID: 32334647 PMCID: PMC7180015 DOI: 10.1016/s2468-2667(20)30096-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 11/24/2022]
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Hancock PA, Kajaks T, Caird JK, Chignell MH, Mizobuchi S, Burns PC, Feng J, Fernie GR, Lavallière M, Noy IY, Redelmeier DA, Vrkljan BH. Challenges to Human Drivers in Increasingly Automated Vehicles. HUMAN FACTORS 2020; 62:310-328. [PMID: 32022583 DOI: 10.1177/0018720819900402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We examine the relationships between contemporary progress in on-road vehicle automation and its coherence with an envisioned "autopia" (automobile utopia) whereby the vehicle operation task is removed from all direct human control. BACKGROUND The progressive automation of on-road vehicles toward a completely driverless state is determined by the integration of technological advances into the private automobile market; improvements in transportation infrastructure and systems efficiencies; and the vision of future driving as a crash-free enterprise. While there are many challenges to address with respect to automated vehicles concerning the remaining driver role, a considerable amount of technology is already present in vehicles and is advancing rapidly. METHODS A multidisciplinary team of experts met to discuss the most critical challenges in the changing role of the driver, and associated safety issues, during the transitional phase of vehicle automation where human drivers continue to have an important but truncated role in monitoring and supervising vehicle operations. RESULTS The group endorsed that vehicle automation is an important application of information technology, not only because of its impact on transportation efficiency, but also because road transport is a life critical system in which failures result in deaths and injuries. Five critical challenges were identified: driver independence and mobility, driver acceptance and trust, failure management, third-party testing, and political support. CONCLUSION Vehicle automation is not technical innovation alone, but is a social as much as a technological revolution consisting of both attendant costs and concomitant benefits.
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Grewal K, Sutradhar R, Krzyzanowska MK, Redelmeier DA, Atzema CL. The association of continuity of care and cancer centre affiliation with outcomes among patients with cancer who require emergency department care. CMAJ 2020; 191:E436-E445. [PMID: 31015348 DOI: 10.1503/cmaj.180962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Patients with cancer have complex care requirements and frequently use the emergency department. The purpose of this study was to determine whether continuity of care, cancer expertise of an institution or both affect outcomes in patients with cancer in the emergency setting. METHODS We conducted a retrospective cohort study using administrative databases from Ontario, Canada, involving records of patients aged 20 years and older who received chemotherapy or radiation in the 30 days before a cancer-related visit to the emergency department between 2006 and 2011. Patients seen in an emergency department at an alternative hospital (not the site where cancer treatment was given) were matched based on propensity score to patients who visited their original hospital (site where cancer treatment was given). Next, patients seen at an alternative emergency department that was in a general hospital (i.e., not a cancer centre) were matched to patients who visited their original hospital or a cancer centre. Outcomes were admission to hospital at the index visit to the emergency department, 30-day mortality, having imaging with computed tomography and return visits to the emergency department. RESULTS We found 42 820 patients who were eligible for our study. Patients seen in the emergency departments at alternative hospitals were less likely to be admitted to hospital (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.74-0.83) and had higher hazards of return visits to the emergency department than matched patients at original hospitals (hazard ratio [HR] 1.06, 95% CI 1.03-1.11). In comparison, patients at alternative general hospitals also had lower odds of admission to hospital (OR 0.83, 95% CI 0.79-0.88) and higher hazards of return visits to the emergency department (HR 1.07, 95% CI 1.03-1.11) compared with matched counterparts; however, these patients had higher 30-day mortality (OR 1.13, 95% CI 1.05-1.22) and lower odds of having CT imaging (OR 0.74, 95% CI 0.69-0.80). INTERPRETATION Cancer expertise of an institution rather than continuity of care may be an important predictor of outcomes following emergency treatment of patients with cancer.
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Redelmeier DA, Ng K. Approach to making the availability heuristic less available. BMJ Qual Saf 2020; 29:528-530. [PMID: 31959715 DOI: 10.1136/bmjqs-2020-010831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 12/20/2022]
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Ravi B, Leroux T, Austin PC, Paterson JM, Aktar S, Redelmeier DA. Factors associated with emergency department presentation after total joint arthroplasty: a population-based retrospective cohort study. CMAJ Open 2020; 8:E26-E33. [PMID: 31992556 PMCID: PMC6996031 DOI: 10.9778/cmajo.20190116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Unplanned visits to the emergency department after total joint arthroplasty are far more common than unplanned readmissions. Our objectives were to characterize the prevalence of presentation to an emergency department for any reason after total joint arthroplasty and to identify risk factors for such visits. METHODS Using health administrative databases, we conducted a population-based retrospective cohort study of adults (19-89 yr of age) who received their first primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure for arthritis between April 2011 and March 2016 in Ontario. We made univariate comparisons between patients who presented to the emergency department within 30 days of surgery and those who did not in. We determined differences in use of health care services between groups by comparing the change in use in the year before and after surgery between patients who presented to the emergency department and those who did not. We developed logistic regression models for the occurrence of an emergency department visit using backward variable elimination. RESULTS We identified 42 273 total hip recipients and 70 725 total knee recipients, of whom 5640 (13.3%) and 11 224 (15.9%), respectively, presented to the emergency department within 30 days of surgery. Fewer than 1% of these patients required admission, and nearly half (45%) went to a different institution from where they had their surgery. Among both THA and TKA recipients, patients who presented to the emergency department had a net increase in their median annual health care costs (THA: $501, TKA: $682), compared to a net decrease for the cohort as a whole. Factors associated with increased risk of an emergency visit included increased patient age, male sex, rural residence and various comorbidities. Predictive regression models showed poor discriminative ability for both THA (C-statistic 0.57) and TKA (C-statistic 0.58) recipients. INTERPRETATION One in 7 patients presented to the emergency department within 30 days of THA or TKA. Some may conceivably have been managed remotely, and very few required readmission. There is a crucial need for strategies to minimize these events.
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Redelmeier DA, Tibshirani RJ. An approach to explore for a sweet spot in randomized trials. J Clin Epidemiol 2019; 120:59-66. [PMID: 31874202 DOI: 10.1016/j.jclinepi.2019.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 11/16/2019] [Accepted: 12/12/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of the study was to demonstrate how a conventional randomized trial can be analyzed through a stratified or a matched approach to identify a potential sweet spot where observed differences might be accentuated in the mid range of disease severity. DESIGN AND SETTING We review a landmark randomized trial of heart failure patients that tested whether implantable defibrillators reduce mortality (n = 2,521). RESULTS Overall, 22% (182/829) of the patients in the defibrillator group died compared with 29% (484/1,692) of patients in the control group. Proportional hazards analysis yielded a modest 25% survival benefit (hazard ratio = 0.75, 95% confidence interval: 0.63 to 0.89). Stratified analysis of the trial yielded a larger 52% survival benefit for those in the middle quintile of disease severity (hazard ratio = 0.48, 95% confidence interval: 0.29 to 0.79). In contrast, little of the survival benefit was explained by patients with the greatest disease severity (hazard ratio = 0.89, 95% confidence interval: 0.69 to 1.15). The discrepancy between crude and stratified analyses could be visualized by graphical displays and replicated with matched comparisons. CONCLUSION Our approach for analyzing a randomized trial could help identify a potential sweet spot of an accentuated treatment effect.
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Ravi B, Jenkinson R, O'Heireamhoin S, Austin PC, Aktar S, Leroux TS, Paterson M, Redelmeier DA. Surgical duration is associated with an increased risk of periprosthetic infection following total knee arthroplasty: A population-based retrospective cohort study. EClinicalMedicine 2019; 16:74-80. [PMID: 31832622 PMCID: PMC6890965 DOI: 10.1016/j.eclinm.2019.09.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is one the most common elective procedures in the world. Post-operative infection is one of its most devastating complications, often necessitating multiple additional surgeries. We aimed to describe the relationship between surgical duration and risk of deep infection following primary elective TKA. METHODS In this cohort study we analyses primary TKAs done between 2009 and 2016 in Ontario, Canada. We utilized restricted cubic splines to identify a threshold of surgical duration that was associated with an increased risk for infection requiring surgery. Patients with a 'short' duration of surgery were matched to those with a 'long' duration on patient age (±3 years), patient sex, severe obesity (BMI > 40), the primary surgeon, the hospital and the type of anesthetic. FINDINGS In 92,343 primary TKAs, the median surgical duration was 106 min. We identified a cut-point of 100 min that was associated with an increased risk for infection. Subsequently, 17,815 TKA recipients with a 'long' procedure length were matched to those with a 'short' procedure length. 'Long' procedures had a higher rate of deep infection (1.1% versus 0.6%, p < 0.0001). This was equal to a relative risk of 1.81 (p < 0.0001). INTERPRETATION In a cohort of TKA recipients, we found that procedure lengths longer than 100 min were associated with a significantly increased risk of deep infection requiring surgery. This time threshold serves a useful time-point to identify patients that require closer surveillance.
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Sinyor M, Schaffer A, Nishikawa Y, Redelmeier DA, Niederkrotenthaler T, Sareen J, Levitt AJ, Kiss A, Pirkis J. The association between suicide deaths and putatively harmful and protective factors in media reports. CMAJ 2019; 190:E900-E907. [PMID: 30061324 DOI: 10.1503/cmaj.170698] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Exposure to media reporting on suicide can lead to suicide contagion and, in some circumstances, may also lead to help-seeking behaviour. There is limited evidence for which specific characteristics of media reports mediate these phenomena. METHODS This observational study examined associations between putatively harmful and protective elements of media reports about suicide in 13 major publications in the Toronto media market and subsequent suicide deaths in Toronto (2011-2014). We used multivariable logistic regression to determine whether specific article characteristics were associated with increases or decreases in suicide deaths in the 7 days after publication, compared with a control window. RESULTS From 2011 to 2014, there were 6367 articles with suicide as the major focus and 947 suicide deaths. Elements most strongly and independently associated with increased suicides were a statement about the inevitability of suicide (odds ratio [OR] 1.97, confidence interval [CI] 1.07-3.62), about asphyxia by a method other than car exhaust (OR 1.72, CI 1.36-2.18), about suicide by jumping from a building (OR 1.70, CI 1.28-2.26) or about suicide pacts (OR 1.63, CI 1.14-2.35), or a headline that included the suicide method (OR 1.41, CI 1.07-1.86). Elements most strongly and independently associated with decreased suicides were unfavourable characteristics (negative judgments about the deceased; OR 1.85, CI 1.20-2.84), or mentions of railway (OR 1.61, CI 1.10-2.36) and cutting or stabbing (OR 1.59, CI 1.19-2.13) deaths, and individual murder-suicide (OR 1.50, CI 1.23-1.84). INTERPRETATION This large study identified significant associations between several specific elements of media reports and suicide deaths. It suggests that reporting on suicide can have a meaningful impact on suicide deaths and that journalists and media outlets and organizations should carefully consider the specific content of reports before publication.
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Lapointe-Shaw L, Bell CM, Austin PC, Abrahamyan L, Ivers NM, Li P, Pechlivanoglou P, Redelmeier DA, Dolovich L. Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study. BMJ Qual Saf 2019; 29:41-51. [DOI: 10.1136/bmjqs-2019-009545] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/12/2019] [Accepted: 07/19/2019] [Indexed: 01/09/2023]
Abstract
BackgroundIn-hospital medication review has been linked to improved outcomes after discharge, yet there is little evidence to support the use of community pharmacy-based interventions as part of transitional care.ObjectiveTo determine whether receipt of a postdischarge community pharmacy-based medication reconciliation and adherence review is associated with a reduced risk of death or re-admission.DesignPropensity score-matched cohort study.SettingOntario, CanadaParticipantsPatients over age 66 years discharged home from an acute care hospital from 1 April 2007 to 16 September 2016.ExposureMedsCheck, a publicly funded medication reconciliation and adherence review provided by community pharmacists.Main outcomeThe primary outcome was time to death or re-admission (defined as an emergency department visit or urgent rehospitalisation) up to 30 days. Secondary outcomes were the 30-day count of outpatient physician visits and time to adverse drug event.ResultsMedsCheck recipients had a lower risk of 30-day death or re-admission (23.4% vs 23.9%, HR 0.97, 95% CI 0.95 to 1.00, p=0.02), driven by a decreased risk of death (1.7% vs 2.1%, HR 0.79, 95% CI 0.73 to 0.86) and rehospitalisation (11.0% vs 11.4%, HR 0.96, 95% 0.93–0.99). In a post hoc sensitivity analysis with pharmacy random effects added to the propensity score model, these results were substantially attenuated. There was no significant difference in 30-day return to the emergency department (22.5% vs 22.8%, HR 0.99, 95% CI 0.96 to 1.01) or adverse drug events (1.5% vs 1.5%, HR 1.03, 95% CI 0.94 to 1.12). MedsCheck recipients had more outpatient visits (mean 2.11 vs 2.09, RR 1.01, 95% CI 1.00 to 1.02, p=0.02).Conclusions and relevanceAmong older adults, receipt of a community pharmacy-based medication reconciliation and adherence review was associated with a small reduced risk of short-term death or re-admission. Due to the possibility of unmeasured confounding, experimental studies are needed to clarify the relationship between postdischarge community pharmacy-based medication review and patient outcomes.
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