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Ong SWX, Patel D, Reinblatt S, Tong SYC, Lee TC, McDonald EG, Daneman N. Choosing the right outcomes in infectious diseases clinical research-putting patients front and centre. Clin Microbiol Infect 2024; 30:10-14. [PMID: 37918512 DOI: 10.1016/j.cmi.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Sean W X Ong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Devangi Patel
- Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada
| | | | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada; Division of Infectious Diseases, McGill University Health Centre, Montréal, QC, Canada
| | - Emily G McDonald
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada; Division of General Internal Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Nick Daneman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Siegal DM, Verbrugge FH, Martin AC, Virdone S, Camm J, Pieper K, Gersh BJ, Goto S, Turpie AGG, Angchaisuksiri P, Fox KAA. Country and health expenditure are major predictors of withholding anticoagulation in atrial fibrillation patients at high risk of stroke. Open Heart 2023; 10:e002506. [PMID: 38097360 PMCID: PMC10729201 DOI: 10.1136/openhrt-2023-002506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Guidelines for patients with atrial fibrillation (AF) at high thromboembolic risk recommend oral anticoagulants (OACs) for preventing stroke and systemic embolism (SE). The reasons for guideline non-adherence are still unclear. AIM The aim is to identify clinical, demographic and non-patient characteristics associated with withholding OAC in patients with AF at high stroke risk. METHODS Patients in the Global Anticoagulant Registry in the FIELD-AF, newly diagnosed with AF between March 2010 and August 2016, and with CHA2DS2-VASc Score≥2 (excluding sex), were grouped by OAC treatment at enrolment. Factors associated with OAC non-use were analysed by multivariable logistic regression. RESULTS Of 40 416 eligible patients, 12 126 (30.0%) did not receive OACs at baseline. Globally, OAC prescription increased over time, from 60.4% in 2010-2011 to 74.7% in 2015-2016. Country of enrolment was the major predictor for OAC withholding (χ2-df=2576). Clinical predictors of OAC non-use included type of AF (χ2-df=404), history of bleeding (χ2-df=263) and vascular disease (χ2-df=99). OACs were used most frequently around the age of 75 years and decreasingly with younger as well as older age beyond 75 years (χ2-df=148). Non-cardiologists (χ2-df=201) and emergency room physicians (χ2-df=14) were less likely to prescribe OACs. OAC prescription correlated positively with country health expenditure. CONCLUSIONS Approximately one out of three AF patients did not receive OAC, while eligible according to the guidelines. Country of enrolment was the major determinant of anticoagulation strategy, while higher country health expenditure was associated with lower likelihood of withholding anticoagulation.
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Affiliation(s)
- Deborah M Siegal
- Medicine, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Anne-Celine Martin
- Cardiology, European Hospital Georges-Pompidou, Paris, Île-de-France, France
| | - Saverio Virdone
- Department of Statistics, Thrombosis Research Institute, London, UK
| | - John Camm
- Cardiology, St George's Hospital, London, UK
| | | | | | - Shinya Goto
- Medicine, Tokai University School of Medicine Graduate School of Medicine, Isehara, Japan
| | | | | | - Keith A A Fox
- Cardiology, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
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Marquis-Gravel G, Faulkner M, Merritt G, Farrehi P, Zemon N, Robertson HR, Jones WS, Kraschnewski J. Importance of patient engagement in the conduct of pragmatic multicenter randomized controlled trials: The ADAPTABLE experience. Clin Trials 2023; 20:31-35. [PMID: 35999816 DOI: 10.1177/17407745221118559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Actively engaging patient partners in the conduct of trials is crucial to ensure the studies answer genuine, patient-centered, unmet clinical needs, and to facilitate participant recruitment and retention. The aim of this article is to demonstrate the feasibility of patient engagement within a large pragmatic multicenter randomized controlled trial, specifically for the purposes of dissemination of study information/updates and to favorize recruitment and retention. METHODS In the patient-centric, pragmatic ADAPTABLE randomized trial, transparent and timely dissemination of information on the study updates to the trial participants was undertaken to create meaningful engagement and to facilitate retention. A national panel of patient partners, the Adaptors, were directly involved in this information dissemination strategy, and study participants were engaged both nationally and locally to design recruitment methods iteratively during the conduct of the trial. All Adaptors had a lived experience with cardiovascular disease. RESULTS Adaptors attended bi-weekly meetings facilitated by the director of the study's patient-powered research network. They drafted and/or edited newsletters and ad hoc educational information written in a lay-friendly manner for study participants, which were regularly distributed to the ADAPTABLE community, in addition to online forums where participants could share their experience of their involvement in ADAPTABLE. To spur recruitment, a patient-driven initiative was to draft letters sharing their story, which were distributed by the local study teams. Patient partners thought that using patients' voice to provide their perspectives on why they believed this project was important would be more engaging for prospective participants than traditional approaches. CONCLUSIONS ADAPTABLE's experience has demonstrated the feasibility of engaging patients as partners in the conduct of a large-scale, multi-center, pragmatic randomized controlled trial. Future trials should embrace and iteratively improve this model by engaging patient partners as early as study protocol development and funding applications, and quantify its impact on the effectiveness and value of the trial.
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Affiliation(s)
| | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Peter Farrehi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
| | - Jennifer Kraschnewski
- Departments of Medicine and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Psychometric Validation of the Chinese Version of the Atrial Fibrillation Knowledge Scale in Chinese Patients With Atrial Fibrillation. J Cardiovasc Nurs 2023; 38:92-100. [PMID: 34935741 DOI: 10.1097/jcn.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Assessment of patients' knowledge on atrial fibrillation (AF) and its management is important for evaluating their learning needs. However, a validated and comprehensive instrument to be used among Chinese patients is yet to be developed. OBJECTIVES The aim of this study was to develop and validate the Chinese version of the Atrial Fibrillation Knowledge Scale (AFKS-C) in Chinese patients. METHODS The 11-item AFKS was translated, and then content and face validations were conducted by an expert panel and patients with AF. A sample of 255 patients with AF was recruited from a university-affiliated hospital to evaluate its psychometric properties. The internal consistency and test-retest reliability were evaluated using the Kuder-Richardson formula 20 and κ statistics. Item analysis determined the item difficulty index and item discrimination coefficients. Factorial and discriminant validity were evaluated using exploratory factor analysis and the known-groups method. RESULTS The content validity index of the AFKS-C was 0.94, and the Kuder-Richardson formula 20 value was 0.60. The difficulty indices of the items ranged from 0.36 to 0.89, and the point-biserial coefficients of the items ranged from 0.122 to 0.255, indicating sufficient discriminatory ability. The test-retest reliability was acceptable, because the κ values ranged from 0.234 to 0.710. The principal axis factoring analysis indicated a 3-factor structure that explained 50.4% of the total variance. The AFKS-C also demonstrated satisfactory discriminant validity, having yielded significantly different scores between patients with newly diagnosed and established AF. CONCLUSION The AFKS-C has acceptable psychometric properties and can be used to measure the knowledge of patients and evaluate the effects of patient education programs.
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Telford JJ, Abraham NS. Management of Antiplatelet and Anticoagulant Agents before and after Polypectomy. Gastrointest Endosc Clin N Am 2022; 32:299-312. [PMID: 35361337 PMCID: PMC9169436 DOI: 10.1016/j.giec.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Antithrombotic medications, including antiplatelet drugs and anticoagulants, are widely prescribed to prevent thromboembolic disease. There is limited evidence informing gastroenterologists of the management of patients on antithrombotic medications undergoing colonoscopy and polypectomy. A patient's risk of thromboembolism versus postpolypectomy bleeding should be carefully considered, incorporating patient preferences concerning benefits and harms of temporary antithrombotic interruption. We will review the available consensus guidelines, current literature, and strategies to mitigate the risk of bleeding following polypectomy. These will be interpreted in the framework of shared decision-making with the patient to arrive at the safest solution best aligned with the patient's preferences.
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Affiliation(s)
- Jennifer J Telford
- Division of Gastroenterology, Department of Medicine, University of British Columbia, 770-1190 Hornby Street, Vancouver, British Columbia V6Z2K5, Canada.
| | - Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
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7
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace 2022; 24:1844-1871. [PMID: 35323922 DOI: 10.1093/europace/euac020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 12/26/2022] Open
Abstract
Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Barcelona, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, SMaria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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8
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Osasu YM, Cooper R, Mitchell C. Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:254. [PMID: 34937557 PMCID: PMC8697449 DOI: 10.1186/s12875-021-01590-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 11/22/2021] [Indexed: 11/10/2022]
Abstract
Background Atrial fibrillation (AF) increases the risk of developing a stroke by 20%. AF related strokes are associated with greater morbidity. Historically, warfarin was the anticoagulant of choice for stroke prevention in patients with AF but lately patients are being switched or started on direct oral anticoagulants (DOACs). DOACs are promoted as safer alternatives to warfarin and it is expected that they will be associated with fewer challenges both for patients and healthcare professionals. This systematic narrative review aimed to explore perspectives of patients and professionals on medicines optimisation of oral anticoagulation with vitamin K antagonists and DOACs in atrial fibrillation. Methods Prospero registration CRD42018091591. Systematic searches undertaken of research studies (qualitative and quantitative), published February 2018 to November 2020 from several databases (Web of Science, Scopus, Medline Via Ovid, CINHAL via Ebsco, and PubMED via NCBI) following PRISMA methodology. Data were organised using Covidence software. Two reviewers independently assessed the quality of the included studies and synthesized the findings (thematic analysis approach). Results Thirty-four studies were included. Studies were critically appraised using established critical appraisal tools (Qualsyst) and a risk of bias was assigned. Clinicians considered old age and the associated complexities such as co-morbidities and the increased potential for bleeding as potential barriers to optimising anticoagulation. Whereas patients’ health and medication beliefs influenced adherence. Notably, structured patient support was important in enhancing safety and effective anticoagulation. For both patients and clinicians, confidence and experience of safe anticoagulation was influenced by the presence of co-morbidities, poor knowledge and understanding of AF and the purpose of anticoagulation. Conclusion Age, complex multimorbidity and polypharmacy influence prescribing, with DOACs being perceived to be safer than warfarin. This systematic narrative review suggests that interventions are needed to support patient self-management. There are residual anxieties associated with long term anticoagulation in the context of complexities. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01590-x.
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Affiliation(s)
- Yeyenta Mina Osasu
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK.
| | | | - Caroline Mitchell
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S5 7AU, UK
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Rissling O, Kaiser L, Schulz S, Langer G, Schwingshackl L. [GRADE guidelines 20: Assessing the certainty of evidence in the importance of outcomes or values and preferences-inconsistency, imprecision, and other domains]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2021; 164:79-89. [PMID: 34253480 DOI: 10.1016/j.zefq.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidance for assessing inconsistency, imprecision, and other domains for the certainty of evidence about the relative importance of outcomes. STUDY DESIGN AND SETTING We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance, and consulted GRADE members and other stakeholders for feedback. RESULTS We describe the rationale for considering the remaining GRADE domains when rating the certainty in a body of evidence for the relative importance of outcomes. As meta-analyses are not common in this context, inconsistency and imprecision assessments are challenging. Furthermore, confusion exists about inconsistency, imprecision, and true variability in the relative importance of outcomes. To clarify this issue, we suggest that the true variability is neither equivalent to inconsistency nor imprecision. Specifically, inconsistency arises from population, intervention, comparison and outcome and methodological elements that should be explored and, if possible, explained. The width of the confidence interval and sample size inform judgments about imprecision. We also provide suggestions on how to detect publication bias and discuss the domains to rate up the certainty. CONCLUSION We provide guidance and examples for rating inconsistency, imprecision, and other domains for a body of evidence describing the relative importance of outcomes.
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Affiliation(s)
- Olesja Rissling
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland.
| | - Laura Kaiser
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Sandra Schulz
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Gero Langer
- Institut für Gesundheits- und Pflegewissenschaft German Center for Evidence-based Nursing »sapere aude«, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, Deutschland
| | - Lukas Schwingshackl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
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10
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Kaiser L, Hübscher M, Rissling O, Schulz S, Langer G, Meerpohl J, Schwingshackl L. [GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences: Risk of bias and indirectness]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2021; 160:78-88. [PMID: 33461905 DOI: 10.1016/j.zefq.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group defines patient values and preferences as the relative importance patients place on the main health outcomes. We provide GRADE guidance for assessing the risk of bias and indirectness domains for certainty of evidence about the relative importance of outcomes. STUDY DESIGN AND SETTING We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance and consulted GRADE members and other stakeholders for feedback. RESULTS This is the first of two articles. A body of evidence addressing the importance of outcomes starts at "high certainty"; concerns with risk of bias, indirectness, inconsistency, imprecision, and publication bias lead to downgrading to moderate, low, or very low certainty. We propose the following subdomains of risk of bias: selection of the study population, missing data, the type of measurement instrument, and confounding; we have developed items for each subdomain. The population, intervention, comparison, and outcome elements associated with the evidence determine the degree of indirectness. CONCLUSION This article provides guidance and examples for rating the risk of bias and indirectness for a body of evidence summarizing the importance of outcomes.
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Affiliation(s)
- Laura Kaiser
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland; Universität Witten/Herdecke, Deutschland.
| | - Markus Hübscher
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Olesja Rissling
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Sandra Schulz
- Abteilung Fachberatung Medizin, Gemeinsamer Bundesausschuss, Berlin, Deutschland
| | - Gero Langer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Jörg Meerpohl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, Freiburg, Deutschland
| | - Lukas Schwingshackl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
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Sommer I, Titscher V, Szelag M, Gartlehner G. What are the Relevant Outcomes of the Periodic Health Examination? A Comparison of Citizens' and Experts' Ratings. Patient Prefer Adherence 2021; 15:57-68. [PMID: 33500615 PMCID: PMC7823095 DOI: 10.2147/ppa.s281466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/04/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Despite evidence from clinical guideline development that physicians and patients show discordance in what they consider important in outcome selection and prioritization, it is unclear to what extent outcome preferences are concordant between experts and citizens when it comes to the context of primary prevention. Therefore, the objective of this study was to assess whether expert judgments about the importance of beneficial and harmful outcomes differ from citizen preferences when considering intervention options for a periodic health examination (PHE) program. PARTICIPANTS AND METHODS We conducted an online survey using a modified Delphi approach. The target population for the survey consisted of citizens who had attended the PHE (n=18) and experts who made evidence-based recommendations (n=11). Citizens and experts assigned a score on a 9-point Likert scale for each outcome of 14 interventions. We analyzed the intragroup agreement based on Krippendorff's alpha and the intergroup agreement using the cube root product measure (CRPm). We further tested for significant differences between the groups using the Mann U-test. RESULTS Agreements within the groups of citizens and experts varied across the interventions and tended to be poor (α ≤0 to 0.20) or fair (α = 0.21 to 0.40), with three exceptions showing moderate agreement (α = 0.44 to 0.55). The agreements between the citizens and experts across the interventions was fair (CRPm = 0.28) during the first Delphi rating round. The mean differences between the citizens and experts on the Likert scale ranged from 0.0 to 3.8 during the first rating round and from 0.0 to 3.3 during the second. Across interventions, the citizens rated the outcomes as more important than the experts did (p<0.01). Individual participants' ratings varied substantially. CONCLUSION Because experts generally underestimated the outcomes' importance to citizens, the involvement of citizens in guideline panels for preventive services is important.
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Affiliation(s)
- Isolde Sommer
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems, Austria
- Correspondence: Isolde Sommer Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, Krems3500, AustriaTel +43 (0)2732 893-2927Fax +43 (0)2732 893-4910 Email
| | - Viktoria Titscher
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | - Monika Szelag
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | - Gerald Gartlehner
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems, Austria
- RTI International, Research Triangle Park, Raleigh, NC, USA
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Using machine learning to predict anticoagulation control in atrial fibrillation: A UK Clinical Practice Research Datalink study. INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Wein T, Lindsay MP, Gladstone DJ, Poppe A, Bell A, Casaubon LK, Foley N, Coutts SB, Cox J, Douketis J, Field T, Gioia L, Habert J, Lang E, Mehta SR, Papoushek C, Semchuk W, Sharma M, Udell JA, Lawrence S, Mountain A, Gubitz G, Dowlatshahi D, Simard A, de Jong A, Smith EE. Canadian Stroke Best Practice Recommendations, seventh edition: acetylsalicylic acid for prevention of vascular events. CMAJ 2020; 192:E302-E311. [PMID: 32392513 DOI: 10.1503/cmaj.191599] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Theodore Wein
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - M Patrice Lindsay
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont.
| | - David J Gladstone
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Alexandre Poppe
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Alan Bell
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Leanne K Casaubon
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Norine Foley
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Shelagh B Coutts
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Jafna Cox
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - James Douketis
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Thalia Field
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Laura Gioia
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Jeffrey Habert
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Eddy Lang
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Shamir R Mehta
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Christine Papoushek
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - William Semchuk
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Mikul Sharma
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Jacob A Udell
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Stephanie Lawrence
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Anita Mountain
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Gord Gubitz
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Dar Dowlatshahi
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Anne Simard
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Andrea de Jong
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
| | - Eric E Smith
- Department of Neurology and Neurosurgery (Wein), McGill University, Montréal, Que.; the Heart and Stroke Foundation of Canada (Lindsay, Lawrence, Simard, de Jong); Division of Neurology (Gladstone, Casaubon), Department of Medicine, University of Toronto; Division of Neurology (Gladstone), Department of Medicine, Regional Stroke Centre; Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Gladstone); Toronto, Ont.; Centre hospitalier de l'Université de Montréal (CHUM) (Poppe, Gioia), Hôpital Notre-Dame, Montréal, Que.; Department of Family Medicine (Bell, Habert), University of Toronto; Toronto Western Hospital Stroke Program (Casaubon), University Health Network, Toronto, Ont.; workHORSE Consulting Ltd. (Foley), London, Ont.; Department of Clinical Neurosciences (Coutts, Smith), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Faculty of Medicine (Cardiology) (Cox), Dalhousie University, Halifax, NS; Department of Medicine (Douketis), McMaster University, Hamilton, Ont.; Division of Neurology (Field), Department of Medicine, University of British Columbia; Vancouver, BC; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Cardiology (Mehta), Department of Medicine, McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Papoushek), Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ont.; College of Pharmacy (Semchuk), University of Saskatchewan, Saskatoon, Sask.; Division of Neurology (Sharma), Department of Medicine, McMaster University, Hamilton, Ont.; Cardiovascular Division (Udell), Department of Medicine Women's College Hospital; Peter Munk Cardiac Centre (Udell), Toronto General Hospital, University of Toronto, Toronto, Ont.; Divisions Physical Medicine and Rehabilitation) (Mountain) and Neurology (Gubitz), Department of Medicine, Dalhousie University; Division of Neurology (Dowlatshahi), Faculty of Medicine, University of Ottawa, Ottawa, Ont
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Wein T, Lindsay MP, Gladstone DJ, Poppe A, Bell A, Casaubon LK, Foley N, Coutts SB, Cox J, Douketis J, Field T, Gioia L, Habert J, Lang E, Mehta SR, Papoushek C, Semchuk W, Sharma M, Udell JA, Lawrence S, Mountain A, Gubitz G, Dowlatshahi D, Simard A, de Jong A, Smith EE. Recommandations canadiennes pour les pratiques optimales de soins de l’AVC, septième édition : l’acide acétylsalicylique pour la prévention d’événements vasculaires. CMAJ 2020; 192:E1174-E1184. [PMID: 33020129 DOI: 10.1503/cmaj.191599-f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Theodore Wein
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - M Patrice Lindsay
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.).
| | - David J Gladstone
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Alexandre Poppe
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Alan Bell
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Leanne K Casaubon
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Norine Foley
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Shelagh B Coutts
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Jafna Cox
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - James Douketis
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Thalia Field
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Laura Gioia
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Jeffrey Habert
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Eddy Lang
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Shamir R Mehta
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Christine Papoushek
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - William Semchuk
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Mikul Sharma
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Jacob A Udell
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Stephanie Lawrence
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Anita Mountain
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Gord Gubitz
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Dar Dowlatshahi
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Anne Simard
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Andrea de Jong
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
| | - Eric E Smith
- Département de neurologie et neurochirurgie [Wein], Université McGill, Montréal (Qc); Fondation des maladies du cœur et de l'AVC du Canada [Lindsay, Lawrence, Simard, de Jong]; Division de neurologie [Gladstone, Casaubon], Département de médecine, Université de Toronto; Division de neurologie [Gladstone], Service de médecine, Centre régional de traitement des AVC; Programme de sciences neurologiques Hurvitz [Gladstone], Centre des sciences de la santé Sunnybrook; Institut de recherche Sunnybrook [Gladstone], Toronto (Ont.); Centre hospitalier de l'Université de Montréal (CHUM) [Poppe, Gioia], Hôpital Notre-Dame, Montréal (Qc); Département de médecine familiale [Bell, Habert], Université de Toronto; Programme de traitement des AVC de l'hôpital Toronto Western [Casaubon], Réseau universitaire de santé, Toronto (Ont.); workHORSE Consulting Ltd. [Foley], London (Ont.); Département de neurosciences cliniques [Coutts, Smith], École de médecine Cumming, Université de Calgary, Calgary (Alb.); Faculté de médecine (cardiologie) [Cox], Université Dalhousie, Halifax (N.-É.); Département de médecine [Douketis], Université McMaster, Hamilton (Ont.); Division de neurologie [Field], Département de médecine, Université de la Colombie-Britannique, Vancouver (C.-B.); Département de médecine d'urgence [Lang], École de médecine Cumming, Université de Calgary, Calgary Alb.); Division de cardiologie [Mehta], Département de médecine, Université McMaster, Hamilton (Ont.); Département de médecine familiale et communautaire [Papoushek], Faculté de pharmacie Leslie-Dan, Université de Toronto, Toronto (Ont.); École de pharmacie [Semchuk], Université de la Saskatchewan, Saskatoon (Sask.); Division de neurologie [Sharma], Département de médecine, Université McMaster, Hamilton (Ont.); Division cardiovasculaire [Udell], Service de médecine, Hôpital Women's College; Centre de cardiologie Peter-Munk [Udell], Hôpital général de Toronto, Université de Toronto, Toronto (Ont.); Divisions de physiatrie et réadaptation [Mountain] et de neurologie [Gubitz], Département de médecine, Université Dalhousie; Division de neurologie [Dowlatshahi], Faculté de médecine, Université d'Ottawa, Ottawa (Ont.)
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15
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Marquis-Gravel G, Moliterno DJ, Francis DP, Jüni P, Rosenberg YD, Claessen BE, Mentz RJ, Mehran R, Cutlip DE, Chauhan C, Quella S, Zannad F, Goodman SG. Improving the Design of Future PCI Trials for Stable Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 76:435-450. [PMID: 32703515 PMCID: PMC10018282 DOI: 10.1016/j.jacc.2020.05.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 01/09/2023]
Abstract
The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.
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Affiliation(s)
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Darrel P Francis
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yves D Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | | | | | - Faiez Zannad
- Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto and Canadian Heart Research Centre, Toronto, Ontario, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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16
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Sridharan K, Al Banny R, Qader AM, Husain A, Qader KM. Health-related quality of life in patients receiving oral anti-coagulants: a cross-sectional study. Expert Rev Cardiovasc Ther 2020; 18:309-314. [DOI: 10.1080/14779072.2020.1760092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Rashed Al Banny
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
| | - Ali Mohamed Qader
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Aysha Husain
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
- RCSI-Bahrain, Manama, Kingdom of Bahrain
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17
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Hauber B, Coulter J. Using the Threshold Technique to Elicit Patient Preferences: An Introduction to the Method and an Overview of Existing Empirical Applications. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:31-46. [PMID: 31541362 DOI: 10.1007/s40258-019-00521-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Patient preference information (PPI) is a topic of interest to regulators and industry. One of many known methods for eliciting PPI is the threshold technique (TT). However, empirical studies of the TT differ from each other in many ways and no effort to date has been made to summarize them or the evidence regarding the performance of the method. We sought to describe the TT and summarize the empirical applications of the method. Forty-three studies were reviewed. Most studies estimated the minimum level of benefit required to make a treatment worthwhile, and over half estimated the maximum level of risk patients would accept to achieve a treatment benefit. The evidence demonstrates that the TT can be used to elicit multiple types of thresholds and can be used to explore preference heterogeneity and preference non-linearity. Some evidence suggests that the method may be sensitive to anchoring and shift-framing effects; however, no evidence suggests that the method is more or less sensitive to these potential biases than other stated-preference methods. The TT may be a viable method for eliciting PPI to support regulatory decision-making; however, additional understanding of the performance of this method may be needed. Future research should focus on TT performance compared with other stated-preference methods, the extent to which results predict patient choice, and the ability of the TT to inform individual treatment decisions at the point of healthcare delivery.
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Affiliation(s)
- Brett Hauber
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA.
| | - Joshua Coulter
- RTI Health Solutions, 3040 East Cornwallis Road, Research Triangle Park, NC, 27709, USA
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18
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Ballesteros-Urpí A, Torralbas-Ortega J, Muro P, Pardo-Hernandez H. Measure of clinical improvement in children and adolescents with psychiatric disorders: an evaluation of multiple perspectives with HoNOSCA. Medwave 2020; 20:e7762. [PMID: 31999674 DOI: 10.5867/medwave.2020.01.7762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/14/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction Routine outcome assessment is helpful to inform decision-making, resource allocation, and health policy design. Routine outcome assessment in the hospital setting for children and adolescents with psychiatric disorders remains limited. The clinical instrument HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents), which has recently become available in Spanish and Catalan, allows outcome assessment in this population from the perspective of patients, their parents or legal guardians, and clinicians. HoNOSCA measures 13 areas of health and psychosocial functioning. Objectives The aim of this study was to assess mental health outcomes in psychiatric day hospital pediatric patients from three perspectives (patient, par-ent/legal guardian, clinician), using the Spanish and Catalan versions of HoNOSCA. Methods We recruited patients up to 18 years old with any psychiatric disorder at the day unit of the Salut Mental Parc Taulí Hospital Universitari (Sabadell, Catalonia, Spain). We obtained admission and discharge HoNOSCA scores for the patients, their parents or legal guardians, and their clinicians. Results We recruited 99 patients over the study period (January 2015 to December 2017), 11 of which were lost to follow-up. Among the remaining 88, we found significant improvement in HoNOSCA scores from admission to discharge. Agreement between the HoNOSCA scores for the three different groups of evaluators (patients, parents/legal guardians, and clinicians) was weak at admission but better at discharge. In general, evaluations from patients and their parents or legal guardians had lower HoNOSCA scores (indicating a better mental health status) at admis-sion compared to those from clinicians. At discharge, however, the scores were more homogenous across the three groups of stakeholders. Conclusions Use of HoNOSCA allows for routine evaluation of mental health outcomes in the psychiatric day hospital setting from the perspective of pa-tients, their parents or legal guardians, and clinicians.
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Affiliation(s)
- Anna Ballesteros-Urpí
- Department of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciences, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Education, Universitat de Barcelona, Barcelona, Spain. Address: . Carrer Villarroel 170, 08036, Barcelona, Spain. ORCID: 0000-0002-7712-2423
| | - Jordi Torralbas-Ortega
- Mental Health Center, Parc Taulí Hospital Universitari, Institut dInvestigació i Innovació Parc Taulí I3PT, Barcelona, Spain
| | - Pilar Muro
- Facultat d'Educació Social i Treball Social, Fundació Pere Tarrés, Universitat Ramon Llull, Barcelona, Spain
| | - Hector Pardo-Hernandez
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain. ORCID: 0000-0003-3714-0309
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19
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John H. Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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20
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Selva A, Sanabria AJ, Niño de Guzman E, Ballesteros M, Selva C, Valli C, Zhang Y, Yepes-Nuñez JJ, Solà I, Schünemann H, Alonso-Coello P. Colorectal cancer guidelines seldom include the patient perspective. J Clin Epidemiol 2019; 116:84-97. [PMID: 31470075 DOI: 10.1016/j.jclinepi.2019.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 08/09/2019] [Accepted: 08/20/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study aimed to describe how colorectal practice guidelines (PGs) incorporate the patient perspective. STUDY DESIGN AND SETTING We searched in the Guidelines International Network library, MEDLINE, National Guideline Clearinghouse, NHS Evidence database, and TRIP database. Two authors independently selected the PGs. We considered recommendations rated or worded as weak or conditional or suggesting multiple options, as potentially preference sensitive. Two authors independently evaluated if, in potentially sensitive recommendations, the patient perspective was incorporated. RESULTS We included 28 PGs that contained 588 recommendations, being 256 potentially preference sensitive. Ten PGs (36%) included patients in the development process, and 12 (43%) provided information about patients' perspectives. Nine PGs (32%) included recommendations in which the patient perspective was explicitly considered, and 13 (46.4%) that recommended a discussion with the patient. From a total of 588 recommendations, 9.7% (25/256) of potentially preference-sensitive recommendations considered the patient perspective. The inclusion of patients in the development process was associated with a more frequent incorporation of the patient perspective in potentially preference sensitive recommendations (70% vs. 0%; P < 0.001). CONCLUSIONS Guideline users should be aware that the incorporation of the patient perspective in colorectal cancer PGs is suboptimal. Guideline developers should make efforts to incorporate the patient perspective, especially in preference-sensitive recommendations.
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Affiliation(s)
- A Selva
- Department of Clinical Epidemiology and Cancer Screening, Corporació Sanitària Parc Taulí, Parc del Taulí,1, 08208 Sabadell, Spain; Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain; Research Network on Health Services in Chronic Diseases (REDISSEC), Spain.
| | - A J Sanabria
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - E Niño de Guzman
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - M Ballesteros
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - C Selva
- Department of Psychology and Educational Science, Open University of Catalonia (UOC), Rambla del Poblenou, 156, Barcelona 08018, Spain
| | - C Valli
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Y Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - J J Yepes-Nuñez
- Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; Faculty of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - I Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain; CIBER Epidemiología y Salud Pública, (CIBERESP), Spain
| | - H Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - P Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain; Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; CIBER Epidemiología y Salud Pública, (CIBERESP), Spain
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21
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Li PWC, Yu DSF, Yan BBY. A nurse-coordinated integrated care model to support decision-making and self-care in patients with atrial fibrillation: A study protocol. J Adv Nurs 2019; 75:3749-3757. [PMID: 31350778 DOI: 10.1111/jan.14164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/02/2019] [Accepted: 07/10/2019] [Indexed: 12/23/2022]
Abstract
AIM This study aims to evaluate the effects of a nurse-coordinated, empowerment-based integrated care model on self-care behaviours and psychosocial outcomes in patients with atrial fibrillation and to explore how this intervention affects patients' self-care behaviours and quality of life. DESIGN This mixed-methods study comprises a randomized controlled trial and an exploratory qualitative study. METHODS A total of 392 community-dwelling patients aged ≥65 years with a confirmed diagnosis of atrial fibrillation, a high stroke risk and no oral anticoagulants treatment will be recruited from the medical outpatient clinics of a university-affiliated hospital. The patients will be randomly allocated to intervention or control groups, which will receive treatment via the nurse-coordinated integrated care model or standard care, respectively. We hypothesize that compared with patients receiving standard care, atrial fibrillation patients exposed to the nurse-coordinated care model will be more likely to achieve compatible patient and physician decisions regarding the use of oral anticoagulants, better changes in medication adherence, anxiety, depression and health-related quality of life after the intervention. A subsample of 30 participants in the intervention group will also participate in a qualitative interview to provide their views and perceptions about the intervention. The ethical approval has obtained on 5 July 2018. This study is supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region on 29 June 2018. DISCUSSION This study will uniquely adopt an empowerment-based approach to equip patients as active agents in atrial fibrillation management through a nurse-coordinated integrated care model that comprehensively addresses their needs. IMPACT Patients with atrial fibrillation are currently receiving inadequate guideline-recommended care. This study will address this important evidence-practice gap by optimizing oral anticoagulant prescription and therapeutic effects and promotes effective patient self-care, so as to achieve worldwide reductions in atrial fibrillation-related morbidity, mortality, and healthcare burdens. CLINICAL TRIAL REGISTRATION This study has been registered at ClinicalTrials.gov (NCT03924739).
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Affiliation(s)
- Polly W C Li
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Doris S F Yu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Bryan B Y Yan
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
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22
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Zhang Y, Alonso-Coello P, Guyatt GH, Yepes-Nuñez JJ, Akl EA, Hazlewood G, Pardo-Hernandez H, Etxeandia-Ikobaltzeta I, Qaseem A, Williams JW, Tugwell P, Flottorp S, Chang Y, Zhang Y, Mustafa RA, Rojas MX, Schünemann HJ. GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences—Risk of bias and indirectness. J Clin Epidemiol 2019; 111:94-104. [DOI: 10.1016/j.jclinepi.2018.01.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/14/2017] [Accepted: 01/11/2018] [Indexed: 12/23/2022]
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23
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Zhang Y, Coello PA, Guyatt GH, Yepes-Nuñez JJ, Akl EA, Hazlewood G, Pardo-Hernandez H, Etxeandia-Ikobaltzeta I, Qaseem A, Williams JW, Tugwell P, Flottorp S, Chang Y, Zhang Y, Mustafa RA, Rojas MX, Xie F, Schünemann HJ. GRADE guidelines: 20. Assessing the certainty of evidence in the importance of outcomes or values and preferences—inconsistency, imprecision, and other domains. J Clin Epidemiol 2019; 111:83-93. [DOI: 10.1016/j.jclinepi.2018.05.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 03/23/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
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Zeballos-Palacios CL, Hargraves IG, Noseworthy PA, Branda ME, Kunneman M, Burnett B, Gionfriddo MR, McLeod CJ, Gorr H, Brito JP, Montori VM. Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice. Mayo Clin Proc 2019; 94:686-696. [PMID: 30642640 PMCID: PMC6450705 DOI: 10.1016/j.mayocp.2018.08.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/02/2018] [Accepted: 08/29/2018] [Indexed: 12/31/2022]
Abstract
Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools-sometimes called conversation aids or decision aids-are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.
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Affiliation(s)
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Peter A. Noseworthy
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | | | - Christopher J. McLeod
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Haeshik Gorr
- Department of Medicine, Hennepin Healthcare System, Minneapolis, MN, USA
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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Muñoz-Velandia O, Guyatt G, Devji T, Zhang Y, Li SA, Alexander PE, Henao D, Gomez AM, Ruiz-Morales Á. Patient Values and Preferences Regarding Continuous Subcutaneous Insulin Infusion and Artificial Pancreas in Adults with Type 1 Diabetes: A Systematic Review of Quantitative and Qualitative Data. Diabetes Technol Ther 2019; 21:183-200. [PMID: 30839227 DOI: 10.1089/dia.2018.0346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE We produced, through a systematic review of quantitative and qualitative evidence, a synthesis of the issues of importance (values and preferences) to adult patients with type 1 diabetes regarding treatment with automated insulin delivery systems. METHODS We searched MEDLINE, CINAHL, EMBASE, and PsycINFO from the inception of each database through September 2018. We included studies examining patient values and preferences for outcomes related to continuous subcutaneous insulin infusion or artificial pancreas treatment. We compiled structured summaries of the results and assessed the relative importance of each outcome. GRADE (Grading of Recommendations, Assessment Development, and Evaluation) and CERQual (Confidence in Evidence from Reviews of Qualitative research) approaches provided the structure for the evaluation of the quality of evidence and confidence in the findings. A mixed-methods result-based convergent design provided the structure for integration and presentation of results. RESULTS We reviewed 1665 unique citations; 19 studies (8 quantitative and 11 qualitative) proved eligible. Glycemic control is the key attribute that drives patients' preference. Reduction of glycemic variability and decreased incidence of hypoglycemia and chronic complications proved of intermediate importance and were ranked similarly to components of treatment burden, including the size and appearance of devices, cost, ease of use, and the embarrassment of public use. CONCLUSIONS Clinician guidance may play a crucial role in determining patient values and preferences (for instance, patients' priority in glucose control rather than avoiding diabetic complications). Our results provide guidance for clinicians in discussing preferred insulin delivery systems with patients with type 1 diabetes.
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Affiliation(s)
- Oscar Muñoz-Velandia
- 1 Department of Internal Medicine and Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
- 2 Department of Clinical Epidemiology and Biostatistics, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Gordon Guyatt
- 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Ontario, Canada
| | - Tahira Devji
- 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Ontario, Canada
| | - Yuan Zhang
- 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Ontario, Canada
| | - Shelly-Anne Li
- 4 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
| | - Paul Elías Alexander
- 3 Department of Health Research Methods, Evidence, and Impact, McMaster University, Ontario, Canada
| | - Diana Henao
- 5 Endocrinology Unit, Department of Internal Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ana-María Gomez
- 5 Endocrinology Unit, Department of Internal Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Álvaro Ruiz-Morales
- 1 Department of Internal Medicine and Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
- 2 Department of Clinical Epidemiology and Biostatistics, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
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Collister D, Healey JS, Conen D, Brimble KS, Rigatto C, Harel Z, Sood MM, Walsh M. Canadian Nephrologist Views Regarding Stroke and Systemic Embolism Prevention in Dialysis Patients With Nonvalvular Atrial Fibrillation: A Survey. Can J Kidney Health Dis 2019; 6:2054358118821945. [PMID: 30671252 PMCID: PMC6327328 DOI: 10.1177/2054358118821945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/05/2018] [Indexed: 12/24/2022] Open
Abstract
Background: Nonvalvular atrial fibrillation (NVAF) is an independent risk factor for ischemic stroke and is common in chronic kidney disease (CKD) and dialysis patients. The use of oral anticoagulation to prevent stroke and systemic embolism in the setting of kidney disease is controversial. Novel alternatives to vitamin K antagonists include left atrial appendage occlusion devices (LAAOD) and apixaban. Objective: We sought to elicit Canadian nephrologist views regarding stroke and systemic embolism prevention therapies in CKD and dialysis patients with NVAF. Design: Survey. Setting: Online via https://www.surveymonkey.com. Participants: Canadian Society of Nephrology members actively treating adult dialysis patients with NVAF. Measurements: Management questions were asked with response options consisting of a Likert scale ranging from 1 to 8 (with 1 being definitely would not and 8 being definitely would). Methods: We randomly allocated each respondent to 2 of 4 cases that varied by stroke and bleeding risks (using varying CHADS2 and HASBLED scores, respectively). Results: There were 91 responses (36.3% response rate) from mostly university (83.5%) and also community with university affiliation (12.1%) and community (4.4%) nephrologists. Warfarin was more likely to be recommended in individuals at high stroke risk and low bleeding risk (mean = 5.47, 95% confidence interval = 4.87-6.07) and less likely to be recommended in individuals at moderate stroke risk and high bleeding risk (mean = 2.89, 95% confidence interval = 2.37-3.41). The likelihood of recommending LAAOD did not vary by stroke or bleeding risks (means ranging from 3.92-4.90). Apixaban was not likely to be recommended in any case (means ranging from 2.60-3.50). However, nephrologists felt there was equipoise regarding anticoagulation strategies allowing participation in appropriate randomized controlled trials (RCTs). Limitations: The survey only involved nephrologists and only 4 cases with dichotomized risk categories were presented instead of complete range of stroke and bleeding risk combinations. As with any survey, there was the potential for responder bias and treatment decisions are not anchored directly to patient management. Conclusions: Nephrologists caring for patients with kidney disease appear willing to include patients in clinical trials examining alternatives to warfarin for stroke and systemic embolism prevention for NVAF in the setting of kidney disease.
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Affiliation(s)
- David Collister
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,St. Joseph's Healthcare Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - K Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Claudio Rigatto
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Ziv Harel
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Michael Walsh
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial. J Gen Intern Med 2018; 33:2070-2077. [PMID: 30076573 PMCID: PMC6258628 DOI: 10.1007/s11606-018-4612-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/20/2018] [Accepted: 07/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants. OBJECTIVE To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants. DESIGN Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network. PARTICIPANTS Primary care physicians (n = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants. INTERVENTION Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm. MAIN MEASURES The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n = 972) vs. usual care (n = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification. KEY RESULTS Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8-5.3%) and usual care (3.2%, 95% CI 2.4-4.2%) arms (p = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert. CONCLUSIONS Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02950285.
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Doorey AJ, Weintraub WS, Schwartz JS. Should Procedures or Patients Be Safe? Bias in Recommendations for Periprocedural Discontinuation of Anticoagulation. Mayo Clin Proc 2018; 93:1173-1176. [PMID: 30100193 DOI: 10.1016/j.mayocp.2018.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 04/10/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - J Sanford Schwartz
- Perelman School of Medicine at the University of Pennsylvania and Wharton School of Business, Philadelphia, PA
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29
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Kuijpers T, Spencer FA, Siemieniuk RAC, Vandvik PO, Otto CM, Lytvyn L, Mir H, Jin AY, Manja V, Karthikeyan G, Hoendermis E, Martin J, Carballo S, O'Donnell M, Vartdal T, Baxter C, Patrick-Lake B, Scott J, Agoritsas T, Guyatt G. Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline. BMJ 2018; 362:k2515. [PMID: 30045912 PMCID: PMC6058599 DOI: 10.1136/bmj.k2515] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ton Kuijpers
- Department of guideline development and research, Dutch College of General Practitioners, Utrecht, The Netherlands
| | | | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Per O Vandvik
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway
| | | | | | | | - Albert Y Jin
- Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Veena Manja
- University of California Davis, Sacramento, CA, USA
| | | | - Elke Hoendermis
- University Medical Center of Groningen, Groningen, The Netherlands
| | - Janet Martin
- Departments of Anesthesia & Perioperative Medicine, and Epidemiology & Biostatistics, Western University, London, Canada
| | - Sebastian Carballo
- Division General Internal Medicine, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | | | | | | | | | | | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Gordon Guyatt
- McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
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Lane DA, Meyerhoff J, Rohner U, Lip GYH. Patients' Perceptions of Atrial Fibrillation, Stroke Risk, and Oral Anticoagulation Treatment: An International Survey. TH OPEN 2018; 2:e233-e241. [PMID: 31249947 PMCID: PMC6524879 DOI: 10.1055/s-0038-1666803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022] Open
Abstract
Background Global differences exist in the management of atrial fibrillation (AF), and cultural differences may influence patients' expectations and perceptions of healthcare. This survey investigated whether country-specific differences in patients' perceptions of AF and oral anticoagulation (OAC) exist and if recent stroke influences these perceptions. Methods Cross-sectional survey of 937 adults with nonvalvular AF receiving OAC for stroke prevention was conducted across United States, Canada, Germany, France, and Japan. Thirty-minute online interviews conducted between April and November 2015 included AF patients with recent stroke, and newly diagnosed AF and established AF, both without recent stroke. Results U.S. patients and those with recent stroke perceived AF as more serious (54.0 and 55.2%, respectively) and were more concerned about stroke (50.0 and 68.0%, respectively). Japanese patients were more likely to perceive AF as not serious (41.0%), but 50.4% were frequently concerned about stroke. Patients in the United States, Canada, and Germany and those without recent stroke preferred to be involved in OAC treatment decisions (either shared decision making or patient's choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose. For all country groups, stroke prevention was the most important factor when choosing OAC. Conclusion In this international cohort of AF patients, country-specific differences exist in patients' perceptions of AF, concerns about stroke, and preference for involvement in OAC treatment decisions; recent experience of stroke significantly influenced patients' values and preferences regarding AF and treatment. Stroke prevention was rated as the most important factor when choosing OAC treatment.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Juliane Meyerhoff
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Ute Rohner
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Mühlbacher AC, Sadler A, Dippel FW, Juhnke C. Treatment Preferences in Germany Differ Among Apheresis Patients with Severe Hypercholesterolemia. PHARMACOECONOMICS 2018; 36:477-493. [PMID: 29388056 DOI: 10.1007/s40273-018-0614-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Severe hypercholesterolemia is a major risk factor of death in patients with coronary heart disease. New adjunctive drug therapies (proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) have gained approval in Europe and the USA. OBJECTIVE In this empirical study, we documented preferences regarding adjuvant drug therapy in apheresis-treated patients with severe familial hypercholesterolemia. METHODS We conducted a systematic literature search to identify patient-relevant outcomes in patients with severe hypercholesterolemia currently undergoing apheresis. Data were used to generate a semi-structured qualitative interview that enabled seven patient-relevant characteristics with three levels each to be identified. For the discrete choice experiment, an experimental design (7 × 3) was generated using NGene Software that consisted of 96 choices divided into eight blocks. The survey was conducted between November 2015 and April 2016 using computer-assisted personal interviews. RESULTS The survey was completed by 348 patients (64.9% male). The random parameter logit estimation showed predominance for the attribute 'reduction of LDL-C (low-density lipoprotein cholesterol) level'. 'Risk of myopathy' and 'frequency of apheresis' dominated next. Within the random parameter logit estimation, all coefficients were significant (P ≤ 0.01). The latent class analysis identified three patient groups. The first group (126 patients) found 'reduction of LDL-C level in blood' to be most important. This group focused solely on this treatment outcome independently of apheresis frequency or additional injections. The second group (106 patients) focused on three attributes: 'frequency of apheresis', 'risk of myopathy', and 'reduction of LDL-C level in blood'. Respondents clearly considered a high frequency of apheresis to have a negative impact. The third group (116 patients) demonstrated the highest preference for apheresis. These patients have adjusted to apheresis for > 10 years. CONCLUSION Regarding patient preference, clinical efficacy seems to dominate. Hence, 'reduction of LDC-C in blood' was ranked highest above patient-relevant modes of administration and adverse effects. In the patient groups identified, reduction of apheresis was important for only a subsegment (30%) of patients. Another 30% wanted effective LDL-C reduction by whatever means necessary. Most strikingly, another 30% preferred higher frequencies of apheresis.
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Affiliation(s)
- Axel C Mühlbacher
- Professur Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Brodaer Straße 2, 17033, Neubrandenburg, Germany.
- Gesellschaft für empirische Beratung GmbH (GEB), Denzlingen, Germany.
| | - Andrew Sadler
- Professur Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Brodaer Straße 2, 17033, Neubrandenburg, Germany
- Gesellschaft für empirische Beratung GmbH (GEB), Denzlingen, Germany
| | | | - Christin Juhnke
- Professur Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Brodaer Straße 2, 17033, Neubrandenburg, Germany
- Gesellschaft für empirische Beratung GmbH (GEB), Denzlingen, Germany
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Zweiker D, Zweiker R, Winkler E, Roesch K, Schumacher M, Stepan V, Krippl P, Bauer N, Heine M, Reicht G, Zweiker G, Sprenger M, Watzinger N. Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study. BMJ Open 2017; 7:e018242. [PMID: 28951417 PMCID: PMC5623506 DOI: 10.1136/bmjopen-2017-018242] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Oral anticoagulation (OAC) is state-of-the-art therapy for atrial fibrillation (AF), the most common arrhythmia worldwide. However, little is known about the perception of patients with AF and how it correlates with risk scores used by their physicians. Therefore, we correlated patients' estimates of their own stroke and bleeding risk with the objectively predicted individual risk using CHA2DS2-VASc and HAS-BLED scores. DESIGN Cross-sectional prevalence study using convenience sampling and telephone follow-up. SETTINGS Eight hospital departments and one general practitioner in Austria. Patients' perception of stroke and bleeding risk was opposed to commonly used risk scoring. PARTICIPANTS Patients with newly diagnosed AF and indication for anticoagulation. MAIN OUTCOME MEASURES Comparison of subjective risk perception with CHA2DS2-VASc and HAS-BLED scores showing possible discrepancies between subjective and objective risk estimation. Patients' judgement of their own knowledge on AF and education were also correlated with accuracy of subjective risk appraisal. RESULTS Ninety-one patients (age 73±11 years, 45% female) were included in this study. Subjective stroke and bleeding risk estimation did not correlate with risk scores (ρ=0.08 and ρ=0.17). The majority of patients (57%) underestimated the individual stroke risk. Patients feared stroke more than bleeding (67% vs 10%). There was no relationship between accurate perception of stroke and bleeding risks and education level. However, we found a correlation between the patients' judgement of their own knowledge of AF and correct assessment of individual stroke risk (ρ=0.24, p=0.02). During follow-up, patients experienced the following events: death (n=5), stroke (n=2), bleeding (n=1). OAC discontinuation rate despite indication was 3%. CONCLUSIONS In this cross-sectional analysis of OAC-naive patients with AF, we found major differences between patients' perceptions and physicians' assessments of risks and benefits of OAC. To ensure shared decision-making and informed consent, more attention should be given to evidence-based and useful communication strategies. TRIAL REGISTRATION NUMBER NCT03061123.
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Affiliation(s)
- David Zweiker
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Robert Zweiker
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Elisabeth Winkler
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Konstantina Roesch
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Martin Schumacher
- Department of Internal Medicine, Hospital Barmherzige Brueder Marschallgasse, Graz, Steiermark, Austria
| | - Vinzenz Stepan
- Department of Internal Medicine, Hospital Elisabethinen, Graz, Austria
| | - Peter Krippl
- Department of Internal Medicine, LKH Fürstenfeld, Krankenhausverbund Feldbach, Fürstenfeld, Austria
| | - Norbert Bauer
- Department of Internal Medicine, LKH Hartberg, Steiermark, Austria
| | - Martin Heine
- Department of Neurology, LKH Feldbach, Krankenhausverbund Feldbach-Fürstenfeld, Feldbach, Steiermark, Austria
| | - Gerhard Reicht
- Department of Internal Medicine, Krankenhaus Barmherzige Bruder Graz-Eggenberg, Graz, Steiermark, Austria
| | - Gudrun Zweiker
- General Practitioner Dr. Gudrun Zweiker, Straden, Austria
| | - Martin Sprenger
- Department of Social Medicine and Epidemiology, Medical University of Graz, Steiermark, Austria
| | - Norbert Watzinger
- Department of Internal Medicine, Landeskrankenhaus Feldbach, Feldbach, Steiermark, Austria
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Glasziou P, Straus S, Brownlee S, Trevena L, Dans L, Guyatt G, Elshaug AG, Janett R, Saini V. Evidence for underuse of effective medical services around the world. Lancet 2017; 390:169-177. [PMID: 28077232 DOI: 10.1016/s0140-6736(16)30946-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
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Affiliation(s)
- Paul Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, Australia.
| | - Sharon Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Lyndal Trevena
- Discipline of General Practice, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Leonila Dans
- University of the Philippines Manila, Manila, Philippines
| | - Gordon Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Ontario, ON, Canada
| | - Adam G Elshaug
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Robert Janett
- Harvard Clinical and Translational Science Center, Boston, MA, USA
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Goodman SM, Miller AS, Turgunbaev M, Guyatt G, Yates A, Springer B, Singh JA. Clinical Practice Guidelines: Incorporating Input From a Patient Panel. Arthritis Care Res (Hoboken) 2017. [PMID: 28620968 DOI: 10.1002/acr.23275] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To describe the integral role of a Patient Panel in the development of the 2017 American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) clinical practice guideline. METHODS We convened a Panel of 11 patients with rheumatoid arthritis and juvenile idiopathic arthritis, all of whom had undergone 1 or more arthroplasties, to review the evidence and provide guidance on recommendations for the 2017 ACR/AAHKS guideline to address the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. The guideline used the Grading of Recommendations Assessment, Development, and Evaluation methodology that acknowledges the critical role of patient values and preferences when the quality of the evidence base is low or when there are important trade-offs between benefits and harms. The Patient Panel considered the relative importance of complications including perioperative infection versus rheumatic disease flare and voted on the recommendations. Before the Voting Panel's own discussion of the recommendations, they reviewed a summary of the Patient Panel's discussion, including their perioperative experience, the relative importance they placed on infections versus flares in the perioperative period, and their votes on the recommendations. RESULTS The Patient Panel placed higher importance on avoiding an infection than a disease flare despite the far greater frequency of flares than infections. The decisions of the Voting Panel were concordant with those of the Patient Panel. For the 7 recommendations that both Panels voted on, the Panels agreed on the direction as well as the strength of recommendation (which was conditional for all recommendations). CONCLUSION The Voting Panel considered the importance that the patients placed on risk of infection. The Patient Panel's values informed the direction and strength of the recommendations in the final 2017 ACR/AAHKS guideline.
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Affiliation(s)
- Susan M Goodman
- Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | - Amy S Miller
- American College of Rheumatology, Atlanta, Georgia
| | | | | | - Adolph Yates
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bryan Springer
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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Selva A, Sanabria AJ, Pequeño S, Zhang Y, Solà I, Pardo-Hernandez H, Selva C, Schünemann H, Alonso-Coello P. Incorporating patients' views in guideline development: a systematic review of guidance documents. J Clin Epidemiol 2017; 88:102-112. [PMID: 28579379 DOI: 10.1016/j.jclinepi.2017.05.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 04/18/2017] [Accepted: 05/25/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess how guidance documents for developing clinical guidelines (CGs) address the incorporation of patients' views in CGs. STUDY DESIGN AND SETTING Systematic review to identify the methodology provided in guidance documents for incorporating (1) patients or representatives and (2) patients' views in the CG development process. The search was performed in 2017 in five databases. Two authors selected the studies, and data extraction was double-checked. RESULTS We included guidance documents from 56 institutions. Of those, 40 (71.4%) recommended the inclusion of patients or their representatives, mainly for developing recommendations (14/40, 35.0%); reviewing the final version (13/40, 32.5%); formulating clinical questions (13/40, 32.5%); defining the scope and objectives (10/40, 25.0%); and dissemination and implementation (10/40, 25.0%). Concrete methods on how to incorporate patients were provided by 47.5% (19/40) of institutions. Forty (71.4%) institutions provided additional strategies to incorporate patients' views. The majority (30/40, 75.0%) suggested sources for obtaining these views (consultation with patients [24/40, 60.0%], using panels' judgment [10/40, 25.0%], conducting de novo research [10/40, 25.0%], or a systematic review [9/40, 22.5%]). CONCLUSION Although most institutions suggest incorporating patients and their views when developing CGs, little detail is provided on how to do this. Institutions should provide more guidance as this could have a positive impact in guideline applicability.
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Affiliation(s)
- Anna Selva
- Clinical Epidemiology and Cancer Screening Department, Corporació Sanitària Parc Taulí, Parc del Taulí 1, 08208, Sabadell, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Research Network on Health Services in Chronic Diseases (REDISSEC), Spain.
| | - Andrea Juliana Sanabria
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Sandra Pequeño
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Yuan Zhang
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública, (CIBERESP), Spain
| | - Héctor Pardo-Hernandez
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública, (CIBERESP), Spain
| | - Clara Selva
- PETRO Research Group, Spain; Department of Social Psychology, Autonomous University of Barcelona, Barcelona, Spain
| | - Holger Schünemann
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada; CIBER Epidemiología y Salud Pública, (CIBERESP), Spain
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Prevalence, predictors, and prognostic implications of residual impairment of functional capacity after transcatheter aortic valve implantation. Clin Res Cardiol 2017; 106:752-759. [PMID: 28444455 PMCID: PMC5565654 DOI: 10.1007/s00392-017-1119-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/20/2017] [Indexed: 12/21/2022]
Abstract
Background Patients with degenerative aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI) typically have advanced cardiac and vascular adverse remodeling and multiple comorbidities and, therefore, might not recover a normal functional capacity after valve replacement. We sought to investigate the prevalence, the predictors, and the prognostic impact of residual impairment of functional capacity after TAVI. Methods and results Out of 790 patients undergoing TAVI with impaired functional capacity (NYHA II–IV) at baseline, NYHA functional class improved in 592 (86.5%) and remained unchanged/worsened in 92 (13.5%) at follow-up [median (IQR): 419 (208–807) days] after TAVI. Normal functional capacity (NYHA I) was recovered in 65.5% (n = 448) of patients, while the rest had variable degrees of residual impairment. On multivariable regression analysis, atrial fibrillation [odds ratio-OR, 2.08 (1.21–3.58), p = 0.008], low-flow–low-gradient AS [OR, 1.97 (1.09–3.57), p = 0.026], chronic obstructive pulmonary disease [OR, 1.92 (1.19–3.12), p = 0.008], and lower hemoglobin at baseline [OR, 1.11 (1.01–1.21) for each g% decrement, p = 0.036] were independently associated with residual impairment of functional capacity. All-cause and cardiac mortality were significantly higher in those with residual impairment of functional capacity than in those in NYHA I class [hazard ratio-HR: 2.37 (95% CI: 1.51–3.72), p < 0.001 and 2.16 (95% CI: 1.08–4.35), p = 0.030, respectively]. Even mild residual functional impairment (NYHA II) was associated with a higher all-cause [HR: 2.02 (95% CI: 1.10–3.72), p = 0.023] and cardiac [HR: 2.08 (95% CI: 1.42–3.07), p < 0.001] mortality. Conclusion Residual impairment of functional capacity is common after TAVI and is independently associated with increased mortality. Predictors of residual impairment of functional status are predominantly patient-rather than procedure-related. Electronic supplementary material The online version of this article (doi:10.1007/s00392-017-1119-9) contains supplementary material, which is available to authorized users.
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Wilke T, Bauer S, Mueller S, Kohlmann T, Bauersachs R. Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review. THE PATIENT 2017; 10:17-37. [PMID: 27461276 PMCID: PMC5250672 DOI: 10.1007/s40271-016-0185-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Since the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs), an additional treatment option, apart from VKAs, has become available for stroke prevention in patients with atrial fibrillation (AF). For various reasons, it is important to consider patients' preferences regarding type of medication, particularly in view of the established relationship between preferences towards treatment, associated burden of treatment, and treatment adherence. This review aimed to systematically analyse the scientific literature assessing the preferences of AF patients with regard to long-term oral anticoagulant (OAC) treatment. METHODS We searched the MEDLINE, Scopus and EMBASE databases (from 1980 to 2015), added records from reference lists of publications found, and conducted a systematic review based on all identified publications. Outcomes of interest included any quantitative information regarding the opinions or preferences of AF patients towards OAC treatment, ideally specified according to different clinical or convenience attributes describing different OAC treatment options. RESULTS Overall, 27 publications describing the results of studies conducted in 12 different countries were included in our review. Among these, 16 studies analysed patient preferences towards OACs in general. These studies predominantly assessed which benefits (mainly lower stroke risk) AF patients would require to tolerate harms (mainly higher bleeding risk) associated with an OAC. Most studies showed that patients were willing to accept higher bleeding risks if a certain threshold in stroke risk reduction could be reached. Nevertheless, most of the publications also showed that the preferences of AF patients towards OACs may differ from the perspective of clinical guidelines or the perspective of physicians. The remaining 11 studies included in our review assessed the preferences of AF patients towards specific OAC medication options, namely NOACs versus VKAs. Our review showed that AF patients prefer easy-to-administer treatments, such as treatments that are applied once daily without any food/drug interactions and without the need for bridging and frequent blood controls. CONCLUSION Stroke risk reduction and a moderate increase in the risk of bleeding are the most important attributes for an AF patient when deciding whether they are for or against OAC treatment. If different anticoagulation options have similar clinical characteristics, convenience attributes matter to patients. In this review, AF patients favour attribute levels that describe NOAC treatment.
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Affiliation(s)
- Thomas Wilke
- IPAM-Institut für Pharmakoökonomie und Arzneimittellogistik, Alter Holzhafen 19, 23966, Wismar, Germany.
| | - Sabine Bauer
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Sabrina Mueller
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Thomas Kohlmann
- Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Straße 48, 17475, Greifswald, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Grafenstr. 9, 64283, Darmstadt, Germany
- Centre for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
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Lytvyn L, Guyatt GH, Manja V, Siemieniuk RA, Zhang Y, Agoritsas T, Vandvik PO. Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review. BMJ Open 2016; 6:e014327. [PMID: 27687903 PMCID: PMC5051506 DOI: 10.1136/bmjopen-2016-014327] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To investigate patients' values and preferences regarding aortic valve replacement therapy for aortic stenosis. SETTING Studies published after transcatheter aortic valve insertion (TAVI) became available (2002). PARTICIPANTS Adults with aortic stenosis who are considering or have had valve replacement, either TAVI or via surgery (surgical aortic valve replacement, SAVR). OUTCOME MEASURES We sought quantitative measurements, or qualitative descriptions, of values and preferences. When reported, we examined correlations between preferences and objective (eg, ejection fraction) or subjective (eg, health-related quality of life) measures of health. RESULTS We reviewed 1348 unique citations, of which 2 studies proved eligible. One study of patients with severe aortic stenosis used a standard gamble study to ascertain that the median hypothetical mortality risk patients were willing to tolerate to achieve full health was 25% (IQR 25-50%). However, there was considerable variability; for mortality risk levels defined by current guidelines, 130 participants (30%) were willing to accept low-to-intermediate risk (≤8%), 224 (51%) high risk (>8-50%) and 85 (19%) a risk that guidelines would consider prohibitive (>50%). Study authors did not, however, assess participants' understanding of the exercise, resulting in a potential risk of bias. A second qualitative study of 15 patients identified the following factors that influence patients to undergo assessment for TAVI: symptom burden; expectations; information support; logistical barriers; facilitators; obligations and responsibilities. The study was limited by serious risk of bias due to authors' conflict of interest (5/9 authors industry-funded). CONCLUSIONS Current evidence on patient values and preferences of adults with aortic stenosis is very limited, and no studies have enrolled patients deciding between TAVI and SAVR. On the basis of the data available, there is evidence of variability in individual values and preferences, highlighting the importance of well-informed and shared decision-making with patients facing this decision. TRIAL REGISTRATION NUMBER PROSPERO CRD42016041907.
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Affiliation(s)
- Lyubov Lytvyn
- Systematic Overviews through Advancing Research Technology, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Veena Manja
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, State University of New York at Buffalo, Buffalo, New York, USA
- VA Western New York Healthcare System at Buffalo, Buffalo, New York, USA
| | - Reed A Siemieniuk
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuan Zhang
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine, and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Per O Vandvik
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-Division, Gjøvik, Norway
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Wilke T, Bauer S, Mueller S, Kohlmann T, Bauersachs R. Patient Preferences for Oral Anticoagulation Therapy in Atrial Fibrillation: A Systematic Literature Review. THE PATIENT 2016. [PMID: 27461276 DOI: 10.1007/s40271‐016‐0185‐9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
OBJECTIVES Since the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs), an additional treatment option, apart from VKAs, has become available for stroke prevention in patients with atrial fibrillation (AF). For various reasons, it is important to consider patients' preferences regarding type of medication, particularly in view of the established relationship between preferences towards treatment, associated burden of treatment, and treatment adherence. This review aimed to systematically analyse the scientific literature assessing the preferences of AF patients with regard to long-term oral anticoagulant (OAC) treatment. METHODS We searched the MEDLINE, Scopus and EMBASE databases (from 1980 to 2015), added records from reference lists of publications found, and conducted a systematic review based on all identified publications. Outcomes of interest included any quantitative information regarding the opinions or preferences of AF patients towards OAC treatment, ideally specified according to different clinical or convenience attributes describing different OAC treatment options. RESULTS Overall, 27 publications describing the results of studies conducted in 12 different countries were included in our review. Among these, 16 studies analysed patient preferences towards OACs in general. These studies predominantly assessed which benefits (mainly lower stroke risk) AF patients would require to tolerate harms (mainly higher bleeding risk) associated with an OAC. Most studies showed that patients were willing to accept higher bleeding risks if a certain threshold in stroke risk reduction could be reached. Nevertheless, most of the publications also showed that the preferences of AF patients towards OACs may differ from the perspective of clinical guidelines or the perspective of physicians. The remaining 11 studies included in our review assessed the preferences of AF patients towards specific OAC medication options, namely NOACs versus VKAs. Our review showed that AF patients prefer easy-to-administer treatments, such as treatments that are applied once daily without any food/drug interactions and without the need for bridging and frequent blood controls. CONCLUSION Stroke risk reduction and a moderate increase in the risk of bleeding are the most important attributes for an AF patient when deciding whether they are for or against OAC treatment. If different anticoagulation options have similar clinical characteristics, convenience attributes matter to patients. In this review, AF patients favour attribute levels that describe NOAC treatment.
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Affiliation(s)
- Thomas Wilke
- IPAM-Institut für Pharmakoökonomie und Arzneimittellogistik, Alter Holzhafen 19, 23966, Wismar, Germany.
| | - Sabine Bauer
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Sabrina Mueller
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Thomas Kohlmann
- Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Straße 48, 17475, Greifswald, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Grafenstr. 9, 64283, Darmstadt, Germany.,Centre for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
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Ferguson C, Inglis SC, Newton PJ, Middleton S, Macdonald PS, Davidson PM. Multi-morbidity, frailty and self-care: important considerations in treatment with anticoagulation drugs. Outcomes of the AFASTER study. Eur J Cardiovasc Nurs 2016; 16:113-124. [DOI: 10.1177/1474515116642604] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Caleb Ferguson
- Graduate School of Health, University of Technology Sydney, Australia
| | - Sally C Inglis
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Australia
| | - Phillip J Newton
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Australia
| | - Sandy Middleton
- St Vincent’s Health Australia (Sydney), Australia
- Australian Catholic University, Australia
| | - Peter S Macdonald
- St Vincent’s Hospital, Sydney, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia
| | - Patricia M Davidson
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Australia
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA
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Conundrums for Atrial Fibrillation Management in Older Adults. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mott DJ, Najafzadeh M. Whose preferences should be elicited for use in health-care decision-making? A case study using anticoagulant therapy. Expert Rev Pharmacoecon Outcomes Res 2015; 16:33-9. [PMID: 26560704 DOI: 10.1586/14737167.2016.1115722] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The question of whose preferences to elicit in health-state valuation has been widely discussed in the literature. The importance of this debate lies in the fact that health-state utility values are used in health technology assessment (HTA); therefore, an individual's preferences can influence decision-making. If preferences differ across groups, making decisions based on one group's preferences may be suboptimal for the other. Preferences for benefits, risks, experiences and health states associated with anticoagulant therapies have been elicited by researchers due to the underutilization of warfarin and the introduction of non-vitamin K antagonist oral anticoagulants. The majority of existing studies elicit preferences from patient populations as opposed to other stakeholders such as the general public. This paper extends the preference debate by using this clinical area as a case study, with a particular focus on HTA guidelines and the recent advocacy of the use of preference information in benefit-risk assessments.
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Affiliation(s)
- David John Mott
- a Health Economics Group, Institute of Health & Society , Newcastle University , Newcastle upon Tyne , UK
| | - Mehdi Najafzadeh
- b Division of Pharmacoepidemiology and Pharmacoeconomics , Brigham & Women's Hospital, Harvard Medical School , Boston , MA , USA
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Carles M, Brosa M, Souto JC, Garcia-Alamino JM, Guyatt G, Alonso-Coello P. Cost-effectiveness analysis of dabigatran and anticoagulation monitoring strategies of vitamin K antagonist. BMC Health Serv Res 2015; 15:289. [PMID: 26215871 PMCID: PMC4515878 DOI: 10.1186/s12913-015-0934-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 06/29/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Vitamin K antagonists are commonly used for the prevention of thromboembolic events. Patient self-monitoring of vitamin K antagonists has proved superior to usual care. Dabigatran has been shown, relative to warfarin, to reduce thromboembolic events without increasing bleeding. METHODS We constructed a Markov model to compare vitamin K self-monitoring strategies to dabigatran including effectiveness and costs of monitoring and complications (thromboembolism and major bleeding). The model was used to project the incidence of these complications, life years, quality-adjusted life years, and health system costs with anticoagulant treatment throughout life. The analysis was conducted from the health system perspective and from the societal perspective. RESULTS Low quality evidence suggests that self-monitoring is at least as effective as dabigatran for the outcomes of thrombosis, bleeding and death. Moderate quality evidence that patient self-monitoring is more effective than other forms of monitoring degree of anticoagulation with vitamin K antagonists, reducing the relative risk of thromboembolism by 41% and death by 34%. The cost per quality adjusted year gained relative to other warfarin monitoring strategies is well below 30,000 € in the short term, and is a dominant alternative from the fourth year. In comparison with dabigatran, the lower annual cost and its equivalence in terms of effectiveness made self-monitoring the dominant option. These results were confirmed in the probabilistic sensitivity analysis. CONCLUSIONS We have moderate quality evidence that self-monitoring of vitamin K antagonists is a cost-effective alternative compared with hospital and primary care monitoring, and low quality evidence, compared with dabigatran. Our analyses contrast with the available cost analysis of dabigatran and usual care of anticoagulated patients.
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Affiliation(s)
- Misericòrdia Carles
- Departament d'Economia and CREIP, Universitat Rovira i Virgili, Avinguda de la Universitat 1, 43204, Reus, Spain.
| | - Max Brosa
- Oblikue Consulting, Barcelona, SL, Spain.
| | - Juan Carlos Souto
- Unitat d'Hemostàsia i Trombosi, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | | | - Gordon Guyatt
- Department of Clinical Epidemiology & Biostatistics, CLARITY Research Group, McMaster University Medical Centre 2C9, 1200 Main St W, Hamilton, ON, Canada.
| | - Pablo Alonso-Coello
- Department of Clinical Epidemiology & Biostatistics, CLARITY Research Group, McMaster University Medical Centre 2C9, 1200 Main St W, Hamilton, ON, Canada.
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau) Research, CIBER of Epidemiology and Public Health (CIBERESP), Sant Antoni M. Claret 167, 08025, Barcelona, Spain.
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Shields AM, Lip GYH. Choosing the right drug to fit the patient when selecting oral anticoagulation for stroke prevention in atrial fibrillation. J Intern Med 2015; 278:1-18. [PMID: 25758241 DOI: 10.1111/joim.12360] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is a growing health problem that is associated with a significantly increased risk of stroke and thromboembolism. Oral anticoagulant (OAC) therapy reduces the risk of stroke and all-cause mortality in patients with AF. OAC therapy is commonly given as a well-controlled vitamin K antagonist (VKA; e.g. warfarin) and can reduce the risk of stroke in AF patients by almost two-thirds. However, the widespread use of VKAs has been hampered by the unpredictable pharmacokinetic and pharmacodynamic properties of the drugs and justifiable concerns about the consequent risk of haemorrhage. The non-VKA OACs (NOACs) have revolutionized thromboprophylaxis in AF by providing therapeutic options with predictable pharmacodynamic and pharmacokinetic properties that are as efficacious as warfarin in the prevention of stroke and thromboembolism but are more convenient to use. In this review, we provide a patient-centred framework to assist clinicians in recommending the right OAC therapy to fit the individual patient with AF, including methods for stratifying the risk of stroke and haemorrhage and the chances of achieving tight control of VKA anticoagulation, and we discuss the properties of the NOACs that favour their use in particular patient cohorts.
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Affiliation(s)
- A M Shields
- Acute Medicine Directorate, Croydon University Hospital, London, UK
| | - G Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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Abstract
BACKGROUND The new generation, non-vitamin K antagonist oral anticoagulants are used in an increasing frequency, partially replacing the vitamin K antagonists in several fields of anticoagulation. Efficacy of the preventive oral anticoagulant regime, however, may be compromised by patient non-compliance. METHODS The authors analyzed treatment discontinuation frequencies in phase 3 trials of anticoagulant treatment in non-valvular atrial fibrillation in a frequentist random effect metaanalysis and in Bayesian multiple treatment network comparison. RESULTS Frequency of discontinuations are heterogeneous and highly inconsistent (Chi2 test for heterogeneity p < 0.001, I2 test for inconsistency 95.1%). Discontinuations were the most frequent with dabigatran followed by rivaroxaban, warfarin, edoxaban and apixaban. Rivaroxaban were less frequently discontinued when compared to the two doses of dabigatran. (OR 0.80; 95% CI: 0.71-0.91 versus 150 mg b.i.d., and OR: 0.77; 95% CI: 0.68-0.87 versus 110 mg b.i.d.). CONCLUSION Important differences exist among the treatment adherence of different anticoagulant protocols. Discontinuation rates experienced during the clinical trials may predict the real life patient adherence.
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Affiliation(s)
- András Komócsi
- a Department of Interventional Cardiology , Heart Institute, University of Pécs , Pécs , Hungary
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Guías de práctica clínica: viejos y nuevos retos. Med Clin (Barc) 2014; 143:306-8. [DOI: 10.1016/j.medcli.2014.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 11/23/2022]
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