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Squires JE, Cho-Young D, Aloisio LD, Bell R, Bornstein S, Brien SE, Decary S, Varin MD, Dobrow M, Estabrooks CA, Graham ID, Greenough M, Grinspun D, Hillmer M, Horsley T, Hu J, Katz A, Krause C, Lavis J, Levinson W, Levy A, Mancuso M, Morgan S, Nadalin-Penno L, Neuner A, Rader T, Santos WJ, Teare G, Tepper J, Vandyk A, Wilson M, Grimshaw JM. Inappropriate use of clinical practices in Canada: a systematic review. CMAJ 2022; 194:E279-E296. [PMID: 35228321 PMCID: PMC9053971 DOI: 10.1503/cmaj.211416] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. Methods: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. Results: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9). Interpretation: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.
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Affiliation(s)
- Janet E Squires
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta.
| | - Danielle Cho-Young
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Laura D Aloisio
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Robert Bell
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Stephen Bornstein
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Susan E Brien
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Simon Decary
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Melissa Demery Varin
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Mark Dobrow
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Carole A Estabrooks
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Ian D Graham
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Megan Greenough
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Doris Grinspun
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michael Hillmer
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Tanya Horsley
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Jiale Hu
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Alan Katz
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Christina Krause
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - John Lavis
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Wendy Levinson
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Adrian Levy
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michelina Mancuso
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Steve Morgan
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Letitia Nadalin-Penno
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Andrew Neuner
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Tamara Rader
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Wilmer J Santos
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Gary Teare
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Joshua Tepper
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Amanda Vandyk
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michael Wilson
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
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Buick JE, Drennan IR, Scales DC, Brooks SC, Byers A, Cheskes S, Dainty KN, Feldman M, Verbeek PR, Zhan C, Kiss A, Morrison LJ, Lin S. Improving Temporal Trends in Survival and Neurological Outcomes After Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2018; 11:e003561. [PMID: 29317455 PMCID: PMC5791528 DOI: 10.1161/circoutcomes.117.003561] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Considerable effort has gone into improving outcomes from out-of-hospital cardiac arrest (OHCA). Studies suggest that survival is improving; however, prior studies had insufficient data to pursue the relationship between markers of guideline compliance and temporal trends. The objective of the study was to evaluate trends in OHCA survival over an 8-year period that included the implementation of the 2005 and 2010 international cardiopulmonary resuscitation (CPR) guidelines. METHODS AND RESULTS This was a population-based cohort study of all consecutive treated OHCA patients of presumed cardiac cause between 2006 and 2013 in the City of Toronto, Canada, and surrounding regions. Temporal changes were measured by χ2 trend test. The association between year of the OHCA and survival was evaluated using logistic regression and joinpoint analysis. A total of 23 619 patients with OHCA met study inclusion criteria. During the study period, survival to hospital discharge doubled (4.8% in 2006 to 9.4% in 2013; P<0.0001), and survival with good neurological outcome increased (6.2% in 2010 to 8.5% in 2013; P=0.005). Improvements occurred in the rates of bystander CPR and automated external defibrillator application, high-quality CPR metrics, and in-hospital targeted temperature management. After adjusting for the Utstein variables, survival to hospital discharge (odds ratio, 1.12; 95% confidence interval, 1.09-1.15) and survival with good neurological outcome (odds ratio, 1.13; 95% confidence interval, 1.05-1.22) increased with each year of study. CONCLUSIONS Survival after OHCA has improved over time. This trend was associated with improved rates of bystander CPR, automated external defibrillator use, high-quality CPR metrics, and in-hospital targeted temperature management. The results suggest that multiple factors, each improving over time, may have contributed to the observed increase in survival.
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Affiliation(s)
- Jason E Buick
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.).
| | - Ian R Drennan
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Damon C Scales
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Steven C Brooks
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Adams Byers
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Sheldon Cheskes
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Katie N Dainty
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Michael Feldman
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - P Richard Verbeek
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Cathy Zhan
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Alex Kiss
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
| | - Laurie J Morrison
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.).
| | - Steve Lin
- From Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.); Division of Emergency Medicine, Department of Medicine (J.E.B., I.R.D., S.C.B., A.B., S.C., K.N.D., C.Z., L.J.M., S.L.), Institute of Medical Science (I.R.D.), Institute of Health Policy, Management and Evaluation (D.C.S., J.E.B., K.N.D., A.K., L.J.M., S.L.), Interdepartmental Division of Critical Care, Department of Medicine (D.C.S.), Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, ON, Canada; Department of Critical Care Medicine (D.C.S.) and Sunnybrook Center for Prehospital Medicine (S.C., M.F., P.R.V.), Sunnybrook Health Sciences Center, Toronto, ON, Canada; and Department of Emergency Medicine, Faculty of Health Sciences, Queens University, Kingston, ON, Canada (S.C.B.)
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