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Kapral MK, Porter J, Kurdyak P, Yu AYX, Matheson E, Fang J, Casaubon LK, Kapoor E, Sheehan KA. Secondary Stroke Prevention in People With Schizophrenia. J Am Heart Assoc 2024; 13:e035589. [PMID: 39056334 DOI: 10.1161/jaha.124.035589] [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: 04/27/2024] [Accepted: 06/12/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND People with schizophrenia are less likely than those without to be treated for cardiovascular disease. We aimed to evaluate the association between schizophrenia and secondary preventive care after ischemic stroke. METHODS AND RESULTS In this retrospective cohort study, we used linked population-based administrative data to identify adults who survived 1 year after ischemic stroke hospitalization in Ontario, Canada between 2004 and 2017. Outcomes were screening, treatment, and control of risk factors, and receipt of outpatient physician services. We used modified Poisson regression to model the relative risk of each outcome among people with and without schizophrenia, adjusting for age and other factors. Among 81 163 people with ischemic stroke, 844 (1.04%) had schizophrenia. Schizophrenia was associated with lower rates of screening for hyperlipidemia (60.5% versus 66.0%, adjusted relative risk [aRR] 0.88 [95% CI, 0.84-0.93]) and diabetes (69.4% versus 73.9%, aRR 0.93 [95% CI, 0.89-0.97]), prescription of antihypertensive medications (91.2% versus 94.7%, aRR 0.96 [95% CI, 0.93-0.99]), achievement of target lipid levels (low-density lipoprotein <2 mmol/L) (30.6% versus 34.6%, aRR 0.86 [95% CI, 0.78-0.96]), and outpatient specialist visits (55.3% versus 67.8%, aRR 0.78 [95% CI, 0.74-0.83]) or primary care physician visits (94.5% versus 98.5%; aRR 0.96 [95% CI, 0.95-0.98]) within 1 year. There were no differences in prescription of antilipemic, antiglycemic, or anticoagulant medications, or in achievement of target hemoglobin A1c ≤7%. CONCLUSIONS People with stroke and schizophrenia are less likely than those without to receive secondary preventive care. This may inform interventions to improve poststroke care and outcomes in those with schizophrenia.
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Affiliation(s)
- Moira K Kapral
- Department of Medicine, Division of General Internal Medicine University of Toronto Canada
- ICES Toronto Canada
- Department of Medicine, Division of Neurology University of Toronto Canada
| | | | - Paul Kurdyak
- ICES Toronto Canada
- Department of Medicine, Division of Neurology University of Toronto Canada
- Department of Psychiatry University of Toronto Canada
| | - Amy Y X Yu
- ICES Toronto Canada
- Department of Medicine, Division of Neurology University of Toronto Canada
- Division of Neurology, Department of Medicine University of Toronto Canada
| | - Emilie Matheson
- Faculty of Arts and Science Queen's University Kingston Ontario Canada
| | | | - Leanne K Casaubon
- Division of Neurology, Department of Medicine University of Toronto Canada
| | - Eshita Kapoor
- Department of Medicine, Division of General Internal Medicine University of Toronto Canada
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Gams Massi D, Niakam Mbouleup FT, Dissongo JI, Mapoure YN. Epidemiology, clinical features and outcome of stroke in rural versus urban hospitals in Cameroon. J Stroke Cerebrovasc Dis 2024; 33:107580. [PMID: 38325033 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVES Stroke is a major public health problem worldwide with disparities between urban and rural areas. The aim of this study was to compare the epidemiological, clinical features and outcomes of stroke between rural and urban hospitals in Cameroon. MATERIALS AND METHODS We conducted a retrospective cohort study at the Douala General Hospital (urban) and Ad Lucem Hospital of Banka (rural) from January 1st, 2014, to December 31st, 2019. The medical records of all patients admitted for stroke, and meeting the inclusion criteria were reviewed. Diagnosis of stroke was based on brain imaging and/or the World Health Organization definition. Data were analyzed using SPSS version 20.0. RESULTS Among the 15277 files reviewed, 752 were included with 623 cases (82.80%) in urban areas. The percentage of patients hospitalized for stroke were 9.06% and 2.85% in urban and rural hospitals respectively. The frequency of patients admitted for severe stroke (Glasgow coma scale ≤ 8) was higher in the rural hospital (p = 0.004). In-hospital mortality (p = 0.010), cumulative mortality at one-month (p = 0.018), poor functional recovery (p = 0.002), one-year stroke recurrence (p = 0.020) were significantly higher in rural setting. Undefined stroke was predictor of mortality in the rural hospital, while hemorrhagic stroke was predictor of mortality at one-month in the urban hospital. CONCLUSIONS Stroke cases were significantly more severe with poor outcomes in the rural hospital. Efforts are needed to improve prevention, and access to stroke care for communities, especially in rural setting.
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Affiliation(s)
- Daniel Gams Massi
- Douala General Hospital, Faculty of Health Sciences, University of Buea, PO Box: 4856, Douala, Cameroon.
| | | | - Jean Ii Dissongo
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Cameroon
| | - Yacouba Njankouo Mapoure
- Douala General Hospital, Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Cameroon
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Yu AYX, Kapral MK, Park AL, Fang J, Hill MD, Kamal N, Field TS, Joundi RA, Peterson S, Zhao Y, Austin PC. Change in Hospital Risk-standardized Stroke Mortality Performance With and Without the Passive Surveillance Stroke Severity Score. Med Care 2023:00005650-990000000-00180. [PMID: 37962442 DOI: 10.1097/mlr.0000000000001944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Adjustment for baseline stroke severity is necessary for accurate assessment of hospital performance. We evaluated whether adjusting for the Passive Surveillance Stroke SeVerity (PaSSV) score, a measure of stroke severity derived using administrative data, changed hospital-specific estimated 30-day risk-standardized mortality rate (RSMR) after stroke. METHODS We used linked administrative data to identify adults who were hospitalized with ischemic stroke or intracerebral hemorrhage across 157 hospitals in Ontario, Canada between 2014 and 2019. We fitted a random effects logistic regression model using Markov Chain Monte Carlo methods to estimate hospital-specific 30-day RSMR and 95% credible intervals with adjustment for age, sex, Charlson comorbidity index, and stroke type. In a separate model, we additionally adjusted for stroke severity using PaSSV. Hospitals were defined as low-performing, average-performing, or high-performing depending on whether the RSMR and 95% credible interval were above, overlapping, or below the cohort's crude mortality rate. RESULTS We identified 65,082 patients [48.0% were female, the median age (25th,75th percentiles) was 76 years (65,84), and 86.4% had an ischemic stroke]. The crude 30-day all-cause mortality rate was 14.1%. The inclusion of PaSSV in the model reclassified 18.5% (n=29) of the hospitals. Of the 143 hospitals initially classified as average-performing, after adjustment for PaSSV, 20 were reclassified as high-performing and 8 were reclassified as low-performing. Of the 4 hospitals initially classified as low-performing, 1 was reclassified as high-performing. All 10 hospitals initially classified as high-performing remained unchanged. CONCLUSION PaSSV may be useful for risk-adjusting mortality when comparing hospital performance. External validation of our findings in other jurisdictions is needed.
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Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto
- ICES
| | - Moira K Kapral
- ICES
- Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, Toronto, ON
| | | | | | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS
| | - Thalia S Field
- Department of Medicine (Neurology), Vancouver Stroke Program, University of British Columbia, Vancouver, BC
| | - Raed A Joundi
- Department of Medicine, Hamilton Health Sciences Centre, McMaster University, Hamilton, ON
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia
| | - Yinshan Zhao
- Population Data BC, University of British Columbia, Vancouver, BC, Canada
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Roston TM, So DY, Liu S, Fordyce CB, Grunau B, Jentzer JC, Bagai A, Luk A, Goodman SG, van Diepen S. Leveraging Existing STEMI Networks to Regionalize Cardiogenic Shock Systems of Care: Efforts to Expand the Scope Could Improve Shock Outcomes. Can J Cardiol 2022; 39:427-431. [PMID: 36402241 DOI: 10.1016/j.cjca.2022.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Thomas M Roston
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Derek Y So
- University of Ottawa Heart Institute, Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Shuangbo Liu
- Section of Cardiology, St Boniface Hospital, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christopher B Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Grunau
- Departments of Emergency Medicine, University of British Columbia and the Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Akshay Bagai
- Division of Cardiology, St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Adriana Luk
- Division of Cardiology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Division of Cardiology, St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sean van Diepen
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.
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Yu AY, Bravata DM, Norrving B, Reeves MJ, Liu L, Kilkenny MF. Measuring Stroke Quality: Methodological Considerations in Selecting, Defining, and Analyzing Quality Measures. Stroke 2022; 53:3214-3221. [DOI: 10.1161/strokeaha.122.036485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Knowledge about stroke and its management is growing rapidly and stroke systems of care must adapt to deliver evidence-based care. Quality improvement initiatives are essential for translating knowledge from clinical trials and recommendations in guidelines into routine clinical practice. This review focuses on issues central to the measurement of the quality of stroke care, including selection and definition of quality measures, identification of the eligible patient cohorts, optimization of data quality, and considerations for data analysis and interpretation.
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Affiliation(s)
- Amy Y.X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (A.Y.X.Y.)
| | - Dawn M. Bravata
- VA HSR&D Center for Health Information and Communication (CHIC)‚ Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.)
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (D.M.B.)
- Regenstrief Institute, Indianapolis, IN (D.M.B.)
| | - Bo Norrving
- Department of Clinical Sciences (Neurology), Lund, Lund University, and Neurology, Skåne University Hospital Lund/Malmö, Sweden (B.N.)
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (L.L.)
| | - Monique F. Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (M.F.K.)
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (M.F.K.)
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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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7
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Cerasuolo JO, Mandzia J, Cipriano LE, Kapral MK, Fang J, Hachinski V, Sposato LA. Intravenous Thrombolysis After First-Ever Ischemic Stroke and Reduced Incident Dementia Rate. Stroke 2021; 53:1170-1177. [PMID: 34965738 DOI: 10.1161/strokeaha.121.034969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The use of intravenous thrombolysis is associated with improved clinical outcomes. Whether thrombolysis is associated with reduced incidence of poststroke dementia remains uncertain. We sought to estimate if the use of thrombolysis following first-ever ischemic stroke was associated with a reduced rate of incident dementia using a pragmatic observational design. METHODS We included first-ever ischemic stroke patients from the Ontario Stroke Registry who had not previously been diagnosed with dementia. The primary outcome was incident dementia ascertained by a validated diagnostic algorithm. We employed inverse probability of treatment-weighted Cox proportional hazard models to estimate the cause-specific hazard ratio for the association of thrombolysis and incident dementia at 1 and 5 years following stroke. RESULTS From July 2003 to March 2013, 7072 patients with ischemic stroke were included, 3276 (46.3%) were female and mean age was 71.0 (SD, 12.8) years. Overall, 38.2% of the cohort (n=2705) received thrombolysis, 77.2% (n=2087) of which was administered within 3 hours of stroke onset. In the first year following stroke, thrombolysis administration was associated with a 24% relative reduction in the rate of developing dementia (cause-specific hazard ratio, 0.76 [95% CI, 0.58-0.97]). This association remained significant at 5 years (cause-specific hazard ratio, 0.79 [95% CI, 0.66-0.91]) and at the end of follow-up (median 6.3 years; cause-specific hazard ratio, 0.79 [95% CI, 0.68-0.89]). CONCLUSIONS Thrombolysis administration following first-ever ischemic stroke was independently associated with a reduced rate of dementia. Incident dementia should be considered as a relevant outcome when evaluating risk/benefit of thrombolysis in ischemic stroke patients.
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Affiliation(s)
- Joshua O Cerasuolo
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, Canada (J.O.C.).,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada (J.O.C.)
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Canada. (J.M., V.H., L.A.S.).,Lawson Health Research Institute, London, Canada (J.M., L.A.S.)
| | - Lauren E Cipriano
- Ivey Business School, Western University, London, Canada. (L.E.C.).,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada. (L.E.C., V.H., L.A.S.)
| | - Moira K Kapral
- ICES, Toronto, Canada (M.K.K., J.F.).,Department of Medicine, University of Toronto, Toronto, Canada (M.K.K.)
| | | | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Canada. (J.M., V.H., L.A.S.).,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada. (L.E.C., V.H., L.A.S.)
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Canada. (J.M., V.H., L.A.S.).,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada. (L.E.C., V.H., L.A.S.).,London Heart & Brain Laboratory, Western University, London, Canada. (L.A.S.).,Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Canada. (L.A.S.).,Lawson Health Research Institute, London, Canada (J.M., L.A.S.).,Robarts Research Institute, London, Canada (L.A.S.)
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8
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Yu AY, Lee DS, Vyas MV, Porter J, Rashid M, Fang J, Austin PC, Hill MD, Kapral MK. Emergency Department Visits, Care, and Outcome After Stroke and Myocardial Infarction During the COVID-19 Pandemic Phases. CJC Open 2021; 3:1230-1237. [PMID: 34723166 PMCID: PMC8548659 DOI: 10.1016/j.cjco.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/02/2021] [Indexed: 12/11/2022] Open
Abstract
Background It is not known if initial reductions in hospitalization for stroke and myocardial infarction early during the coronavirus disease–2019 pandemic were followed by subsequent increases. We describe the rates of emergency department visits for stroke and myocardial infarction through the pandemic phases. Methods We used linked administrative data to compare the weekly age- and sex-standardized rates of visits for stroke and myocardial infarction in Ontario, Canada in the first 9 months of 2020 to the mean baseline rates (2015-2019) using rate ratios (RRs) and 95% confidence intervals (CIs). We compared care and outcomes by pandemic phases (pre-pandemic was January-March, lockdown was March-May, early reopening was May-July, and late reopening was July-September). Results We identified 15,682 visits in 2020 for ischemic stroke (59.2%; n = 9279), intracerebral hemorrhage (12.2%; n = 1912), or myocardial infarction (28.6%; n = 4491). The weekly rates for stroke visits in 2020 were lower during the lockdown and early reopening than at baseline (RR 0.76, 95% CI [0.66, 0.87] for the largest weekly decrease). The weekly rates for myocardial infarction visits were lower during the lockdown only (RR 0.61, 95% CI [0.46, 0.77] for the largest weekly decrease), and there was a compensatory increase in visits following reopening. Ischemic stroke 30-day mortality was increased during the lockdown phase (11.5% pre-coronavirus disease; 12.2% during lockdown; 9.2% during early reopening; and 10.6% during late reopening, P = 0.015). Conclusion After an initial reduction in visits for stroke and myocardial infarction, there was a compensatory increase in visits for myocardial infarction. The death rate after ischemic stroke was higher during the lockdown than in other phases.
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Affiliation(s)
- Amy Y.X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Corresponding author: Dr Amy Y.X. Yu, Neurologist, Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Office A-455, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-4866; fax: +1-416-480-5753.
| | - Douglas S. Lee
- ICES, Toronto, Ontario, Canada
- Department of Medicine (Cardiology), University of Toronto–University Health Network, Toronto, Ontario, Canada
| | - Manav V. Vyas
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | | | | | - Michael D. Hill
- Department of Clinical Neurosciences, Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Moira K. Kapral
- ICES, Toronto, Ontario, Canada
- Department of Medicine (General Internal Medicine), University of Toronto–University Health Network, Toronto, Ontario, Canada
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9
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Abstract
BACKGROUND Stroke survivors have higher unmet health care needs than the general population. However, it is unclear whether such needs have changed over time, and whether these have been affected by the introduction of integrated systems of stroke care. METHODS We used data from the Canadian Community Health Surveys between 2000 and 2014. We developed multivariable log-binomial generalized estimating equations to obtain adjusted risk ratios (aRRs) of unmet health care needs in stroke survivors compared to the general population, and over time. We conducted a difference in differences analysis to determine the association between the implementation of integrated systems of stroke care and unmet health care needs. RESULTS Data from 350,084 respondents were included in the study; 8072 (2.3%) were stroke survivors. Compared to the general population, stroke survivors were more likely to report unmet health care needs (aRR 1.27; 95% CI, 1.22-1.32). The unmet health care needs reported by stroke survivors were lower after compared to before 2006 (15.8% vs. 31.9%, P < 0.001). After accounting for temporal trends, there was no association between the implementation of integrated systems of stroke care and change in unmet health care needs of stroke survivors. However, this requires cautious interpretation due to limitations in the data available for this study. CONCLUSIONS Unmet health care needs of stroke survivors have reduced over time but remain higher than the general population. Future research should focus on identifying stroke- and policy-related factors to mitigate disparities in health care access for stroke survivors.
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10
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Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada. Can J Neurol Sci 2021; 47:301-308. [PMID: 31918777 DOI: 10.1017/cjn.2020.9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada. METHODS We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers. RESULTS Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT). CONCLUSIONS Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.
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11
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Joundi RA, Smith EE, Yu AYX, Rashid M, Fang J, Kapral MK. Temporal Trends in Case Fatality, Discharge Destination, and Admission to Long-term Care After Acute Stroke. Neurology 2021; 96:e2037-e2047. [PMID: 33970881 DOI: 10.1212/wnl.0000000000011791] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/13/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine contemporary trends in case fatality, discharge destination, and admission to long-term care after acute ischemic stroke and intracerebral hemorrhage (ICH) using a large, population-based cohort. METHODS We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever ischemic stroke or ICH in Ontario, Canada, from 2003 to 2017. We calculated crude and age-/sex-standardized risk of death at 30 days and 1 year from stroke onset. We stratified crude trends by stroke type, age, and sex and used the Kendall τ-b correlation coefficient to evaluate the significance of trends. We determined trends in discharge home and to rehabilitation and admission to long-term care at 1 year. We used Cox proportional hazard and logistic regression models to assess whether trends in outcomes persisted after adjustment for baseline factors, estimated stroke severity, and use of life-sustaining care. RESULTS There were 163,574 people with acute ischemic stroke or ICH across the study period. Between 2003 and 2017, age-/sex-standardized 30-day stroke case fatality decreased from 20.5% to 13.2% (7.3% absolute and 36% relative reduction) while that at 1 year decreased from 32.2% to 22.8% (9.3% absolute and 29% relative reduction). Findings were consistent across age, sex, and stroke type, and after adjustment for comorbid conditions, stroke severity, and use of life-sustaining care. There was a reduction in long-term care admission after ischemic stroke and an increase in discharge home or to rehabilitation for both stroke types. CONCLUSION We observed substantial reductions in acute stroke case fatality from 2003 to 2017 with a concurrent increase in discharge to home or rehabilitation and a decrease in long-term care admissions, suggesting continuous improvements in stroke systems of care.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Amy Y X Yu
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Mohammed Rashid
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Jiming Fang
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Moira K Kapral
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada.
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12
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Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015. Can J Neurol Sci 2020; 48:335-343. [PMID: 32959741 DOI: 10.1017/cjn.2020.205] [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: 11/07/2022]
Abstract
BACKGROUND Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. METHODS Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. RESULTS From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001). INTERPRETATION At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.
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13
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Hall RE, Porter J, Quan H, Reeves MJ. Developing an adapted Charlson comorbidity index for ischemic stroke outcome studies. BMC Health Serv Res 2019; 19:930. [PMID: 31796024 PMCID: PMC6892203 DOI: 10.1186/s12913-019-4720-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 11/06/2019] [Indexed: 12/27/2022] Open
Abstract
Background The Charlson comorbidity index (CCI) is commonly used to adjust for patient casemix. We reevaluated the CCI in an ischemic stroke (IS) cohort to determine whether the original seventeen comorbidities and their weights are relevant. Methods We identified an IS cohort (N = 6988) from the Ontario Stroke Registry (OSR) who were discharged from acute hospitals (N = 100) between April 1, 2012 and March 31, 2013. We used hospital discharge ICD-10-CA data to identify Charlson comorbidities. We developed a multivariable Cox model to predict one-year mortality retaining statistically significant (P < 0.05) comorbidities with hazard ratios ≥1.2. Hazard ratios were used to generate revised weights (1–6) for the comorbid conditions. The performance of the IS adapted Charlson comorbidity index (ISCCI) mortality model was compared to the original CCI using the c-statistic and continuous Net Reclassification Index (cNRI). Results Ten of the 17 Charlson comorbid conditions were retained in the ISCCI model and 7 had reassigned weights when compared to the original CCI model . The ISCCI model showed a small but significant increase in the c-statistic compared to the CCI for 30-day mortality (c-statistic 0.746 vs. 0.732, p = 0.009), but no significant increase in c-statistic for in-hospital or one-year mortality. There was also no improvement in the cNRI when the ISCCI model was compared to the CCI. Conclusions The ISCCI model had similar performance to the original CCI model. The key advantage of the ISCCI model is it includes seven fewer comorbidities and therefore easier to implement in situations where coded data is unavailable.
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Affiliation(s)
- Ruth E Hall
- ICES, 2075 Bayview Ave., G-Wing, Toronto, Ontario, M4N 3M5, Canada. .,Institute for Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Toronto, Canada.
| | - Joan Porter
- ICES, 2075 Bayview Ave., G-Wing, Toronto, Ontario, M4N 3M5, Canada
| | - Hude Quan
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Calgary, Canada
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
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Yu AYX, Fang J, Kapral MK. One-Year Home-Time and Mortality After Thrombolysis Compared With Nontreated Patients in a Propensity-Matched Analysis. Stroke 2019; 50:3488-3493. [PMID: 31570086 DOI: 10.1161/strokeaha.119.026922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator) is associated with improved early functional outcome after stroke, but its long-term effects are less understood. We aimed to determine the association between r-tPA and 1-year outcomes after stroke. Methods- We used the Ontario Stroke Registry to identify patients diagnosed with ischemic stroke between 2002 and 2013 in Ontario, Canada, their baseline characteristics, and whether they received r-tPA. We used propensity score methods to match patients treated with r-tPA to nontreated patients. The primary outcome was 1-year home-time, defined as the number of days spent outside of any healthcare institutions in the first 365 days after the index date of admission. Secondary outcomes were admission to a nursing home and all-cause mortality in the first year. Outcomes were determined using linked administrative data. We used paired t tests to compare mean home-time days and Cox proportional hazards models for mortality and nursing home admission to estimate hazard ratios and 95% CI. Results- All 4449 patients treated with r-tPA in the registry were matched to nontreated patients. Compared with nontreated patients, those treated with r-tPA experienced more time at home in the first year (mean±SD was 248.9 days±137.2 treated versus 239.4 days±139.0 nontreated, P=0.005) and were less likely to be admitted to nursing homes (9.4% treated versus 12.2% nontreated; hazard ratio, 0.84; 95% CI, 0.78-0.91). One-year all-cause mortality was similar between the 2 groups (13.2% treated versus 12.4% nontreated; hazard ratio, 1.07; 95% CI, 0.96-1.20). Conclusions- Despite similar mortality, patients who received r-tPA spent more time at home and were less likely to require nursing home admission in the first year after stroke compared with nontreated patients, suggesting long-term benefits and safety of this treatment.
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Affiliation(s)
- Amy Y X Yu
- From the Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, ON, Canada (A.Y.X.Y.).,ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.)
| | - Moira K Kapral
- ICES, Toronto, ON, Canada (A.Y.X.Y., J.F., M.K.K.).,Department of Medicine (General Internal Medicine), University of Toronto-University Health Network, ON, Canada (M.K.K.)
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15
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Tseung V, Jaglal SB, Salbach NM, Yoshida K, Cameron JI. Key informants' perspectives on implementing caregiver programs in an organized system of stroke care. Disabil Rehabil 2019; 43:1145-1152. [PMID: 31424961 DOI: 10.1080/09638288.2019.1652704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Family caregivers provide essential support to individuals recovering after experiencing a stroke. Although clinical guidelines recommend the provision of caregiver education and support, these guidelines have not been implemented into standard clinical practice. The objective of this study was to gain insight from key informants-affiliates of a regional stroke system-to identify organization and system level barriers and facilitators associated with implementing stroke caregiver programs. METHODS Twelve key informants were interviewed. Informants discussed their experiences with and perceptions of caregiver programs. They also identified barriers and facilitators to implementing caregiver programs. Interview data were analyzed using inductive thematic analysis. RESULTS Three themes were generated: (1) lack of consensus on the need for caregiver education and support programs as part of the health care system; (2) a collaborative process is needed to engage stakeholders and identify champions (3) stakeholders need different types of evidence in support of implementation. CONCLUSIONS This study provides initial insight into the potential barriers and facilitators needed to develop and implement stroke caregiver programs. Further exploration of these topics can inform caregiver program development and their implementation into stroke systems of care.IMPLICATIONS FOR REHABILITATIONRehabilitation research needs to demonstrate that caregivers are a unique group in need of support from the health care system.Rehabilitation research needs to contribute to the evidence that caregiver programs can improve patient, caregiver, and health system outcomes.Researchers can enhance caregiver program implementation through collaboration between researchers, stakeholders, and system change champions starting with program development.
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Affiliation(s)
- Victrine Tseung
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Susan B Jaglal
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Nancy M Salbach
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Karen Yoshida
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Jill I Cameron
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
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16
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Egan MY, Laliberté-Rudman D, Rutkowski N, Lanoix M, Meyer M, McEwen S, Collver M, Linkewich E, Montgomery P, Quant S, Donnelly B, Fearn J. The implications of the Canadian Stroke Best Practice Recommendations for design and allocation of rehabilitation after hospital discharge: a problematization. Disabil Rehabil 2019; 42:3403-3415. [PMID: 30973029 DOI: 10.1080/09638288.2019.1592244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction: Implementation of the Canadian Stroke Best Practice Recommendations has improved inpatient rehabilitation. As attention is turned to the design and allocation of rehabilitation after hospitalization, examination of their implications for post-discharge rehabilitation could help optimize service planningMethods: Critical discourse analysis modeled on Alvesson and Sandberg's method of problematization was conducted to determine how the Canadian Stroke Best Practice Recommendations envision and shape post-discharge rehabilitation, and identify any tensions and potential ways to resolve them.Results: Within the Canadian Stroke Best Practice Recommendations post-discharge rehabilitation is implicitly viewed as a continuation of inpatient rehabilitation. Rehabilitation is largely envisioned as a set of biomedical procedures aimed at normalization through correction of impairment. There is potential tension between this implicit goal and the explicit goal of providing patient and family-centered care and promoting reengagement in valued activities and roles.Conclusion: An alternate vision of post-discharge rehabilitation could help resolve this tension. Post-discharge rehabilitation could be envisioned as a self-management intervention. Rather than primarily an expert-driven process of measuring impairment and applying procedures aimed at normalization, rehabilitation would be considered facilitation of self-management with the goal of reengaging in forms of participation that comprise a satisfying life.Implications for RehabilitationImplicit assumptions within best practice guidelines powerfully influence recommendations. These ideas are difficult to examine because they seem self-evident.Implicit assumptions in the Canadian Stroke Best Practice Guidelines envision post-discharge stroke rehabilitation as an expert-driven, impairment-focused biomedical procedure.This biomedical image makes it difficult to provide care that meets the guideline's explicit goals of client- and family-centeredness.Reimagining post-discharge stroke rehabilitation as a chronic self-care management intervention aimed at developing a satisfying life after stroke could improve patient care.
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Affiliation(s)
- Mary Y Egan
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | | | | | - Monique Lanoix
- Faculty of Philosophy, Saint Paul University, Ottawa, ON, Canada
| | - Matthew Meyer
- London Health Sciences Centre, Matthew Meyer, London, ON, Canada
| | - Sara McEwen
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Margo Collver
- London Health Sciences Centre, Southwestern Ontario Stroke Network, London, ON, Canada
| | - Elizabeth Linkewich
- North and East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Sylvia Quant
- North and East GTA Stroke Network, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Beth Donnelly
- Champlain Stroke Network, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jennifer Fearn
- Health Sciences North, Northeastern Ontario Stroke Network, Sudbury, ON, Canada
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17
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Kapral MK, Austin PC, Jeyakumar G, Hall R, Chu A, Khan AM, Jin AY, Martin C, Manuel D, Silver FL, Swartz RH, Tu JV. Rural-Urban Differences in Stroke Risk Factors, Incidence, and Mortality in People With and Without Prior Stroke. Circ Cardiovasc Qual Outcomes 2019; 12:e004973. [DOI: 10.1161/circoutcomes.118.004973] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Moira K. Kapral
- Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Geerthana Jeyakumar
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland (G.J.)
| | - Ruth Hall
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Anna Chu
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Anam M. Khan
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
| | - Albert Y. Jin
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada (A.Y.J.)
| | - Cally Martin
- Kingston Health Sciences Centre, Kingston, Ontario, Canada (C.M.)
| | - Doug Manuel
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.M.)
| | - Frank L. Silver
- Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada
| | - Richard H. Swartz
- Division of Neurology, Department of Medicine (F.L.S., R.H.S.), University of Toronto, Toronto, Ontario, Canada
| | - Jack V. Tu
- Division of General Internal Medicine, Department of Medicine (M.K.K., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (M.K.K., P.C.A., J.V.T.), University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada (M.K.K., P.C.A., R.H., A.C., A.M.K., D.M., J.V.T.)
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18
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Hachinski V. Dementia: new vistas and opportunities. Neurol Sci 2019; 40:763-767. [PMID: 30666474 DOI: 10.1007/s10072-019-3714-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022]
Abstract
Over the past four decades, Alzheimer disease has become near synonymous with dementia and the amyloid/tau hypothesis as its dominant explanation. However, this monorail approach to etiology has failed to yield a single disease-modifying drug. Part of the explanation stems from the fact that most dementias in the elderly result from interactive Alzheimer and cerebrovascular pathologies. Stroke and dementia share the same risk factors and their control is associated with a decrease in stroke and some dementias. Additionally, intensive control of risk factors and enhancement of protective factors improve cognition. Moreover, anticoagulation of atrial fibrillation patients decreases their chance of developing dementia by 48%. Preliminary data suggest that treating blood pressure to a target of 120 mmHg systolic compared to a target of 140 mmHg decreases the chances of mild cognitive impairment by 19%. The Berlin Manifesto establishes the scientific bases of "preventing dementia by preventing stroke." Enlarging our vista of dementia to include cerebrovascular disease offers the opportunity of preventing not only stroke, but some dementias, beginning now.
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Affiliation(s)
- Vladimir Hachinski
- Department of Clinical Neurological Sciences, Western University, 339 Windermere Road, London, Ontario, N6A 5A5, Canada.
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19
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Bartlett RS, Thibeault SL. Insights Into Oropharyngeal Dysphagia From Administrative Data and Clinical Registries: A Literature Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2018; 27:868-883. [PMID: 29710238 PMCID: PMC6105122 DOI: 10.1044/2018_ajslp-17-0158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/25/2017] [Accepted: 12/27/2017] [Indexed: 06/08/2023]
Abstract
Purpose The call for data-driven health care has been bolstered by the digitization of medical records, quality initiatives, and payment reform. Administrative databases and clinical registries are increasingly being used to study oropharyngeal dysphagia and to facilitate data-driven decision making. The objective of this work was to summarize key findings, etiologies studied, data sources used, study objectives, and quality of evidence of all original research articles that have investigated oropharyngeal dysphagia or aspiration pneumonia using administrative or clinical registry data to date. Method A literature search was completed in MEDLINE, Scopus, and Google Scholar (January 1, 1990, to February 1, 2017). Each study that met inclusion criteria was rated for quality of evidence on a 5-point scale. Results Eighty-four research articles were included in the final analysis (n = 221-1,649,871). Over the past 20 years, the number of new publications in this area has quintupled. Most of the administrative database and clinical registry studies of dysphagia have been retrospective cohort studies and cross-sectional studies and limited to quality of evidence levels of 3-4. In these studies, much has been learned about risk factors for dysphagia and pneumonia in defined populations and health care costs and usage. Little has been gleaned from these studies regarding swallowing physiology or dysphagia management. Conclusions Investigators are just beginning to develop the methods to study oropharyngeal dysphagia using administrative data and clinical registries. Future research is needed in all areas, from the fundamental issue of how to identify individuals with dysphagia with high sensitivity in these data sets to evaluating treatment effectiveness. Supplemental Material https://doi.org/10.23641/asha.6066515.
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Affiliation(s)
- Rebecca S. Bartlett
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison
| | - Susan L. Thibeault
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison
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20
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Bernhardt J, Zorowitz RD, Becker KJ, Keller E, Saposnik G, Strbian D, Dichgans M, Woo D, Reeves M, Thrift A, Kidwell CS, Olivot JM, Goyal M, Pierot L, Bennett DA, Howard G, Ford GA, Goldstein LB, Planas AM, Yenari MA, Greenberg SM, Pantoni L, Amin-Hanjani S, Tymianski M. Advances in Stroke 2017. Stroke 2018; 49:e174-e199. [DOI: 10.1161/strokeaha.118.021380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Julie Bernhardt
- From the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (J.B.)
| | - Richard D. Zorowitz
- MedStar National Rehabilitation Network and Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC (R.D.Z.)
| | - Kyra J. Becker
- Department of Neurology, University of Washington, Seattle (K.J.B.)
| | - Emanuela Keller
- Division of Internal Medicine, University Hospital of Zurich, Switzerland (E.K.)
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Germany (M.D.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, OH (D.W.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Amanda Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.T.)
| | - Chelsea S. Kidwell
- Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
| | - Jean Marc Olivot
- Acute Stroke Unit, Toulouse Neuroimaging Center and Clinical Investigation Center, Toulouse University Hospital, France (J.M.O.)
| | - Mayank Goyal
- Department of Diagnostic and Interventional Neuroradiology, University of Calgary, AB, Canada (M.G.)
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, CHU Reims, Reims Champagne-Ardenne University, France (L.P.)
| | - Derrick A. Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (D.A.B.)
| | - George Howard
- Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.)
| | - Gary A. Ford
- Oxford Academic Health Science Network, United Kingdom (G.A.F.)
| | | | - Anna M. Planas
- Department of Brain Ischemia and Neurodegeneration, Institute for Biomedical Research of Barcelona (IIBB), Consejo Superior de Investigaciones CIentíficas (CSIC), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (A.M.P.)
| | - Midori A. Yenari
- Department of Neurology, University of California, San Francisco (M.A.Y.)
- San Francisco Veterans Affairs Medical Center, CA (M.A.Y.)
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| | - Leonardo Pantoni
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P.)
| | | | - Michael Tymianski
- Departments of Surgery and Physiology, University of Toronto, ON, Canada (M.T.)
- Department of Surgery, University Health Network (Neurosurgery), Toronto, ON, Canada (M.T.)
- Krembil Research Institute, Toronto Western Hospital, ON, Canada (M.T.)
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21
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Nucera A, Hachinski V. Cerebrovascular and Alzheimer disease: fellow travelers or partners in crime? J Neurochem 2018; 144:513-516. [PMID: 29266273 DOI: 10.1111/jnc.14283] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/30/2017] [Accepted: 12/06/2017] [Indexed: 12/22/2022]
Abstract
In this review, we will discuss the progressive decline in cognitive and intellectual performance in late life that has led to great challenges for medical and community services. The term 'vascular cognitive impairment' is defined as any cognitive impairment that is caused by or associated with vascular factors. It can occur alone or in association with Alzheimer disease. The good news is that because vascular risk factors are treatable, it should be possible to prevent or delay some dementias. Since vascular cognitive impairment may often go unrecognized, many experts recommend screening with brief tests to assess memory, thinking, and reasoning for everyone considered to be at high risk for this disorder. Up to 64% of persons 65 years or older who have experienced a stroke have some degree of cognitive impairment with up to one third developing dementia. Postmortem studies indicate that up to 34% of dementia cases show significant vascular pathology. It suggests that ischemic stroke triggers additional pathophysiological process that may lead to a secondary degenerative process that may interact with Alzheimer disease pathology thus accelerating the ongoing primary neurodegeneration. Mechanisms could include hypoperfusion, hypoxia, and neuroinflammation, one of the links between the two pathologies. Stroke and dementia share the same risk and protective factors. Since stroke interact with dementia of all types it may already be possible to reduce or delay some dementias by a number of interventions known to prevent stroke. This article is part of the Special Issue "Vascular Dementia".
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Affiliation(s)
- Antonia Nucera
- Department of Clinical Neurological Science, University Hospital, the University of Western Ontario, London, Ontario, Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Science, University Hospital, the University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatics, the University of Western Ontario, London, Ontario, Canada
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22
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Kassardjian CD, Willems JD, Skrabka K, Nisenbaum R, Barnaby J, Kostyrko P, Selchen D, Saposnik G. In-Patient Code Stroke. Stroke 2017; 48:2176-2183. [DOI: 10.1161/strokeaha.117.017622] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/09/2017] [Accepted: 05/23/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Charles D. Kassardjian
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Jacqueline D. Willems
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Krystyna Skrabka
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Rosane Nisenbaum
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Judith Barnaby
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Pawel Kostyrko
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Daniel Selchen
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
| | - Gustavo Saposnik
- From the Division of Neurology, Department of Medicine (C.D.K., J.D.W., K.S., P.K., D.S., G.S.) and Applied Health Research Centre, Li Ka Shing Knowledge Institute (R.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of Neurology (C.D.K., D.S., G.S.) and Dalla Lana School of Public Health (R.N.), University of Toronto, Ontario, Canada; and Ryerson University, Toronto, Ontario, Canada (J.B.)
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23
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Edwards JD, Kapral MK, Fang J, Swartz RH. Long-term morbidity and mortality in patients without early complications after stroke or transient ischemic attack. CMAJ 2017; 189:E954-E961. [PMID: 28739847 DOI: 10.1503/cmaj.161142] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Secondary prevention after stroke and transient ischemic attack (TIA) has focused on high early risk of recurrence, but survivors of stroke can have substantial long-term morbidity and mortality. We quantified long-term morbidity and mortality for patients who had no early complications after stroke or TIA and community-based controls. METHODS This longitudinal case-control study included all ambulatory or hospitalized patients with stroke or TIA (discharged from regional stroke centres in Ontario from 2003 to 2013) who survived for 90 days without recurrent stroke, myocardial infarction, all-cause admission to hospital, admission to an institution or death. Cases and controls were matched on age, sex and geographic location. The primary composite outcome was death, stroke, myocardial infarction, or admission to long-term or continuing care. We calculated 1-, 3- and 5-year rates of composite and individual outcomes and used cause-specific Cox regression to estimate long-term hazards for cases versus controls and for patients with stroke versus those with TIA. RESULTS Among patients who were initially stable after stroke or TIA (n = 26 366), the hazard of the primary outcome was more than double at 1 year (hazard ratio [HR] 2.4, 95% confidence interval [CI] 2.3-2.5), 3 years (HR 2.2, 95% CI 2.1-2.3) and 5 years (HR 2.1, 95% CI 2.1-2.2). Hazard was highest for recurrent stroke at 1 year (HR 6.8, 95% CI 6.1-7.5), continuing to 5 years (HR 5.1, 95% CI 4.8-5.5), and for admission to an institution (HR 2.1, 95% CI 1.9-2.2). Survivors of stroke had higher mortality and morbidity, but 31.5% (1789/5677) of patients with TIA experienced an adverse event within 5 years. INTERPRETATION Patients who survive stroke or TIA without early complications are typically discharged from secondary stroke prevention services. However, these patients remain at substantial long-term risk, particularly for recurrent stroke and admission to an institution. Novel approaches to prevention, potentially embedded in community or primary care, are required for long-term management of these initially stable but high-risk patients.
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Affiliation(s)
- Jodi D Edwards
- Sunnybrook Research Institute (Edwards, Swartz), Toronto, Ont.; Canadian Partnership for Stroke Recovery (Edwards), Ottawa, Ont.; Department of Medicine, Division of General Internal Medicine (Kapral), Institute of Health Policy, Management and Evaluation (Kapral), and Department of Medicine, Neurology (Swartz), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Fang), Toronto, Ont
| | - Moira K Kapral
- Sunnybrook Research Institute (Edwards, Swartz), Toronto, Ont.; Canadian Partnership for Stroke Recovery (Edwards), Ottawa, Ont.; Department of Medicine, Division of General Internal Medicine (Kapral), Institute of Health Policy, Management and Evaluation (Kapral), and Department of Medicine, Neurology (Swartz), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Fang), Toronto, Ont
| | - Jiming Fang
- Sunnybrook Research Institute (Edwards, Swartz), Toronto, Ont.; Canadian Partnership for Stroke Recovery (Edwards), Ottawa, Ont.; Department of Medicine, Division of General Internal Medicine (Kapral), Institute of Health Policy, Management and Evaluation (Kapral), and Department of Medicine, Neurology (Swartz), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Fang), Toronto, Ont
| | - Richard H Swartz
- Sunnybrook Research Institute (Edwards, Swartz), Toronto, Ont.; Canadian Partnership for Stroke Recovery (Edwards), Ottawa, Ont.; Department of Medicine, Division of General Internal Medicine (Kapral), Institute of Health Policy, Management and Evaluation (Kapral), and Department of Medicine, Neurology (Swartz), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Fang), Toronto, Ont.
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Zwicker J, Martineau I, Walsh S, Lavoie J, Weger E, Scott J. Improving the comfort of nurses caring for stroke patients at the end of life. Int J Palliat Nurs 2017; 23:248-254. [PMID: 28548912 DOI: 10.12968/ijpn.2017.23.5.248] [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: 11/11/2022]
Abstract
BACKGROUND End-of-life care of stroke patients is an important aspect of stroke care. It has been previously reported that nurses express discomfort caring for patients at the end of life or caring for patients who have suffered severe strokes. Nurses at our centre expressed similar discomfort. AIM To improve the comfort of nurses caring for patients at the end of life after stroke. DESIGN Nurses were asked to rate their comfort with treating patients at the end of life using the Stroke End-of-Life Care Comfort Scale before and after attending an education session. The education sessions included the presentation of a checklist for suggested orders for end-of-life care. SETTING/PARTICIPANTS The project was conducted with the neurosciences nurses at a tertiary care hospital. 54 out of a possible 122 nurses attended an education session. RESULTS There was a significant improvement in the Stroke End-of-Life Care Comfort Scale score (p=0.00004) 3-4 weeks after the education session compared to the score before the session. CONCLUSIONS The combination of focused education sessions and an order checklist can significantly improve the comfort of nurses caring for patients at the end-of-life after stroke.
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Affiliation(s)
- Jocelyn Zwicker
- Assistant Professor, Division of Neurology, Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Sarah Walsh
- Neurology Resident, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jenny Lavoie
- Palliative care nurse consultant, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Evelyn Weger
- Neurology social worker, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John Scott
- Associate Professor, Division of Palliative Care, Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
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Cerasuolo JO, Cipriano LE, Sposato LA, Kapral MK, Fang J, Gill SS, Hackam DG, Hachinski V. Population‐based stroke and dementia incidence trends: Age and sex variations. Alzheimers Dement 2017; 13:1081-1088. [DOI: 10.1016/j.jalz.2017.02.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Joshua O. Cerasuolo
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry Western University London Ontario Canada
| | - Lauren E. Cipriano
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry Western University London Ontario Canada
- Ivey Business School Western University London Ontario Canada
| | - Luciano A. Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre Western University London Ontario Canada
| | - Moira K. Kapral
- Department of Medicine University of Toronto Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences Toronto Ontario Canada
| | - Sudeep S. Gill
- Institute for Clinical Evaluative Sciences Queen's University Kingston Ontario Canada
- Division of Geriatric Medicine Queen's University Kingston Ontario Canada
- Division of Geriatric Medicine St. Mary's of the Lake Hospital Kingston Ontario Canada
| | - Daniel G. Hackam
- Division of Clinical Pharmacology, Department of Medicine Western University London Ontario Canada
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, London Health Sciences Centre Western University London Ontario Canada
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Trends and Regional Variation in Hospital Mortality, Length of Stay and Cost in Hospital of Ischemic Stroke Patients in Alberta Accompanying the Provincial Reorganization of Stroke Care. J Stroke Cerebrovasc Dis 2016; 25:2844-2850. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 07/30/2016] [Indexed: 11/23/2022] Open
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Kapral MK, Fang J, Alibhai SMH, Cram P, Cheung AM, Casaubon LK, Prager M, Stamplecoski M, Rashkovan B, Austin PC. Risk of fractures after stroke: Results from the Ontario Stroke Registry. Neurology 2016; 88:57-64. [PMID: 27881629 DOI: 10.1212/wnl.0000000000003457] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/22/2016] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To determine the risk of fractures after stroke. METHODS Using the Ontario Stroke Registry, we identified a population-based sample of consecutive patients seen in the emergency department or hospitalized with stroke (n = 23,751) or TIA (n = 11,240) at any of 11 stroke centers in Ontario, Canada, and discharged alive between July 1, 2003, and March 31, 2012. We compared the risk of low-trauma fractures in patients with stroke vs those with TIA using propensity score methods to adjust for differences in baseline factors. Secondary analyses compared fracture risk poststroke with that in age-/sex-matched controls without stroke or TIA (n = 23,751) identified from the Ontario Registered Persons Database. RESULTS The 2-year rate of fracture was 5.7% in those with stroke compared to 4.8% in those with TIA (adjusted cause-specific hazard ratio [aHR] for those with stroke vs TIA 1.32; 95% confidence interval [CI] 1.19-1.46) and 4.1% in age-/sex-matched controls (aHR for those with stroke vs controls 1.47; 95% CI 1.35-1.60). In the cohort with stroke, factors associated with fractures were older age, female sex, moderate stroke severity, prior fractures or falls, and preexisting osteoporosis, rheumatoid arthritis, hyperparathyroidism, and atrial fibrillation. CONCLUSIONS Stroke is associated with an increased risk of low-trauma fractures. Individuals with stroke and additional risk factors for fractures may benefit from targeted screening for low bone mineral density and initiation of treatment for fracture prevention.
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Affiliation(s)
- Moira K Kapral
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada.
| | - Jiming Fang
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Shabbir M H Alibhai
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Peter Cram
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Angela M Cheung
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Leanne K Casaubon
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Marla Prager
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Melissa Stamplecoski
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Brennan Rashkovan
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
| | - Peter C Austin
- From the Institute for Clinical Evaluative Sciences (M.K.K., J.F., P.C., M.S., P.C.A.), Toronto; Department of Medicine, Division of General Internal Medicine (M.K.K., S.M.H.A., P.C., A.M.C., M.P.), Institute of Health Policy, Management and Evaluation (M.K.K., S.M.H.A., P.C., A.M.C., P.C.A.), and Department of Medicine, Division of Neurology (L.K.C.), University of Toronto; Division of General Internal Medicine and Geriatrics and Toronto General Research Institute (M.K.K., S.M.H.A., P.C., A.M.C.), Osteoporosis Program and Centre for Excellence in Skeletal Health Assessment (M.K.K., S.M.H.A., A.M.C.), and Department of Medicine, Division of Neurology (L.K.C.), University Health Network, Toronto; and Schulich School of Medicine and Dentistry (B.R.), University of Western Ontario, London, Canada
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Hall RE, Fang J, Hodwitz K, Saposnik G, Bayley MT. Does the Volume of Ischemic Stroke Admissions Relate to Clinical Outcomes in the Ontario Stroke System? CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S141-7. [PMID: 26515202 DOI: 10.1161/circoutcomes.115.002079] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Better outcomes have been found among hospitals treating higher volumes of patients for specific surgical and medical conditions. We examined hospital ischemic stroke (IS) volume and 30-day mortality to inform regionalization planning. METHODS AND RESULTS Using a population-based hospital discharge administrative database (2005/2006 to 2011/2012), average annual IS patient volumes were calculated for 162 Ontario acute hospitals. Hospitals were ranked and classified as small (<126), medium (126-202), and large (>202). Hierarchical multivariable logistic regression was used to estimate the odds of death within 7 and 30 days to account for the homogeneity in outcomes for patients treated at the same hospital. Overall, 73 368 patients were hospitalized for IS, and 30-day mortality was 15.3%. The mean (±SD) of annual hospitalizations for IS was 29 (31) for small-volume hospitals, 156 (20) for medium-volume hospitals, and 300 (78) for high-volume hospitals. High-volume hospitals admitted younger patients (mean [±SD] age, 73.0 [13.9] years) compared with medium- and small-volume hospitals (74.0 [13.2] and 75.5 [12.5] years, respectively; P<0.0001). Patients at small-volume hospitals were more likely than patients at high-volume hospitals to die at 30 days after an acute IS (adjusted odds ratio, 1.37; 95% confidence interval, 1.14-1.65). CONCLUSIONS Hospital IS volume is associated with 30-day mortality in Ontario. Patients admitted to hospitals with annual IS volumes <126 annually are more likely to die within 30 days than patients admitted to hospitals that see on average 300 patients annually. This finding supports centralizing care in stroke-specialized hospitals.
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Affiliation(s)
- Ruth E Hall
- From the Institute for Clinical Evaluative Sciences (R.E.H., J.F., G.S., M.T.B.); Ontario Stroke Network (R.E.H., M.T.B.); College of Physicians and Surgeons of Ontario (K.H.); Department of Medicine, University of Toronto (G.S., M.T.B.); St. Michael's Hospital (G.S.); and Toronto Rehabilitation Institute, University Hospital Network (M.T.B.); Toronto, Ontario, Canada.
| | - Jiming Fang
- From the Institute for Clinical Evaluative Sciences (R.E.H., J.F., G.S., M.T.B.); Ontario Stroke Network (R.E.H., M.T.B.); College of Physicians and Surgeons of Ontario (K.H.); Department of Medicine, University of Toronto (G.S., M.T.B.); St. Michael's Hospital (G.S.); and Toronto Rehabilitation Institute, University Hospital Network (M.T.B.); Toronto, Ontario, Canada
| | - Kathryn Hodwitz
- From the Institute for Clinical Evaluative Sciences (R.E.H., J.F., G.S., M.T.B.); Ontario Stroke Network (R.E.H., M.T.B.); College of Physicians and Surgeons of Ontario (K.H.); Department of Medicine, University of Toronto (G.S., M.T.B.); St. Michael's Hospital (G.S.); and Toronto Rehabilitation Institute, University Hospital Network (M.T.B.); Toronto, Ontario, Canada
| | - Gustavo Saposnik
- From the Institute for Clinical Evaluative Sciences (R.E.H., J.F., G.S., M.T.B.); Ontario Stroke Network (R.E.H., M.T.B.); College of Physicians and Surgeons of Ontario (K.H.); Department of Medicine, University of Toronto (G.S., M.T.B.); St. Michael's Hospital (G.S.); and Toronto Rehabilitation Institute, University Hospital Network (M.T.B.); Toronto, Ontario, Canada
| | - Mark T Bayley
- From the Institute for Clinical Evaluative Sciences (R.E.H., J.F., G.S., M.T.B.); Ontario Stroke Network (R.E.H., M.T.B.); College of Physicians and Surgeons of Ontario (K.H.); Department of Medicine, University of Toronto (G.S., M.T.B.); St. Michael's Hospital (G.S.); and Toronto Rehabilitation Institute, University Hospital Network (M.T.B.); Toronto, Ontario, Canada
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Abstract
AbstractObjective: Administrative data validation is essential for identifying biases and misclassification in research. The objective of this study was to determine the accuracy of diagnostic codes for acute stroke and transient ischemic attack (TIA) using the Ontario Stroke Registry (OSR) as the reference standard. Methods: We identified stroke and TIA events in inpatient and emergency department (ED) administrative data from eight regional stroke centres in Ontario, Canada, from April of 2006 through March of 2008 using ICD–10–CA codes for subarachnoid haemorrhage (I60, excluding I60.8), intracerebral haemorrhage (I61), ischemic (H34.1 and I63, excluding I63.6), unable to determine stroke (I64), and TIA (H34.0 and G45, excluding G45.4). We linked administrative data to the Ontario Stroke Registry and calculated sensitivity and positive predictive value (PPV). Results:: We identified 5,270 inpatient and 4,411 ED events from the administrative data. Inpatient administrative data had an overall sensitivity of 82.2% (95% confidence interval [CI95%]=81.0, 83.3) and a PPV of 68.8% (CI95%=67.5, 70.0) for the diagnosis of stroke, with notable differences observed by stroke type. Sensitivity for ischemic stroke increased from 66.5 to 79.6% with inclusion of I64. The sensitivity and PPV of ED administrative data for diagnosis of stroke were 56.8% (CI95%=54.8, 58.7) and 59.1% (CI95%=57.1, 61.1), respectively. For all stroke types, accuracy was greater in the inpatient data than in the ED data. Conclusion: The accuracy of stroke identification based on administrative data from stroke centres may be improved by including I64 in ischemic stroke type, and by considering only inpatient data.
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The Operational and Economic Impact of a Neurovascular Unit in an Acute Care Academic Hospital. Can J Neurol Sci 2016; 42:292-8. [PMID: 26348900 DOI: 10.1017/cjn.2015.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is strong evidence that clinical outcomes are improved for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital (TWH) created a Neurovascular Unit (NVU) using resources from General Internal Medicine, Neurology, and Neurosurgery for patients with stroke and acute neurovascular conditions. Under resource-constrained conditions, the operational and economic impacts of the Neurovascular Unit were unknown. METHODS Retrospective patient-level data was studied from two years prior and one year post NVU implementation. Descriptive statistical analysis and non-parametric testing were conducted on the acute length of stay (LOS), alternate level of care LOS, total cost per bed-day and per visit, and patient flow within each medical service and hospital wide. RESULTS The median acute LOS per hospitalization for NVU-eligible patients decreased significantly (p=0.001). For Neurology patients, mean acute LOS decreased from 9.1 days pre-Neurovascular Unit to 7.6 days post and median acute LOS decreased from 6 to 5 days (p=0.002); however, mean alternate level of care LOS per visit more than doubled (from 1.6 to 4.1 days, p=0.001). For the Neurology service, the mean cost per visit decreased by $945, representing a 5% reduction (p=0.042) and the mean cost per bed-day decreased by $233, or 12.5% (p=0.026). Hospital wide, a saving of over C$450 000 was achieved. CONCLUSIONS During the first year of operation, the NVU at TWH achieved decreased acute LOS per visit and lowered the total hospitalization cost per year for NVU-eligible patients. Addressing the issue of increased alternate level of care LOS could result in additional efficiencies.
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Tung YC, Chang GM. The Relationships Among Regionalization, Processes, and Outcomes for Stroke Care: A Nationwide Population-based Study. Medicine (Baltimore) 2016; 95:e3327. [PMID: 27082581 PMCID: PMC4839825 DOI: 10.1097/md.0000000000003327] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Regionalization for stroke care, including stroke center designation, is being implemented in the United States, Canada, or other countries. Limited information is available, however, concerning the relationships among regionalization, processes, and outcomes for stroke care. We examined the association of regionalization with processes and outcomes, and the mediating effect of processes of care on the association between regionalization and mortality for acute stroke in Taiwan. We analyzed all 229,568 admissions with acute ischemic stroke from January 2004 to September 2012 through Taiwan's National Health Insurance Research Database. Regionalized care for acute stroke has been implemented since July 2009 in Taiwan. Rates of thrombolytic therapy within 3 hours after onset of ischemic stroke, average numbers of processes of care, and 30-day mortality rates at monthly intervals for baseline (66 months) and 39 months after the implementation of regionalization. After accounting for secular trends and other confounders, changes in rates of thrombolytic therapy (level change 0.269% per month, P = 0.017 and trend change 0.010% per month, P = 0.048), average numbers of processes of care (trend change 0.001 per month, P = 0.030), and 30-day mortality rates (level change -0.442% per month, P = 0.007 and trend change -0.021% per month, P = 0.015) were attributable to regionalization. The processes of care were mediators of the association between regionalization and 30-day mortality after stroke. Regionalization for stroke care may improve timeliness and processes of stroke care, including access to timely thrombolytic therapy from emergency medical services to hospital care, which may in turn enhance stroke outcomes.
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Affiliation(s)
- Yu-Chi Tung
- From the Institute of Health Policy and Management, National Taiwan University (Y-CT), Taipei; and Department of Family Medicine, Cardinal Tien Hospital; and School of Medicine, Fu Jen Catholic University (G-MC), New Taipei City, Taiwan
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The association between rural residence and stroke care and outcomes. J Neurol Sci 2016; 363:16-20. [DOI: 10.1016/j.jns.2016.02.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 11/18/2022]
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Kapral MK, Hall R, Fang J, Austin PC, Silver FL, Gladstone DJ, Casaubon LK, Stamplecoski M, Tu JV. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology 2016; 86:1582-9. [PMID: 27016521 DOI: 10.1212/wnl.0000000000002614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 12/04/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the care and outcomes of patients with TIA or minor stroke admitted to the hospital vs discharged from the emergency department (ED). METHODS We used the Ontario Stroke Registry to create a cohort of patients with minor ischemic stroke/TIA who presented to the hospital April 1, 2008, to March 31, 2009, or April 1, 2010, to March 31, 2011, in the province of Ontario, Canada. We compared processes of care and outcomes (death or recurrent stroke/TIA) in patients admitted to the hospital and discharged with and without stroke prevention clinic follow-up. RESULTS In our sample of 8,540 patients, the use of recommended interventions was highest in admitted patients, followed by discharged patients referred to prevention clinics, followed by those discharged without clinic referral. Eight percent of nonadmitted patients returned to the hospital with recurrent stroke/TIA within 1 week of the index event. One-year stroke case-fatality was similar in admitted and discharged patients (adjusted hazard ratio 1.11; 95% confidence interval 0.92-1.34). Among patients discharged from EDs, referral to a stroke prevention clinic was associated with a markedly lower risk of mortality (adjusted hazard ratio 0.49; 95% confidence interval 0.38-0.64). CONCLUSIONS Patients with minor ischemic stroke or TIA discharged from the ED are less likely than admitted patients to receive timely stroke care interventions. Among discharged patients, referral to a stroke prevention clinic is associated with improved processes of care and lower mortality. Additional strategies are needed to improve access to high-quality outpatient TIA care.
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Affiliation(s)
- Moira K Kapral
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Ruth Hall
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jiming Fang
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Peter C Austin
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Frank L Silver
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - David J Gladstone
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Leanne K Casaubon
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Melissa Stamplecoski
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jack V Tu
- From the Institute for Clinical Evaluative Sciences (M.K.K., R.H., J.F., P.C.A., F.L.S., D.J.G., M.S., J.V.T.), Toronto; Department of Medicine (M.K.K., F.L.S., D.J.G., L.K.C., J.V.T.), University of Toronto; Institute of Health Policy, Management and Evaluation (M.K.K., R.H., P.C.A., J.V.T.), Toronto; Division of General Internal Medicine and Toronto General Research Institute (M.K.K.) and Division of Neurology (F.L.S.), University Health Network, Toronto; Sunnybrook Research Institute (M.K.K., D.J.G., J.V.T.), Toronto; and Divisions of Neurology (D.J.G.) and Cardiology (J.V.T.), Sunnybrook Health Sciences Centre, Toronto, Canada
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Ganesh A, Lindsay P, Fang J, Kapral MK, Côté R, Joiner I, Hakim AM, Hill MD. Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis. Neurology 2016; 86:898-904. [PMID: 26850979 PMCID: PMC4782112 DOI: 10.1212/wnl.0000000000002443] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 10/07/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the association between the presence of integrated systems of stroke care and stroke case-fatality across Canada. METHODS We used the Canadian Institute of Health Information's Discharge Abstract Database to retrospectively identify a cohort of stroke/TIA patients admitted to all acute care hospitals, excluding the province of Quebec, in 11 fiscal years from 2003/2004 to 2013/2014. We used a modified Poisson regression model to compute the adjusted incidence rate ratio (aIRR) of 30-day in-hospital mortality across time for provinces with stroke systems compared to those without, controlling for age, sex, stroke type, comorbidities, and discharge year. We conducted surveys of stroke care resources in Canadian hospitals in 2009 and 2013, and compared resources in provinces with integrated systems to those without. RESULTS A total of 319,972 patients were hospitalized for stroke/TIA. The crude 30-day mortality rate decreased from 15.8% in 2003/2004 to 12.7% in 2012/2013 in provinces with stroke systems, while remaining 14.5% in provinces without such systems. Starting with the fiscal year 2009/2010, there was a clear reduction in relative mortality in provinces with stroke systems vs those without, sustained at aIRR of 0.85 (95% confidence interval 0.79-0.92) in the 2011/2012, 2012/2013, and 2013/2014 fiscal years. The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services. CONCLUSION In this retrospective study, the implementation of integrated systems of stroke care was associated with a population-wide reduction in mortality after stroke.
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Affiliation(s)
- Aravind Ganesh
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Patrice Lindsay
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Jiming Fang
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Moira K Kapral
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Robert Côté
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Ian Joiner
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Antoine M Hakim
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada
| | - Michael D Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G.), and Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine (M.D.H.), University of Calgary; The Heart & Stroke Foundation of Canada (P.L., I.J.), Ottawa; Institute for Clinical Evaluative Sciences (J.F., M.K.K.), Toronto; Department of Medicine (M.K.K.), University of Toronto; Department of Neurology (R.C.), McGill University, Montréal; and Division of Neurology and Ottawa Hospital Research Institute (A.M.H.), University of Ottawa and The Heart & Stroke Foundation Centre for Stroke Recovery, Ottawa, Canada.
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Temporal Changes in the Quality of Acute Stroke Care in Five National Audits across Europe. BIOMED RESEARCH INTERNATIONAL 2015; 2015:432497. [PMID: 26783519 PMCID: PMC4689962 DOI: 10.1155/2015/432497] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022]
Abstract
Background. Data on potential variations in delivery of appropriate stroke care over time are scarce. We investigated temporal changes in the quality of acute hospital stroke care across five national audits in Europe over a period of six years. Methods. Data were derived from national stroke audits in Germany, Poland, Scotland, Sweden, and England/Wales/Northern Ireland participating within the European Implementation Score (EIS) collaboration. Temporal changes in predefined quality indicators with comparable information between the audits were investigated. Multivariable logistic regression analyses were performed to estimate adherence to quality indicators over time. Results. Between 2004 and 2009, individual data from 542,112 patients treated in 538 centers participating continuously over the study period were included. In most audits, the proportions of patients who were treated on a SU, were screened for dysphagia, and received thrombolytic treatment increased over time and ranged from 2-fold to almost 4-fold increase in patients receiving thrombolytic therapy in 2009 compared to 2004. Conclusions. A general trend towards a better quality of stroke care defined by standardized quality indicators was observed over time. The association between introducing a specific measure and higher adherence over time might indicate that monitoring of stroke care performance contributes to improving quality of care.
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Merali Z, Sharma S, MacDonald RD, Massicotte EM. Emergent and Urgent Transfers to Neurosurgical Centers in Ontario. PREHOSP EMERG CARE 2015; 20:245-53. [PMID: 26529260 DOI: 10.3109/10903127.2015.1086847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Critically ill neurosurgical patients require expedient access to neurosurgical centers (NC) to improve outcome. In regionalized health systems patients are often initially evaluated at a non-neurosurgical center (NNC) and are subsequently transferred to a NC using air or ground vehicles. We sought to identify barriers to accessing a NC for critically ill patients by analyzing interfacility transfer times and referral patterns in the province of Ontario. A retrospective observational analysis was undertaken. The cohort included patients in Ontario with emergent and urgent neurologic pathologies who underwent transfer from a NNC to NC between January 1, 2011 and December 31, 2013. Timing, clinical, and geographic data were collected for each transfer. We identified 1103 emergent/urgent transfers. The median transfer time to a NC was 3.4 h (IQR -2.2, 3.8) and varied by the geographic region of origin. A total of 17% of the patients bypassed a closer NC during transfer to their destination NC. Transfers that bypassed a closer NC travelled further (101 miles vs. 296 miles, p < 0.001), took longer (3.1 h vs. 3.9 h, p < 0.001), and in some regions were associated with a higher risk of in-transit clinical decline (3.0% vs. 8.3%, p < 0.05) when compared with transfers that ended at the closest NC. Regionalization of neurosurgical services in Ontario has led to heavy reliance upon patient transfers to maintain continuity of care. Access to a NC varied across the province, which may represent regional differences in neurosurgical bed availability, resource limitations at smaller NCs, or environmental factors. Our descriptions of referral patterns and transport times can guide health system planning in Ontario and similar jurisdictions in the United States and Canada.
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Willeit J, Geley T, Schöch J, Rinner H, Tür A, Kreuzer H, Thiemann N, Knoflach M, Toell T, Pechlaner R, Willeit K, Klingler N, Praxmarer S, Baubin M, Beck G, Berek K, Dengg C, Engelhardt K, Erlacher T, Fluckinger T, Grander W, Grossmann J, Kathrein H, Kaiser N, Matosevic B, Matzak H, Mayr M, Perfler R, Poewe W, Rauter A, Schoenherr G, Schoenherr HR, Schinnerl A, Spiss H, Thurner T, Vergeiner G, Werner P, Wöll E, Willeit P, Kiechl S. Thrombolysis and clinical outcome in patients with stroke after implementation of the Tyrol Stroke Pathway: a retrospective observational study. Lancet Neurol 2015; 14:48-56. [DOI: 10.1016/s1474-4422(14)70286-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Regional variations in in-hospital mortality, care processes, and spending in acute ischemic stroke patients in Japan. J Stroke Cerebrovasc Dis 2014; 24:239-51. [PMID: 25444024 DOI: 10.1016/j.jstrokecerebrovasdis.2014.09.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/11/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Little is known about the regional variations in ischemic stroke care in Japan. This study investigates the regional variations and associations among outcomes, care processes, spending, and physician workforce availability in acute ischemic stroke care. METHODS Using administrative claims data from National Claims Database, we identified National Health Insurance beneficiaries aged 65 years and older and Long Life Medical Care System beneficiaries from 9 prefectures who had been hospitalized for acute ischemic stroke between April 2010 and March 2012. Patients were grouped according to their subprefectural regions of residence known as secondary medical areas (SMAs). Performances in 8 outcome and process of care measures were analyzed in each SMA. Multilevel regression models with 2 levels (patient and regional) were used to analyze age- and sex-adjusted in-hospital mortality, hospitalization spending, and tissue plasminogen activator (tPA) utilization rate. The associations between regional supply of physicians for stroke care and the various quality measures were investigated. RESULTS We analyzed 49,440 acute ischemic stroke patients. The regional variations among SMAs in in-hospital mortality, spending, and tPA utilization were 3.2-, 1.7-, and 5.9-fold, respectively. Higher physician supply was significantly associated with lower in-hospital mortality and higher spending. Additionally, spending had a significantly negative correlation with regional continuity of care planning rate but a significantly positive correlation with rehabilitation rate. CONCLUSIONS The study revealed substantial regional variations in Japanese ischemic stroke care. Improving the allocative efficiency of physicians and establishing continuity of care networks may be useful in mitigating regional disparities and reconstructing the stroke care system.
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Hahn-Goldberg S, Chow E, Appel E, Ko FTF, Tan P, Gavin MB, Ng T, Abrams HB, Casaubon LK, Carter MW. Discrete event simulation of patient admissions to a neurovascular unit. JOURNAL OF HEALTHCARE ENGINEERING 2014; 5:347-59. [PMID: 25193372 DOI: 10.1260/2040-2295.5.3.347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Evidence exists that clinical outcomes improve for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital created a Neurovascular Unit (NVU) using beds from general internal medicine, Neurology and Neurosurgery to care for patients with stroke and acute neurovascular conditions. Using patient-level data for NVU-eligible patients, a discrete event simulation was created to study changes in patient flow and length of stay pre- and post-NVU implementation. Varying patient volumes and resources were tested to determine the ideal number of beds under various conditions. In the first year of operation, the NVU admitted 507 patients, over 66% of NVU-eligible patient volumes. With the introduction of the NVU, length of stay decreased by around 8%. Scenario testing showed that the current level of 20 beds is sufficient for accommodating the current demand and would continue to be sufficient with an increase in demand of up to 20%.
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Affiliation(s)
- S Hahn-Goldberg
- Centre for Innovation in Complex Care, University Health Network, Toronto, Ontario, Canada
| | - E Chow
- Centre for Innovation in Complex Care, University Health Network, Toronto, Ontario, Canada
| | - E Appel
- Centre for Innovation in Complex Care, University Health Network, Toronto, Ontario, Canada
| | - F T F Ko
- Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - P Tan
- Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - M B Gavin
- Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - T Ng
- Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - H B Abrams
- Centre for Innovation in Complex Care, University Health Network, Toronto, Ontario, Canada University Health Network, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada
| | - L K Casaubon
- University Health Network, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada
| | - M W Carter
- Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Barbara G. Vickrey
- From the Department of Neurology, University of California, Los Angeles (B.G.V.); Department of Neurology, Greater Los Angeles VA HealthCare System, CA (B.G.V.); Epidemiology and Prevention Unit, Stroke and Ageing Research Centre (STARC), Department of Medicine, Southern Clinical School, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia (A.G.T.); and National Stroke Research Institute, Florey Neuroscience Institutes, Heidelberg, Victoria, Australia (A.G.T.)
| | - Amanda G. Thrift
- From the Department of Neurology, University of California, Los Angeles (B.G.V.); Department of Neurology, Greater Los Angeles VA HealthCare System, CA (B.G.V.); Epidemiology and Prevention Unit, Stroke and Ageing Research Centre (STARC), Department of Medicine, Southern Clinical School, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia (A.G.T.); and National Stroke Research Institute, Florey Neuroscience Institutes, Heidelberg, Victoria, Australia (A.G.T.)
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