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Sankar A, Stukel TA, Baxter NN, Wijeysundera DN, Hwang SW, Wilton AS, Chan TCY, Sarhangian V, Simpson AN, de Mestral C, Pincus D, Campbell RJ, Urbach DR, Irish J, Gomez D. Disparities in surgery rates during the COVID-19 pandemic: retrospective study. BJS Open 2024; 8:zrae088. [PMID: 39186678 PMCID: PMC11346633 DOI: 10.1093/bjsopen/zrae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/11/2024] [Accepted: 07/03/2024] [Indexed: 08/28/2024] Open
Affiliation(s)
- Ashwin Sankar
- Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anaesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anaesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Timothy C Y Chan
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Vahid Sarhangian
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Andrea N Simpson
- Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Charles de Mestral
- Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Pincus
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert J Campbell
- ICES, Toronto, Ontario, Canada
- Department of Ophthalmology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - David R Urbach
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Irish
- Department of Otolaryngology-Head and Neck Surgery and Surgical Oncology, University Health Network, University of Toronto, and Cancer Care Ontario-Ontario Health, Toronto, Ontario, Canada
| | - David Gomez
- Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Hatch WV, Leung V, Ahmed I, Schlenker M, Babaei Omali N, Pope K, Lebovic G, McReelis K, Delpero W, Campbell RJ, El Defrawy S. Ontario Cataract Quality Outcome Initiative: appropriateness and prioritization of cataract surgery. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:382-390. [PMID: 35792177 DOI: 10.1016/j.jcjo.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To explore the utility of the Catquest 9SF visual function (VF) questionnaire along with visual acuity (VA) for determining appropriateness and priority for cataract surgery. To evaluate the feasibility of administering the Catquest-9SF in a clinical setting using web-based electronic data capture and interpretation. DESIGN Prospective multicentred interventional observational study. PARTICIPANTS Subjects undergoing sequential cataract surgery in both eyes at 4 sites in Ontario. METHODS We recorded best-corrected VA (BCVA) and VA with current correction (CCVA) in each eye and both eyes (OU) and Catquest-9SF responses on a tablet before and after cataract surgery. Linear regression models were employed to test for associations between VA and visual function (VF). RESULTS Preoperative BCVA and CCVA in the worse eye were significant predictors of change in VF (p = 0.006 and p = 0.008, respectively); subjects with worse VA had a greater improvement in VF after surgery. There was a significant association between improvement in VF and improvement in CCVA OU (p = 0.001). Fourteen of 151 subjects (9%) had no improvement or worse VF scores after surgery. Within this group, 10 of 14 subjects had a preoperative score ≤-3, which is suggestive of minimal visual disability. Within this subset, 4 of 14 subjects (2.6%) had a preoperative BCVA of 20/30 or better in their worse eye. CONCLUSIONS For patient groups with equal VA, the Catquest-9SF score can help determine priority for surgery. Web-based data capture and interpretation allow for efficient virtual assessments of VF. A BCVA in the worse eye of 20/30 or better combined with a Catquest-9SF score <-3 can be used as a guideline for lowest priority.
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Affiliation(s)
- Wendy V Hatch
- Kensington Eye Institute, Toronto, ON; Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON.
| | - Victoria Leung
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON
| | - Iqbal Ahmed
- Kensington Eye Institute, Toronto, ON; Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON; Prism Eye Institute, Brampton, ON
| | - Matthew Schlenker
- Kensington Eye Institute, Toronto, ON; Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON; Prism Eye Institute, Brampton, ON
| | | | - Karen Pope
- Unity Health Toronto, St. Michael's Hospital, Toronto, ON
| | - Gerald Lebovic
- Unity Health Toronto, St. Michael's Hospital, Toronto, ON; Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON
| | - Kylen McReelis
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON; Department of Ophthalmology, Peterborough Regional Health Centre, Peterborough, ON
| | - Walter Delpero
- Department of Ophthalmology, University of Ottawa, Ottawa, ON
| | - Robert J Campbell
- Department of Ophthalmology, Queen's University, Kingston, ON; Department of Ophthalmology, Kingston Health Sciences Centre, Kingston, ON; Scientist, Institute for Clinical Evaluative Sciences, Toronto, ON
| | - Sherif El Defrawy
- Kensington Eye Institute, Toronto, ON; Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON
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Jivraj NK, Ladha KS, Goel A, Hill A, Wijeysundera DN, Bateman BT, Neuman M, Wunsch H. Nonopioid Analgesic Prescriptions Filled after Surgery among Older Adults in Ontario, Canada: A Population-based Cohort Study. Anesthesiology 2023; 138:195-207. [PMID: 36512729 PMCID: PMC10411646 DOI: 10.1097/aln.0000000000004443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective was to assess changes over time in prescriptions filled for nonopioid analgesics for older postoperative patients in the immediate postdischarge period. The authors hypothesized that the number of patients who filled a nonopioid analgesic prescription increased during the study period. METHODS The authors performed a population-based cohort study using linked health administrative data of 278,366 admissions aged 66 yr or older undergoing surgery between fiscal year 2013 and 2019 in Ontario, Canada. The primary outcome was the percentage of patients with new filled prescriptions for nonopioid analgesics within 7 days of discharge, and the secondary outcome was the analgesic class. The authors assessed whether patients filled prescriptions for a nonopioid only, an opioid only, both opioid and nonopioid prescriptions, or a combination opioid/nonopioid. RESULTS Overall, 22% (n = 60,181) of patients filled no opioid prescription, 2% (n = 5,534) filled a nonopioid only, 21% (n = 59,608) filled an opioid only, and 55% (n = 153,043) filled some combination of opioid and nonopioid. The percentage of patients who filled a nonopioid prescription within 7 days postoperatively increased from 9% (n = 2,119) in 2013 to 28% (n = 13,090) in 2019, with the greatest increase for acetaminophen: 3% (n = 701) to 20% (n = 9,559). The percentage of patients who filled a combination analgesic prescription decreased from 53% (n = 12,939) in 2013 to 28% (n = 13,453) in 2019. However, the percentage who filled both an opioid and nonopioid prescription increased: 4% (n = 938) to 21% (n = 9,880) so that the overall percentage of patients who received both an opioid and a nonopioid remained constant over time 76% (n = 18,642) in 2013 to 75% (n = 35,391) in 2019. CONCLUSIONS The proportion of postoperative patients who fill prescriptions for nonopioid analgesics has increased. However, rather than a move to use of nonopioids alone for analgesia, this represents a shift away from combination medications toward separate prescriptions for opioids and nonopioids. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Naheed K Jivraj
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Akash Goel
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Mark Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Wunsch
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Quinn KL, Huang A, Bell CM, Detsky AS, Lapointe-Shaw L, Rosella LC, Urbach DR, Razak F, Verma AA. Complications Following Elective Major Noncardiac Surgery Among Patients With Prior SARS-CoV-2 Infection. JAMA Netw Open 2022; 5:e2247341. [PMID: 36525270 PMCID: PMC9856240 DOI: 10.1001/jamanetworkopen.2022.47341] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE There is an urgent need for evidence to inform preoperative risk assessment for the millions of people who have had SARS-CoV-2 infection and are awaiting elective surgery, which is critical to surgical care planning and informed consent. OBJECTIVE To assess the association of prior SARS-CoV-2 infection with death, major adverse cardiovascular events, and rehospitalization after elective major noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study included adults who had received a polymerase chain reaction test for SARS-CoV-2 infection within 6 months prior to elective major noncardiac surgery in Ontario, Canada, between April 2020 and October 2021, with 30 days follow-up. EXPOSURES Positive SARS-CoV-2 polymerase chain reaction test result. MAIN OUTCOMES AND MEASURES The main outcome was the composite of death, major adverse cardiovascular events, and all-cause rehospitalization within 30 days after surgery. RESULTS Of 71 144 patients who underwent elective major noncardiac surgery (median age, 66 years [IQR, 57-73 years]; 59.8% female), 960 had prior SARS-CoV-2 infection (1.3%) and 70 184 had negative test results (98.7%). Prior infection was not associated with the composite risk of death, major adverse cardiovascular events, and rehospitalization within 30 days of elective major noncardiac surgery (5.3% absolute event rate [n = 3770]; 960 patients with a positive test result; adjusted relative risk [aRR], 0.91; 95% CI, 0.68-1.21). There was also no association between prior infection with SARS-CoV-2 and postoperative outcomes when the time between infection and surgery was less than 4 weeks (aRR, 1.15; 95% CI, 0.64-2.09) or less than 7 weeks (aRR, 0.95; 95% CI, 0.56-1.61) and among those who were previously vaccinated (aRR, 0.81; 95% CI, 0.52-1.26). CONCLUSIONS AND RELEVANCE In this study, prior infection with SARS-CoV-2 was not associated with death, major adverse cardiovascular events, or rehospitalization following elective major noncardiac surgery, although low event rates and wide 95% CIs do not preclude a potentially meaningful increase in overall risk.
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Affiliation(s)
- Kieran L. Quinn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
- Temmy Latner Centre for Palliative Care, Toronto, Ontario, Canada
| | - Anjie Huang
- ICES, Toronto, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
| | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Allan S. Detsky
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Laura C. Rosella
- ICES, Toronto, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David R. Urbach
- Women’s College Hospital, Women’s College Research Institute, Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Department of Medicine, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Amol A. Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Department of Medicine, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Trends in postoperative opioid prescribing in Ontario between 2013 and 2019: a population-based cohort study. Can J Anaesth 2022; 69:974-985. [DOI: 10.1007/s12630-022-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/15/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
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Patient Sex and Postoperative Outcomes after Inpatient Intraabdominal Surgery: A Population-based Retrospective Cohort Study. Anesthesiology 2022; 136:577-587. [PMID: 35188547 DOI: 10.1097/aln.0000000000004136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Intraabdominal surgeries are frequently performed procedures that lead to a high volume of unplanned readmissions and postoperative complications. Patient sex may be a determinant of adverse outcomes in this population, possibly due to differences in biology or care delivery, but it is understudied. The authors hypothesized that there would be no association between patient sex and the risk of postoperative adverse outcomes in intraabdominal surgery. METHODS This retrospective, population-based cohort study involved adult inpatients aged 18 yr or older who underwent intraabdominal surgeries in Ontario, Canada, between April 2009 and March 2016. The authors studied the association of patient sex on the primary composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Inverse probability of exposure weighting based on propensity scores (computed using demographic characteristics such as rural residence status and median neighborhood income quintile, common comorbidities, and surgery- and hospital-specific characteristics) was used to estimate the adjusted association of sex on outcomes. RESULTS The cohort included 215,846 patients (52.3% female). The primary outcome was observed in 24,712 (21.9%) females and 25,486 (24.7%) males (unadjusted risk difference, 2.8% [95% CI, 2.5 to 3.2%]; P < 0.001). After adjustment, the association between the male sex and the primary outcome was not statistically significant (adjusted risk difference, -0.2% [95% CI, -0.5 to 0.2%]; P = 0.378). CONCLUSIONS In a large population of intraabdominal surgical patients, there was no differential risk between sexes in the composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. EDITOR’S PERSPECTIVE
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Cusimano MC, Moineddin R, Chiu M, Ferguson SE, Aktar S, Liu N, Baxter NN. Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study. Am J Obstet Gynecol 2021; 224:585.e1-585.e30. [PMID: 33359174 DOI: 10.1016/j.ajog.2020.12.1206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown. OBJECTIVE This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research. STUDY DESIGN We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications. RESULTS Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records. CONCLUSION Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.
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Cost-effectiveness Analysis of Preoperative Screening Strategies for Obstructive Sleep Apnea among Patients Undergoing Elective Inpatient Surgery. Anesthesiology 2020; 133:787-800. [DOI: 10.1097/aln.0000000000003429] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background
Obstructive sleep apnea is underdiagnosed in surgical patients. The cost-effectiveness of obstructive sleep apnea screening is unknown. This study’s objective was to evaluate the cost-effectiveness of preoperative obstructive sleep apnea screening (1) perioperatively and (2) including patients’ remaining lifespans.
Methods
An individual-level Markov model was constructed to simulate the perioperative period and lifespan of patients undergoing inpatient elective surgery. Costs (2016 Canadian dollars) were calculated from the hospital perspective in a single-payer health system. Remaining model parameters were derived from a structured literature search. Candidate strategies included: (1) no screening; (2) STOP-Bang questionnaire alone; (3) STOP-Bang followed by polysomnography (STOP-Bang + polysomnography); and (4) STOP-Bang followed by portable monitor (STOP-Bang + portable monitor). Screen-positive patients (based on STOP-Bang cutoff of at least 3) received postoperative treatment modifications and expedited definitive testing. Effectiveness was expressed as quality-adjusted life month in the perioperative analyses and quality-adjusted life years in the lifetime analyses. The primary outcome was the incremental cost-effectiveness ratio.
Results
In perioperative and lifetime analyses, no screening was least costly and least effective. STOP-Bang + polysomnography was the most effective strategy and was more cost-effective than both STOP-Bang + portable monitor and STOP-Bang alone in both analyses. In perioperative analyses, STOP-Bang + polysomnography was not cost-effective compared to no screening at the $4,167/quality-adjusted life month threshold (incremental cost-effectiveness ratio $52,888/quality-adjusted life month). No screening was favored in more than 90% of iterations in probabilistic sensitivity analyses. In contrast, in lifetime analyses, STOP-Bang + polysomnography was favored compared to no screening at the $50,000/quality-adjusted life year threshold (incremental cost-effectiveness ratio $2,044/quality-adjusted life year). STOP-Bang + polysomnography was favored in most iterations at thresholds above $2,000/quality-adjusted life year in probabilistic sensitivity analyses.
Conclusions
The cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Jivraj NK, Raghavji F, Bethell J, Wijeysundera DN, Ladha KS, Bateman BT, Neuman MD, Wunsch H. Persistent Postoperative Opioid Use: A Systematic Literature Search of Definitions and Population-based Cohort Study. Anesthesiology 2020; 132:1528-1539. [PMID: 32243330 PMCID: PMC8202398 DOI: 10.1097/aln.0000000000003265] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events. METHODS The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery. RESULTS Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00. CONCLUSIONS The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
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Affiliation(s)
- Naheed K Jivraj
- From the Department of Anesthesiology and Pain Medicine (N.K.J., D.N.W., K.S.L., H.W.) Interdepartmental Division of Critical Care Medicine (H.W.), University of Toronto, Toronto, Canada the Institute of Health Policy Management and Evaluation, Toronto, Canada (N.K.J., D.N.W., K.S.L., H.W.) the University of Limerick, Limerick, Ireland (F.R.) the Sunnybrook Research Institute, Toronto, Canada (J.B., H.W.) the Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada (D.N.W., K.S.L.) the Department of Anesthesia, Perioperative, and Pain Medicine, and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B.) the Department of Anesthesiology and Critical Care, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (M.D.N.) the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada (H.W.)
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Disparities in Deep Brain Stimulation Use for Parkinson's Disease in Ontario, Canada. Can J Neurol Sci 2020; 47:642-655. [PMID: 32329424 DOI: 10.1017/cjn.2020.79] [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
OBJECTIVE To examine whether sociodemographic characteristics and health care utilization are associated with receiving deep brain stimulation (DBS) surgery for Parkinson's disease (PD) in Ontario, Canada. METHODS Using health administrative data, we identified a cohort of individuals aged 40 years or older diagnosed with incident PD between 1995 and 2009. A case-control study was used to examine whether select factors were associated with DBS for PD. Patients were classified as cases if they underwent DBS surgery at any point 1-year after cohort entry until December 31, 2016. Conditional logistic regression modeling was used to estimate the adjusted odds of DBS surgery for sociodemographic and health care utilization indicators. RESULTS A total of 46,237 individuals with PD were identified, with 543 (1.2%) receiving DBS surgery. Individuals residing in northern Ontario were more likely than southern patients to receive DBS surgery [adjusted odds ratio (AOR) = 2.23, 95% confidence interval (CI) = 1.15-4.34]; however, regional variations were not observed after accounting for medication use among older adults (AOR = 1.04, 95% CI = 0.26-4.21). Patients living in neighborhoods with the highest concentration of visible minorities were less likely to receive DBS surgery compared to patients living in predominantly white neighborhoods (AOR = 0.27, 95% CI = 0.16-0.46). Regular neurologist care and use of multiple PD medications were positively associated with DBS surgery. CONCLUSIONS Variations in use of DBS may reflect differences in access to care, specialist referral pathways, health-seeking behavior, or need for DBS. Future studies are needed to understand drivers of potential disparities in DBS use.
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Weyerstraß J, Prediger B, Neugebauer E, Pieper D. Results of a patient-oriented second opinion program in Germany shows a high discrepancy between initial therapy recommendation and second opinion. BMC Health Serv Res 2020; 20:237. [PMID: 32192450 PMCID: PMC7083019 DOI: 10.1186/s12913-020-5060-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 02/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background As of 2015, second opinions are legally implemented in Germany. However, empirical results from German second opinion programs are lacking. The aim of this study was to examine several aspects within a population of a German second opinion program. Methods Study population consisted of patients who sought a second opinion in the period from August 2011 to December 2016. Multivariate logistic regression and ANOVA were used to examine differences in patient characteristics, differentiated by agreement of initial therapy recommendation and second opinion. Follow-up points for patient satisfaction and HRQoL were defined at 1, 3 and 6 months after obtaining the second opinion. Results Total number of patients who sought a second opinion was 1414. Most common indications concerned the knee (37.3%), spine (27.3%), hip (11.5%) and shoulder (10.1%). The independent specialists did not confirm the initial therapy recommendations in two out of three cases. The type of indication influenced the agreement between initial therapy recommendation and the second opinion significantly (p = 0.035). The second opinion and the offered service was highly valued by the patients (89%). Conclusions The second opinion offers patients the possibility to confirm a medical indication independently and support patients in their decision making process. Reasons for the large discrepancy between initial therapy recommendation and second opinion should be addressed in future research.
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Affiliation(s)
- Jan Weyerstraß
- University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, Witten, 58455, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Edmund Neugebauer
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.,Brandenburg Medical School Theodor Fontane (MHB), Brandenburg, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.
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Jivraj NK, Scales DC, Gomes T, Bethell J, Hill A, Pinto R, Wijeysundera DN, Wunsch H. Evaluation of opioid discontinuation after non-orthopaedic surgery among chronic opioid users: a population-based cohort study. Br J Anaesth 2020; 124:281-291. [PMID: 32000975 DOI: 10.1016/j.bja.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Many patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. METHODS We performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. RESULTS The cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. CONCLUSIONS For chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.
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Affiliation(s)
- Naheed K Jivraj
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
| | - Damon C Scales
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Tara Gomes
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | | | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy Management and Evaluation, Toronto, ON, Canada; Department of Anaesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
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Nouhi M, Hadian M, Jahangiri R, Hakimzadeh M, Gray S, Olyaeemanesh A. The economic consequences of practice style variation in providing medical interventions: A systematic review of the literature. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2019; 8:119. [PMID: 31334271 PMCID: PMC6615132 DOI: 10.4103/jehp.jehp_386_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 01/12/2019] [Indexed: 05/03/2023]
Abstract
The practice style variation (PSV) incurs undesirable clinical and economic consequences for patients and the healthcare system. This review aims to analyze the economic consequences of PSV in medical interventions. A comprehensive electronic search was conducted through PubMed, Web of Sciences, EBSCO, EMBASE, and Cochrane databases to retrieve studies on economic consequences of PSV within 1975-2018. The studies were independently assessed by two reviewers. The quality of studies was assessed by Strengthening the Reporting of Observational Studies in Epidemiology checklist. No language restriction was applied. Only four studies met the eligibility criteria. These studies have been conducted retrospectively in developed countries. Most of the included studies used consumer demand theory to measure the economic consequences of PSV. Findings showed 12%-74% of all variations in healthcare services are related to PSV, thereby incurring up to 23 million dollars for the healthcare system. The PSV is related to the total expenditure, price elasticity, and coefficient of variation of healthcare services. PSV associated with huge inefficiency and inequity in access to healthcare services. To mitigate the consequences of PSV, policymakers should consider PSV in both developing the medical education plans as well as cost management. Using multilevel analysis to investigate the determinants of PSV would be beneficial.
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Affiliation(s)
- Mojtaba Nouhi
- Health Economics Department, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Hadian
- Health Economics Department, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
- Address for correspondence: Dr. Mohamad Hadian, Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran. E-mail:
| | - Reza Jahangiri
- Health Economics Department, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Hakimzadeh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Serajaddin Gray
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Olyaeemanesh
- Health Economics Department, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
- Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
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14
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Muratov S, Lee J, Holbrook A, Costa A, Paterson JM, Guertin JR, Mbuagbaw L, Gomes T, Khuu W, Tarride JE. Regional variation in healthcare spending and mortality among senior high-cost healthcare users in Ontario, Canada: a retrospective matched cohort study. BMC Geriatr 2018; 18:262. [PMID: 30382828 PMCID: PMC6211423 DOI: 10.1186/s12877-018-0952-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. This study describes the regional variation in healthcare costs and mortality across Ontario’s health planning districts [Local Health Integration Networks (LHIN)] among senior incident HCU and non-HCU and explores the relationship between healthcare spending and mortality. Methods We conducted a retrospective population-based matched cohort study of incident senior HCU defined as Ontarians aged ≥66 years in the top 5% most costly healthcare users in fiscal year (FY) 2013. We matched HCU to non-HCU (1:3) based on age, sex and LHIN. Primary outcomes were LHIN-based variation in costs (total and 12 cost components) and mortality during FY2013 as measured by variance estimates derived from multi-level models. Outcomes were risk-adjusted for age, sex, ADGs, and low-income status. In a cost-mortality analysis by LHIN, risk-adjusted random effects for total costs and mortality were graphically presented together in a cost-mortality plane to identify low and high performers. Results We studied 175,847 incident HCU and 527,541 matched non-HCU. On average, 94 out of 1000 seniors per LHIN were HCU (CV = 4.6%). The mean total costs for HCU in FY2013 were 12 times higher that of non-HCU ($29,779 vs. $2472 respectively), whereas all-cause mortality was 13.6 times greater (103.9 vs. 7.5 per 1000 seniors). Regional variation in costs and mortality was lower in senior HCU compared with non-HCU. We identified greater variability in accessing the healthcare system, but, once the patient entered the system, variation in costs was low. The traditional drivers of costs and mortality that we adjusted for played little role in driving the observed variation in HCUs’ outcomes. We identified LHINs that had high mortality rates despite elevated healthcare expenditures and those that achieved lower mortality at lower costs. Some LHINs achieved low mortality at excessively high costs. Conclusions Risk-adjusted allocation of healthcare resources to seniors in Ontario is overall similar across health districts, more so for HCU than non-HCU. Identified important variation in the cost-mortality relationship across LHINs needs to be further explored. Electronic supplementary material The online version of this article (10.1186/s12877-018-0952-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sergei Muratov
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. .,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, ON, Canada.
| | - Justin Lee
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Geriatric Education and Research in Aging Sciences Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jason R Guertin
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec City, QC, Canada.,Centre de recherche du CHU de Québec, Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Québec City, QC, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Wayne Khuu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, ON, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada
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Abstract
The Commonwealth Fund 2017 report ranked Canada's healthcare system low in access to care and last among all 11 counties studied in terms of timeliness of care. While long wait times for certain elective surgical procedures appear to be emblematic of Canadian Medicare, they are not inevitable. Wait times could be improved by focusing on public awareness and measurement of wait times and improving the appropriateness, efficiency (eg, with implementation of single-entry models for surgical referrals and greater use of ambulatory surgery), and productivity of surgical care (eg, by activity-based funding for surgical procedures and by reducing the cost of perioperative care). Ideas on how physician leaders can build on recent accomplishments are provided.
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Affiliation(s)
- David R Urbach
- 1 Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada
- 2 Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- 3 Women's College Hospital Research Institute, Toronto, Ontario, Canada
- 4 Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- 5 Department of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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16
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Pincus D, Wasserstein D, Ravi B, Huang A, Paterson JM, Jenkinson RJ, Kreder HJ, Nathens AB, Wodchis WP. Medical Costs of Delayed Hip Fracture Surgery. J Bone Joint Surg Am 2018; 100:1387-1396. [PMID: 30106820 DOI: 10.2106/jbjs.17.01147] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs. METHODS We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days). RESULTS The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours. CONCLUSIONS Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery. LEVEL OF EVIDENCE Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Pincus
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - David Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anjie Huang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - Richard J Jenkinson
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hans J Kreder
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery B Nathens
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
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17
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[First results of a German second opinion program show high patient satisfaction and large discrepancies between initial therapy recommendations and second opinion]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2018; 133:46-50. [PMID: 29482914 DOI: 10.1016/j.zefq.2018.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/21/2017] [Accepted: 01/30/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although legally anchored, there are no empirical results from German second opinion programs. In this study, various aspects within a population of a second opinion program are examined. METHODS In this study patients were analyzed who sought a second opinion in the period from August 2011 to December 2016. Differences in patient characteristics, differentiated by agreement of first and second opinion, were analyzed using multivariate logistic regression. Patients' satisfaction and quality of life were examined one, three and six months after obtaining the second opinion. RESULTS In total, 1,414 patients sought a second opinion. Most frequently, second opinions were sought on knee (38.7 %), back (26.8 %), hip (11.7 %), and shoulder (10.2 %) complaints. Except for the indication (p=0.035), no patient characteristic had influence on the conformation of the second opinion. Approximately two out of three initial recommendations were not confirmed by the specialists. 89 % of the patients were satisfied or very satisfied with the second opinion and the service offered. CONCLUSIONS The second opinion offers patients the opportunity to seek an additional independent medical opinion and thus provides support for decision making. Further research is needed to examine the reasons for the high discrepancies between the first and second opinions.
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18
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Muratov S, Lee J, Holbrook A, Paterson JM, Guertin JR, Mbuagbaw L, Gomes T, Khuu W, Pequeno P, Costa AP, Tarride JE. Senior high-cost healthcare users' resource utilization and outcomes: a protocol of a retrospective matched cohort study in Canada. BMJ Open 2017; 7:e018488. [PMID: 29282266 PMCID: PMC5770942 DOI: 10.1136/bmjopen-2017-018488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Senior high-cost users (HCUs) are estimated to represent 60% of all HCUs in Ontario, Canada's most populous province. To improve our understanding of individual and health system characteristics related to senior HCUs, we will examine incident senior HCUs to determine their incremental healthcare utilisation and costs, characteristics of index hospitalisation episodes, mortality and their regional variation across Ontario. METHODS AND ANALYSIS A retrospective, population-based cohort study using administrative healthcare records will be used. Incident senior HCUs will be defined as Ontarians aged ≥66 years who were in the top 5% of healthcare cost users during fiscal year 2013 but not during fiscal year 2012. Each HCU will be matched to three non-HCUs by age, sex and health planning region. Incremental healthcare use and costs will be determined using the method of recycled predictions. We will apply multivariable logistic regression to determine patient and health service factors associated with index hospitalisation and inhospital mortality during the incident year. The most common causes of admission will be identified and contrasted with the most expensive hospitalised conditions. We will also calculate the ratio of inpatient costs incurred through admissions of ambulatory care sensitive conditions to the total inpatient expenditures. The magnitude of variation in costs and health service utilisation will be established by calculating the extremal quotient, the coefficient of variation and the Gini mean difference for estimates obtained through multilevel regression analyses. ETHICS AND DISSEMINATION This study has been approved by Hamilton Integrated Research Ethics Board (ID#1715-C). The results of the study will be distributed through peer-reviewed journals. They also will be disseminated at research events in academic settings, national and international conferences as well as with presentations to provincial health authorities.
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Affiliation(s)
- Sergei Muratov
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Justin Lee
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Jason Robert Guertin
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Quebec City, Quebec, Canada
- Centre de recherche du CHU de Québec, Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Quebec City, Quebec, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wayne Khuu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Priscila Pequeno
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Big Data and Geriatric Models of Care Cluster, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
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19
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Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ 2017; 359:j4366. [PMID: 29018008 PMCID: PMC6284261 DOI: 10.1136/bmj.j4366] [Citation(s) in RCA: 330] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective To examine the effect of surgeon sex on postoperative outcomes of patients undergoing common surgical procedures.Design Population based, retrospective, matched cohort study from 2007 to 2015.Setting Population based cohort of all patients treated in Ontario, Canada.Participants Patients undergoing one of 25 surgical procedures performed by a female surgeon were matched by patient age, patient sex, comorbidity, surgeon volume, surgeon age, and hospital to patients undergoing the same operation by a male surgeon.Interventions Sex of treating surgeon.Main outcome measure The primary outcome was a composite of death, readmission, and complications. We compared outcomes between groups using generalised estimating equations.Results 104 630 patients were treated by 3314 surgeons, 774 female and 2540 male. Before matching, patients treated by female doctors were more likely to be female and younger but had similar comorbidity, income, rurality, and year of surgery. After matching, the groups were comparable. Fewer patients treated by female surgeons died, were readmitted to hospital, or had complications within 30 days (5810 of 52 315, 11.1%, 95% confidence interval 10.9% to 11.4%) than those treated by male surgeons (6046 of 52 315, 11.6%, 11.3% to 11.8%; adjusted odds ratio 0.96, 0.92 to 0.99, P=0.02). Patients treated by female surgeons were less likely to die within 30 days (adjusted odds ratio 0.88; 0.79 to 0.99, P=0.04), but there was no significant difference in readmissions or complications. Stratified analyses by patient, physician, and hospital characteristics did not significant modify the effect of surgeon sex on outcome. A retrospective analysis showed no difference in outcomes by surgeon sex in patients who had emergency surgery, where patients do not usually choose their surgeon.Conclusions After accounting for patient, surgeon, and hospital characteristics, patients treated by female surgeons had a small but statistically significant decrease in 30 day mortality and similar surgical outcomes (length of stay, complications, and readmission), compared with those treated by male surgeons. These findings support the need for further examination of the surgical outcomes and mechanisms related to physicians and the underlying processes and patterns of care to improve mortality, complications, and readmissions for all patients.
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Affiliation(s)
- Christopher Jd Wallis
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, ON M4N 3M5, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto
| | - Bheeshma Ravi
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre
| | - Natalie Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, ON M4N 3M5, Canada
| | - Allan S Detsky
- Institute of Health Policy, Management, and Evaluation, University of Toronto
- Department of Medicine, Mount Sinai Hospital, University Health Network, University of Toronto
| | - Raj Satkunasivam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, ON M4N 3M5, Canada
- Department of Urology and Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA
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Skeith L, Gonsalves C. Identifying the factors influencing practice variation in thrombosis medicine: A qualitative content analysis of published practice-pattern surveys. Thromb Res 2017; 159:52-57. [PMID: 28982030 DOI: 10.1016/j.thromres.2017.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/22/2017] [Accepted: 09/24/2017] [Indexed: 01/22/2023]
Abstract
Practice variation, the differences in clinical management between physicians, is one reason why patient outcomes may differ. Identifying factors that contribute to practice variation in areas of clinical uncertainty or equipoise may have implications for understanding and improving patient care. To discern what factors may influence practice variation, we completed a qualitative content analysis of all practice-pattern surveys in thrombosis medicine in the last 10years. Out of 2117 articles screened using a systematic search strategy, 33 practice-pattern surveys met eligibility criteria. Themes were identified using constant comparative analysis of qualitative data. Practice variation was noted in all 33 practice-pattern surveys. Contributing factors to variation included lack of available evidence, lack of clear and specific guideline recommendations, past experience, patient context, institutional culture and the perceived risk and benefit of a particular treatment. Additional themes highlight the value placed on expertise in challenging clinical scenarios, the complexity of practice variation and the value placed on minimizing practice variation.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Carol Gonsalves
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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21
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Rate of and Risk Factors for Intermediate-Term Reoperation After Ankle Fracture Fixation: A Population-Based Cohort Study. J Orthop Trauma 2017; 31:e315-e320. [PMID: 28614147 DOI: 10.1097/bot.0000000000000920] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Establish baseline rates of and risk factors for reoperation within 1 or 2 years of ankle open reduction internal fixation (ORIF). DESIGN Retrospective, population-based cohort study. SETTING Two hundred two hospitals in Ontario, Canada (approximate population 13.6 million in 2014). PATIENTS/PARTICIPANTS Forty five thousand four hundred forty-four patients who underwent ankle ORIF performed by 710 different surgeons between January 1, 1994, and December 31, 2011. MAIN OUTCOME MEASUREMENTS Intermediate-term reoperation because of isolated implant removal, repeat ORIF, irrigation and debridement (I&D) for infection, or amputation. Multivariable logistic regression related potential prognostic factors (patient, provider, and injury) to reoperation. RESULTS There were 8906 patients who underwent at least one subsequent operation (19.6%). The most common procedure was isolated implant removal (18.1%); odds of removal being higher for females [odds ratio (OR), 1.53; 95% confidence interval (CI), 1.45-1.62; P < 0.001]. N = 674 patients (1.5%) underwent reoperation for another reason. The odds of repeat ORIF and I&D infection were greater for open fractures (OR 2.17; 95% CI, 1.22-3.86; P = 0.008 and OR 3.12; 95% CI, 1.94-5.03; P < 0.001). Odds of amputation was highest for diabetics (OR 7.42; 95% CI, 3.73-14.86; P < 0.001). CONCLUSIONS Isolated implant removal accounts for the vast majority of intermediate-term reoperations after ankle ORIF. Reoperation for other reasons (repeat ORIF, I&D, or amputation) was extremely rare, even among the highest risk patients. Concerns regarding reoperation for these reasons should not preclude operative treatment in any patient, provider, or injury group we considered. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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22
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Sutherland JM, Busse R. Canada: Focus on a country's health system with provincial diversity. Health Policy 2017; 120:729-31. [PMID: 27381071 DOI: 10.1016/j.healthpol.2016.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Jason M Sutherland
- Michael Smith Foundation for Health Research, Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Reinhard Busse
- Department of Health Care Management, Berlin University of Technology, Germany
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