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Aryal K, Mowbray FI, Miroshnychenko A, Strum RP, Dash D, Hillmer MP, Malikov K, Costa AP, Jones A. Evaluating methods for risk prediction of Covid-19 mortality in nursing home residents before and after vaccine availability: a retrospective cohort study. BMC Med Res Methodol 2024; 24:77. [PMID: 38539074 PMCID: PMC10976701 DOI: 10.1186/s12874-024-02189-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/22/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND SARS-CoV-2 vaccines are effective in reducing hospitalization, COVID-19 symptoms, and COVID-19 mortality for nursing home (NH) residents. We sought to compare the accuracy of various machine learning models, examine changes to model performance, and identify resident characteristics that have the strongest associations with 30-day COVID-19 mortality, before and after vaccine availability. METHODS We conducted a population-based retrospective cohort study analyzing data from all NH facilities across Ontario, Canada. We included all residents diagnosed with SARS-CoV-2 and living in NHs between March 2020 and July 2021. We employed five machine learning algorithms to predict COVID-19 mortality, including logistic regression, LASSO regression, classification and regression trees (CART), random forests, and gradient boosted trees. The discriminative performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC) for each model using 10-fold cross-validation. Model calibration was determined through evaluation of calibration slopes. Variable importance was calculated by repeatedly and randomly permutating the values of each predictor in the dataset and re-evaluating the model's performance. RESULTS A total of 14,977 NH residents and 20 resident characteristics were included in the model. The cross-validated AUCs were similar across algorithms and ranged from 0.64 to 0.67. Gradient boosted trees and logistic regression had an AUC of 0.67 pre- and post-vaccine availability. CART had the lowest discrimination ability with an AUC of 0.64 pre-vaccine availability, and 0.65 post-vaccine availability. The most influential resident characteristics, irrespective of vaccine availability, included advanced age (≥ 75 years), health instability, functional and cognitive status, sex (male), and polypharmacy. CONCLUSIONS The predictive accuracy and discrimination exhibited by all five examined machine learning algorithms were similar. Both logistic regression and gradient boosted trees exhibit comparable performance and display slight superiority over other machine learning algorithms. We observed consistent model performance both before and after vaccine availability. The influence of resident characteristics on COVID-19 mortality remained consistent across time periods, suggesting that changes to pre-vaccination screening practices for high-risk individuals are effective in the post-vaccination era.
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Affiliation(s)
- Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada.
- ICES, Hamilton, ON, Canada.
| | - Fabrice I Mowbray
- College of Nursing, Michigan State University, East Lansing, MI, USA
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Michael P Hillmer
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Capacity Planning and Analytics, Ontario Ministry of Health, Toronto, Canada
| | - Kamil Malikov
- Capacity Planning and Analytics, Ontario Ministry of Health, Toronto, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
- ICES, Hamilton, ON, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
- ICES, Hamilton, ON, Canada
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Strum RP, Mondoux S, Mowbray FI, Griffith LE, Worster A, Tavares W, Miller P, Aryal K, Sivakumaran R, Costa AP. Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study. PLoS One 2024; 19:e0297689. [PMID: 38261589 PMCID: PMC10805301 DOI: 10.1371/journal.pone.0297689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION The Emergency Department Avoidability Classification (EDAC) retrospectively classifies emergency department (ED) visits that could have been safely managed in subacute primary care settings, but has not been validated against a criterion standard. A validated EDAC could enable accurate and reliable quantification of avoidable ED visits. We compared agreement between the EDAC and ED physician judgements to specify avoidable ED visits. MATERIALS AND METHODS We conducted a cluster randomized, single-blinded agreement study in an academic hospital in Hamilton, Canada. ED visits between January 1, 2019, and December 31, 2019 were clustered based on EDAC classes and randomly sampled evenly. A total of 160 ED visit charts were randomly assigned to ten participating ED physicians at the academic hospital for evaluation. Physicians judged if the ED visit could have been managed appropriately in subacute primary care (an avoidable visit); each ED visit was evaluated by two physicians independently. We measured interrater agreement between physicians with a Cohen's kappa and 95% confidence intervals (CI). We evaluated the correlation between the EDAC and physician judgements using a Spearman rank correlation and ordinal logistic regression with odds ratios (ORs) and 95% CIs. We examined the EDAC's precision to identify avoidable ED visits using accuracy, sensitivity and specificity. RESULTS ED physicians agreed on 139 visits (86.9%) with a kappa of 0.69 (95% CI 0.59-0.79), indicating substantial agreement. Physicians judged 96.2% of ED visits classified as avoidable by the EDAC as suitable for management in subacute primary care. We found a high correlation between the EDAC and physician judgements (0.64), as well as a very strong association to classify avoidable ED visits (OR 80.0, 95% CI 17.1-374.9). The EDACs avoidable and potentially avoidable classes demonstrated strong accuracy to identify ED visits suitable for management in subacute care (82.8%, 95% CI 78.2-86.8). DISCUSSION The EDAC demonstrated strong evidence of criterion validity to classify avoidable ED visits. This classification has important potential for accurately monitoring trends in avoidable ED utilization, measuring proportions of ED volume attributed to avoidable visits and informing interventions intended at reducing ED use by patients who do not require emergency or life-saving healthcare.
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Affiliation(s)
- Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shawn Mondoux
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- College of Nursing, Michigan State University, East Lansing, Michigan, United States of America
| | - Lauren E. Griffith
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- McMaster Institute for Research and Aging, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Walter Tavares
- The Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Paul Miller
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
- Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Komal Aryal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ravi Sivakumaran
- Health Information Management Department, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Dash D, Mowbray FI, Poss JW, Aryal K, Stall NM, Hirdes JP, Hillmer MP, Heckman GA, Bowdish DME, Costa AP, Jones A. The association between frailty, long-term care home characteristics and COVID-19 mortality before and after SARS-CoV-2 vaccination: a retrospective cohort study. Age Ageing 2023; 52:afad229. [PMID: 38163287 DOI: 10.1093/ageing/afad229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/19/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC. METHODS We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability. RESULTS There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41-1.65) and 1.62 (95% CrI: 1.46-1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42-1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period. INTERPRETATION Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.
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Affiliation(s)
- Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Fabrice I Mowbray
- College of Nursing, Michigan State University, East Lansing, MI, USA
| | - Jeffrey W Poss
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan M Stall
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John P Hirdes
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Michael P Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Dawn M E Bowdish
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St. Joseph's Health Care Hamilton, Hamilton, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Gagnon S, Nadeau A, Tanguay K, Archambault PM, Brousseau AA, Carmichael PH, Emond M, Deshaies JF, Benhamed A, Blanchard PG, Mowbray FI, Mercier E. Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study. CAN J EMERG MED 2023; 25:953-958. [PMID: 37853307 DOI: 10.1007/s43678-023-00600-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs. METHODS This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse. RESULTS A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]). CONCLUSION When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.
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Affiliation(s)
- Samuel Gagnon
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
| | - Alexandra Nadeau
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
| | - Katherine Tanguay
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
| | - Patrick M Archambault
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
- Centre de recherche intégrée pour un système de santé apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière Appalaches, Lévis, QC, Canada
| | - Audrey-Anne Brousseau
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine et sciences de la santé, Université de Sherbrooke, Sherbooke, QC, Canada
| | | | - Marcel Emond
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
| | - Jean-Francois Deshaies
- Centre de recherche intégrée pour un système de santé apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière Appalaches, Lévis, QC, Canada
| | - Axel Benhamed
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hopitaux Civils de Lyon, Lyon, France
| | - Pierre-Gilles Blanchard
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
| | - Fabrice I Mowbray
- College of Nursing, Michigan State University, East Lansing, MI, USA
| | - Eric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada.
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada.
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada.
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Strum RP, Mondoux S, Mowbray FI, Miller P, Worster A, Ferron R, Costa AP. Quantifying the escalating impact of paramedic transported emergency department visits for opioid-related conditions in Ontario, Canada: A population-based cohort study. PLoS One 2023; 18:e0291194. [PMID: 37682861 PMCID: PMC10490960 DOI: 10.1371/journal.pone.0291194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION While overdoses comprise the majority of opioid research, the comprehensive impact of the opioid crisis on emergency departments (EDs) and paramedic services has not been reported. We examined temporal changes in population-adjusted incidence rates of ED visits and paramedic transports due to opioid-related conditions. MATERIALS AND METHODS We conducted a population-based cohort study of all ED visits in the National Ambulatory Care Reporting System from January 1, 2009 to December 31, 2019 in Ontario, Canada. We included all patients with a primary diagnosis naming opioids as the underlying cause for the visit, without any other drugs or substances. We clustered geographic regions using Local Health Integration Network boundaries. Descriptive statistics, incidence rate ratios (IRR) and 95% confidence intervals (CIs) were calculated to analyze population-adjusted temporal changes. RESULTS Overall, 86,403 ED visits were included in our study. Incidence of opioid-related ED visits increased by 165% in the study timeframe, with paramedic transported patients increasing by 429%. Per 100,000 residents, annual ED visits increased from 40.4 to 97.2, and paramedic transported patients from 12.1 to 67.9. The proportion of opioid-related ED visits transported by paramedics increased from 35.0% to 69.9%. The medical acuity of opioid-related ED visits increased throughout the years (IRR 6.8. 95% CI 5.9-7.7), though the proportion of discharges remained constant (~75%). The largest increases in ED visits and paramedic transports were concentrated to urbanized regions. DISCUSSION Opioid-related ED visits and paramedic transports increased substantially between 2009 and 2019. The proportion of ED visits transported by paramedics doubled. Our findings could provide valuable support to health stakeholders in implementing timely strategies aimed at safely reducing opioid-related ED visits. The increased use of paramedics followed by high rates of ED discharge calls for exploration of alternative care models within paramedic systems, such as direct transport to specialized substance abuse centres.
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Affiliation(s)
- Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Shawn Mondoux
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- College of Nursing, Michigan State University, East Lansing, Michigan, United States of America
| | - Paul Miller
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
- Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Richard Ferron
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Niagara Emergency Medical Services, Niagara on the Lake, Ontario, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
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Mowbray FI, Ellis B, Schumacher C, Heckman G, de Wit K, Strum RP, Jones A, Correia RH, Mercier E, Costa AP. The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department. Can J Nurs Res 2023; 55:404-412. [PMID: 36632010 PMCID: PMC10416548 DOI: 10.1177/08445621221144667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.
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Affiliation(s)
- Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Brittany Ellis
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Connie Schumacher
- School of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catherine's, Ontario, Canada
| | - George Heckman
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca H. Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec City, Québec, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Strum RP, Mowbray FI, Zargoush M, Jones AP. Prehospital prediction of hospital admission for emergent acuity patients transported by paramedics: A population-based cohort study using machine learning. PLoS One 2023; 18:e0289429. [PMID: 37616228 PMCID: PMC10449470 DOI: 10.1371/journal.pone.0289429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION The closest emergency department (ED) may not always be the optimal hospital for certain stable high acuity patients if further distanced ED's can provide specialized care or are less overcrowded. Machine learning (ML) predictions may support paramedic decision-making to transport a subgroup of emergent patients to a more suitable, albeit more distanced, ED if hospital admission is unlikely. We examined whether characteristics known to paramedics in the prehospital setting were predictive of hospital admission in emergent acuity patients. MATERIALS AND METHODS We conducted a population-level cohort study using four ML algorithms to analyze ED visits of the National Ambulatory Care Reporting System from January 1, 2018 to December 31, 2019 in Ontario, Canada. We included all adult patients (≥18 years) transported to the ED by paramedics with an emergent Canadian Triage Acuity Scale score. We included eight characteristic classes as model predictors that are recorded at ED triage. All ML algorithms were trained and assessed using 10-fold cross-validation to predict hospital admission from the ED. Predictive model performance was determined using the area under curve (AUC) with 95% confidence intervals and probabilistic accuracy using the Brier Scaled score. Variable importance scores were computed to determine the top 10 predictors of hospital admission. RESULTS All machine learning algorithms demonstrated acceptable accuracy in predicting hospital admission (AUC 0.77-0.78, Brier Scaled 0.22-0.24). The characteristics most predictive of admission were age between 65 to 105 years, referral source from a residential care facility, presenting with a respiratory complaint, and receiving home care. DISCUSSION Hospital admission was accurately predicted based on patient characteristics known prehospital to paramedics prior to arrival. Our results support consideration of policy modification to permit certain emergent acuity patients to be transported to a further distanced ED. Additionally, this study demonstrates the utility of ML in paramedic and prehospital research.
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Affiliation(s)
- Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- College of Nursing, Michigan State University, East Lansing, Michigan, United States of America
| | - Manaf Zargoush
- Department of Health Policy and Management, McMaster University, Hamilton, Ontario, Canada
| | - Aaron P. Jones
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Institute for Clinical Evaluative Sciences, McMaster University, Hamilton, Ontario, Canada
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Buchholz SW, Mowbray FI, Allman G, Verboncoeur JP, Beam L, Small L. Wearable Devices and Nurses' Health: Protocol for an Integrative Review. JMIR Res Protoc 2023; 12:e48178. [PMID: 37477950 PMCID: PMC10403791 DOI: 10.2196/48178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Nurses comprise over half of the global health care workforce, and the nursing care they provide is critical for the global population's health. High patient volumes and increased medical complexity have increased the workload and stress of nurses. As a result, the health of nurses is often negatively impacted. Wearables are used within the health care setting to assess patient outcomes; however, efforts to synthesize the use of wearable devices focusing on nurses' health are limited. OBJECTIVE The primary objective of our integrative review is to synthesize available data concerning the utility of wearable devices for evaluating or improving (or both) the health of nurses. METHODS We are conducting an integrative review synthesizing data specific to wearable devices and nurses' health. The research question for this review aims to answer how wearable devices are used to evaluate health outcomes among nurses. We searched the following electronic databases from inception until July 2022: PubMed, Embase, CINAHL, Web of Science, IEEE Explore, and AS&T. Titles and abstracts were imported into Covidence software, where citations were screened and duplicates removed. Title and abstract screening has been completed; however, full-text screening has not been started. Further screening is being conducted independently and in duplicate by 2 teams of 2 reviewers each. These reviewers will extract data independently. RESULTS Search strategies have been developed, and data were extracted from 6 databases. After the removal of duplicates, we collected 8603 studies for title and abstract screening. Two independent reviewers conducted the title and abstract review, and after resolving conflicts, 277 full-text articles are available for review to determine whether they meet the inclusion criteria. CONCLUSIONS This integrative review will provide synthesized data to inform nurses and other stakeholders about the extent of wearable device-related work done with nurses and provide direction for future research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48178.
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Affiliation(s)
- Susan W Buchholz
- College of Nursing, Michigan State University, East Lansing, MI, United States
| | - Fabrice I Mowbray
- College of Nursing, Michigan State University, East Lansing, MI, United States
| | - Gabrielle Allman
- College of Nursing, Michigan State University, East Lansing, MI, United States
| | - John P Verboncoeur
- College of Engineering, Michigan State University, East Lansing, MI, United States
| | - Lauren Beam
- College of Nursing, Michigan State University, East Lansing, MI, United States
| | - Leigh Small
- College of Nursing, Michigan State University, East Lansing, MI, United States
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Mowbray FI, Heckman G, Hirdes JP, Costa AP, Beauchet O, Archambault P, Eagles D, Wang HT, Perry JJ, Sinha SK, Jantzi M, Hebert P. Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study. CAN J EMERG MED 2023; 25:209-217. [PMID: 36857018 PMCID: PMC10014815 DOI: 10.1007/s43678-023-00458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - George Heckman
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
- Schlegel Research Institute for Aging, Waterloo, ON, Canada
| | - John P Hirdes
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Olivier Beauchet
- Department of Medicine and Research Center of the Geriatric University Institute of Montreal, University of Montreal, Montreal, QC, Canada
- Division of Geriatric Medicine, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Sainte-Marie, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Debra Eagles
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Han Ting Wang
- Division of Critical Care Medicine, Department of Medicine, Universite de Montreal, Montreal, QC, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samir K Sinha
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Micaela Jantzi
- School of Public Health Science, University of Waterloo, Waterloo, ON, Canada
| | - Paul Hebert
- Division of Palliative Care, Department of Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
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Strum RP, Mowbray FI, Mondoux SE, Costa AP. Evaluating emergency department transfers from urgent care centres: insights for paramedic integration with subacute healthcare. BMJ Open Qual 2023; 12:e002160. [PMID: 36894178 PMCID: PMC10008425 DOI: 10.1136/bmjoq-2022-002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Paramedics redirecting non-emergent patients from emergency departments (EDs) to urgent care centres is a new and forthcoming strategy to reduce overcrowding and improve primary care integration. Which patients are likely not suitable for paramedic redirection are unknown. To describe and specify patients inappropriate for urgent care centres, we examined associations between patient characteristics and transfer to the ED after patients initially presented to an urgent care centre. METHODS A population-based retrospective cohort study of all adult (≥18 years) visits to an urgent care centre from 1 April 2015 to 31 March 2020 in Ontario, Canada. Binary logistic regression was used to determine unadjusted and adjusted associations between patient characteristics and being transferred to an ED using OR and 95% CIs. We calculated the absolute risk difference for the adjusted model. RESULTS A total of 1 448 621 urgent care visits were reported, with 63 343 (4.4%) visits transferred to an ED for definitive care. Being 65 years and older (OR 2.29, 95% CI 2.23 to 2.35), scored an emergent Canadian Triage and Acuity Scale of 1 or 2 (OR 14.27, 95% CI 13.45 to 15.12) and higher comorbidity count (OR 1.51, 95% CI 1.46 to 1.58) had added odds of association with being transferred out to an ED. CONCLUSION Readily available patient characteristics were independently associated with interfacility transfers between urgent care centres and the ED. This study can support paramedic redirection protocol development, highlighting which patients may not be best suited for ED redirection.
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Affiliation(s)
- Ryan P Strum
- Health Research, Evidence and Impact, McMaster University, Hamilton, New Zealand, Canada
| | - Fabrice I Mowbray
- Health Research, Evidence and Impact, McMaster University, Hamilton, New Zealand, Canada
- College of Nursing, Michigan State University, East Lansing, Michigan, USA
| | - Shawn E Mondoux
- Medicine, Division of Emergency Medicine, McMaster University, Hamilton, New Zealand, Canada
| | - Andrew P Costa
- Health Research, Evidence and Impact, McMaster University, Hamilton, New Zealand, Canada
- Medicine, McMaster University, Hamilton, New Zealand, Canada
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Mowbray FI, Heckman G, Hirdes JP, Costa AP, Beauchet O, Eagles D, Perry JJ, Sinha S, Archambault P, Wang H, Jantzi M, Hebert P. Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high-risk older emergency department patients: A Canadian multiprovince prospective cohort study. J Am Coll Emerg Physicians Open 2023; 4:e12876. [PMID: 36660313 PMCID: PMC9838565 DOI: 10.1002/emp2.12876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/08/2022] [Accepted: 11/30/2022] [Indexed: 01/15/2023] Open
Abstract
Objectives We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours). Methods We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high-risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care. Results A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one-third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy. Conclusion The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient-important health outcomes in older ED patients, highlighting its value for vulnerability screening.
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Affiliation(s)
- Fabrice I. Mowbray
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - George Heckman
- School of Public Health ScienceUniversity of WaterlooWaterlooOntarioCanada,Schlegel Research Institute for AgingWaterlooOntarioCanada
| | - John P. Hirdes
- School of Public Health ScienceUniversity of WaterlooWaterlooOntarioCanada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Olivier Beauchet
- Departments of Medicine and Research Center of the Geriatric University Institute of MontrealUniversity of MontrealMontrealQuebecCanada,Department of MedicineDivision of Geriatric MedicineSir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical ResearchMcGill UniversityMontrealQuebecCanada,Lee Kong Chian School of MedicineNanyang Technological UniversitySingaporeSingapore
| | - Debra Eagles
- Department of Emergency MedicineSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Jeffrey J. Perry
- Department of Emergency MedicineSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Samir Sinha
- Department of MedicineDivision of Geriatric MedicineSinai Health and University Health NetworkTorontoOntarioCanada,Department of MedicineDivision of Geriatric MedicineUniversity of TorontoTorontoOntarioCanada
| | - Patrick Archambault
- Department of Family Medicine and Emergency MedicineUniversité LavalQuébec CityOntarioCanada,Centre intégré de santé et de services sociaux de Chaudière‐AppalachesSainte‐MarieOntarioCanada,Department of Anesthesiology and Critical Care MedicineDivision of Critical Care MedicineUniversité LavalQuébec CityOntarioCanada
| | - Hanting Wang
- Department of MedicineDivision of Critical Care MedicineUniversite de MontrealMontrealQuebecCanada
| | - Michaela Jantzi
- School of Public Health ScienceUniversity of WaterlooWaterlooOntarioCanada
| | - Paul Hebert
- Department of MedicineDivision of Palliative CareBruyere Research InstituteUniversity of OttawaOttawaOntarioCanada
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12
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Aryal K, Mowbray FI, Strum RP, Dash D, Tanuseputro P, Heckman G, Costa AP, Jones A. Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents. J Am Med Dir Assoc 2023; 24:100-104.e2. [PMID: 36379265 DOI: 10.1016/j.jamda.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs). DESIGN We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers. SETTING AND PARTICIPANTS We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs. METHODS We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision. RESULTS Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13). CONCLUSIONS AND IMPLICATIONS PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.
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Affiliation(s)
- Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto, Ontario, Canada; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - George Heckman
- Schlegel Research Chair in Geriatric Medicine, Schlegel Research Institute for Aging, Waterloo, Ontario, Canada; School of Public Health Sciences, University of Waterloo, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
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13
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Mowbray FI, Jones A, Strum RP, Turcotte L, Foroutan F, de Wit K, Worster A, Griffith LE, Hebert P, Heckman G, Ko DT, Schumacher C, Gayowsky A, Costa AP. Prognosis of cardiac arrest in home care clients and nursing home residents: A population-level retrospective cohort study. Resusc Plus 2022; 12:100328. [DOI: 10.1016/j.resplu.2022.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/23/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022] Open
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14
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Jones A, Mowbray FI, Falk L, Stall NM, Brown KA, Malikov K, Malecki SL, Lail S, Jung HY, Costa AP, Verma AA, Razak F. Variations in long-term care home resident hospitalizations before and during the COVID-19 pandemic in Ontario. PLoS One 2022; 17:e0264240. [PMID: 36331926 PMCID: PMC9635742 DOI: 10.1371/journal.pone.0264240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To examine how the COVID-19 pandemic affected the demographic and clinical characteristics, in-hospital care, and outcomes of long-term care residents admitted to general medicine wards for non-COVID-19 reasons. METHODS We conducted a retrospective cohort study of long-term care residents admitted to general medicine wards, for reasons other than COVID-19, in four hospitals in Toronto, Ontario between January 1, 2018 and December 31, 2020. We used an autoregressive linear model to estimate the change in monthly admission volumes during the pandemic period (March-December 2020) compared to the previous two years, adjusting for any secular trend. We summarized and compared differences in the demographics, comorbidities, interventions, diagnoses, imaging, psychoactive medications, and outcomes of residents before and during the pandemic. RESULTS Our study included 2,654 long-term care residents who were hospitalized for non-COVID-19 reasons between January 2018 and December 2020. The crude rate of hospitalizations was 79.3 per month between March-December of 2018-2019 and 56.5 per month between March-December of 2020. The was an adjusted absolute difference of 27.0 (95% CI: 10.0, 43.9) fewer hospital admissions during the pandemic period, corresponding to a relative drop of 34%. Residents admitted during the pandemic period had similar demographics and clinical characteristics but were more likely to be admitted for delirium (pandemic: 7% pre-pandemic: 5%, p = 0.01) and were less likely to be admitted for pneumonia (pandemic: 3% pre-pandemic: 6%, p = 0.004). Residents admitted during the pandemic were more likely to be prescribed antipsychotics (pandemic: 37%, pre-pandemic: 29%, p <0.001) and more likely to die in-hospital (pandemic:14% pre-pandemic: 10%, p = 0.04). CONCLUSIONS AND IMPLICATIONS Better integration between long-term care and hospitals systems, including programs to deliver urgent medical care services within long-term care homes, is needed to ensure that long-term care residents maintain equitable access to acute care during current and future public health emergencies.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- * E-mail: (AJ); (FR)
| | - Fabrice I. Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lindsey Falk
- Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
| | - Nathan M. Stall
- Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital Research Institute, Toronto, Ontario, Canada
| | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kamil Malikov
- Health Data Science Branch, Capacity Planning and Analytics Divisions, Ontario Ministry of Health, Toronto, ON, Canada
| | - Sarah L. Malecki
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sharan Lail
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Hae Young Jung
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Amol A. Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- * E-mail: (AJ); (FR)
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15
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Strum RP, Drennan IR, Mowbray FI, Mondoux S, Worster A, Babe G, Costa AP. Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to 2019. CAN J EMERG MED 2022; 24:742-750. [PMID: 35984572 PMCID: PMC9389513 DOI: 10.1007/s43678-022-00363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022]
Abstract
Purpose We examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in. Methods We conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes. Results Overall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26–1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03–1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates. Conclusion There was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.
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Affiliation(s)
- Ryan P Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Ian R Drennan
- Department of Family and Community Medicine, Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Hospital, Toronto, ON, Canada
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Shawn Mondoux
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Glenda Babe
- Institute for Clinical Evaluative Sciences, McMaster University, Hamilton, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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Mercier E, Mowbray FI. Patient-important outcomes following in-hospital cardiac arrest: Using frailty to move beyond prediction of immediate survival. Resuscitation 2022; 179:38-40. [PMID: 35933058 DOI: 10.1016/j.resuscitation.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Eric Mercier
- VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgence - Soins Intensifs, Centre de recherche du CHU de Québec, Université Laval, Québec, Canada; Département de médecine familiale et médecine d'urgence, Faculté de Médecine, Université Laval, Québec, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
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17
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Mowbray FI, Manlongat D, Shukla M. Sensitivity Analysis: A Method to Promote Certainty and Transparency in Nursing and Health Research. Can J Nurs Res 2022; 54:371-376. [PMID: 35702010 PMCID: PMC9605992 DOI: 10.1177/08445621221107108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Nursing and health researchers may be presented with uncertainty regarding the utilization or legitimacy of methodological or analytic decisions. Sensitivity analyses are purposed to gain insight and certainty about the validity of research findings reported. Reporting guidelines and health research methodologists have emphasized the importance of utilizing and reporting sensitivity analyses in clinical research. However, sensitivity analyses are underreported in nursing and health research. The aim of this methodological overview is to provide an introduction to the purpose, conduct, interpretation, and reporting of sensitivity analyses, using a series of simulated and contemporary case examples.
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Affiliation(s)
- Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Donna Manlongat
- College of Nursing, Wayne State University, Detroit, Michigan, United States
| | - Meghna Shukla
- College of Nursing, Wayne State University, Detroit, Michigan, United States
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Lelak KA, Arora R, Mowbray FI, Arkatkar Bs A, Krouse C, Cloutier D, Donoghue L, Sethuraman U. Cardiopulmonary Resuscitation and Epinephrine Use in Pediatric Traumatic Cardiac Arrest. Am Surg 2022:31348221094213. [PMID: 35499210 DOI: 10.1177/00031348221094213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Karima A Lelak
- Division of Emergency Medicine, Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA
| | - Rajan Arora
- Division of Emergency Medicine, Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, 3710McMaster University, Hamilton, ON, Canada
| | - Anooj Arkatkar Bs
- 3078Department of Biochemistry and Molecular Biology, Michigan State University, Lansing, MI, USA
| | - Carolyn Krouse
- Department of Pediatric Surgery, 2969Children's Hospital of Michigan, Detroit, MI, USA
| | - Dawn Cloutier
- Department of Pediatric Surgery, 2969Children's Hospital of Michigan, Detroit, MI, USA
| | - Lydia Donoghue
- Department of Pediatric Surgery, 2969Children's Hospital of Michigan, Detroit, MI, USA.,Department of Surgery, Wayne State University, Detroit, MI, USA
| | - Usha Sethuraman
- Division of Emergency Medicine, Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, 2969Central Michigan University, Detroit, MI, USA
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19
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Correia RH, Mowbray FI, Dash D, Katz PR, Moser A, Strum RP, Jones A, von Schlegell A, Costa AP. Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study. BMC Geriatr 2022; 22:320. [PMID: 35413884 PMCID: PMC9003172 DOI: 10.1186/s12877-022-03011-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Objectives We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs). Design Multi-site cross-sectional. Setting and participants We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017. Methods We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident’s first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit. Results Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 – 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 – 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 – 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 – 71.02), new medication use (OR = 1.31, 95% CI 1.09 – 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 – 1.49). Conclusions and implications Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03011-9.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Paul R Katz
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ahmad von Schlegell
- Trillium Health Partners, Mississauga, ON, Canada.,Schlegel Villages, Kitchener, ON, Canada.,DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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20
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Correia RH, Jabbar A, Siu HYH, Hogeveen S, Dash D, Mowbray FI, Costa AP, Vanstone M. Comparing the scopes of practice of geriatric-focused physicians in Canada: a qualitative study of core competencies. CMAJ Open 2022; 10:E563-E569. [PMID: 35728839 PMCID: PMC9343128 DOI: 10.9778/cmajo.20210193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Given long-standing deficits of medical expertise to care for a growing population of older adults, it is important to understand the geriatric medical workforce. We aimed to describe and compare the scopes of practice of the 3 geriatric-focused physician providers in Canada (i.e., family physicians with certification in Care of the Elderly [FM-COE], geriatricians and geriatric psychiatrists). METHODS We conducted a qualitative study to compare competencies across geriatric-focused physician provider types in Canada, using a directed content analysis approach. We identified and obtained relevant publicly available documents that described the competencies required for certification by searching the websites of The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada between June 2 and July 31, 2020. An inductive content analysis was used to compare content within each CanMEDS Role according to the CanMEDS Framework. RESULTS We identified and obtained 4 relevant publicly available documents describing the competencies required for geriatric-focused certification for the 3 geriatric-focused physician provider types. We found substantial overlaps in the expected medical expertise of FM-COE and geriatricians. The few substantive differences across providers may result from different priorities about which competencies were made explicit for providers. The focused nature of mental health care is apparent in several competencies unique to geriatric psychiatry. INTERPRETATION This work highlights substantial overlaps in the scopes of practice for FM-COE and geriatricians. Our findings may encourage efforts to develop more robust delineations between the scopes of practice of these related professionals to facilitate inter-specialty collaboration to lead to more equitable and accessible medical care for older adults.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont.
| | - Amina Jabbar
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Henry Yu-Hin Siu
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Sophie Hogeveen
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Darly Dash
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
| | - Meredith Vanstone
- Department of Health Research Methods, Evidence and Impact (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa), and Big Data and Geriatric Models of Care Cluster (Correia, Jabbar, Hogeveen, Dash, Mowbray, Costa) and Department of Family Medicine (Siu, Vanstone), McMaster University, Hamilton, Ont
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21
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Strum RP, Mowbray FI, Worster A, Tavares W, Leyenaar MS, Correia RH, Costa AP. Examining the association between paramedic transport to the emergency department and hospital admission: a population-based cohort study. BMC Emerg Med 2021; 21:117. [PMID: 34641823 PMCID: PMC8506085 DOI: 10.1186/s12873-021-00507-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Increasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission. Methods We conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics. Results During the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74–3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems. Conclusions Transport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00507-2.
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Affiliation(s)
- Ryan P Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, CRL B106, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, CRL B106, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence and Impact, McMaster University, CRL B106, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Walter Tavares
- The Wilson Centre, University of Toronto, Toronto, Canada.,York Region Paramedic and Senior Services, Regional Municipality of York, Newmarket, Canada
| | - Matthew S Leyenaar
- Department of Health Research Methods, Evidence and Impact, McMaster University, CRL B106, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University, CRL B106, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, CRL B106, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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22
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DeLaroche AM, Mowbray FI, Bohsaghcheghazel M, Zalewski K, Obudzinski K. Early versus delayed administration of intravenous magnesium sulfate for pediatric asthma. Am J Emerg Med 2021; 50:36-40. [PMID: 34271233 DOI: 10.1016/j.ajem.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE This study aims to describe and examine the factors associated with the early administration of intravenous magnesium sulfate (IV Mg) in children presenting to the pediatric emergency department (ED) for an asthma exacerbation. METHODS Retrospective cohort study of children aged 5-11 years who received IV Mg in the pediatric ED between September 1, 2018 and August 31, 2019 for management of an asthma exacerbation. Primary outcome was administration of IV Mg in ≤60 min from ED triage ('early administration'). Comparison of clinical management and therapies in children who received early versus delayed IV Mg and the factors associated with early administration of IV Mg were examined. RESULTS Early (n = 90; 31.6%) IV Mg was associated with more timely bronchodilators (47 versus 68 min; p ≤ 0.001) and systemic corticosteroids (36 versus 46.5 min; p ≤ 0.001). There was no difference between the two cohorts in returns to the ED within 72 h (1.1% versus 2.1%; p = .99) or readmissions within 1 week one week (2.2% versus 0.5%; p = .2). Hypoxia (aOR = 3.76; 95% CI = 2.02-7.1), respiratory rate (aOR = 1.04; 95% CI = 1.02-1.07), retractions (aOR = 2.21; 95% CI = 1.25-3.94), and prior hospital use for asthma-related complaints (aOR = 2.1; 95% CI = 1.16-3.84) were significantly associated with early IV Mg. CONCLUSIONS Early administration of IV Mg was associated with more timely delivery of first-line asthma therapies, was safe, and improved ED throughput without increasing return ED visits or hospitalizations for asthma.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States of America; College of Medicine, Central Michigan University, Mount Pleasant, MI, United States of America.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Maryam Bohsaghcheghazel
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States of America
| | - Kristina Zalewski
- School of Medicine, Wayne State University, Detroit, MI, United States of America
| | - Katherine Obudzinski
- Pediatrics Residency Program, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States of America
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23
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Mowbray FI, Manlongat D, Correia RH, Strum RP, Fernando SM, McIsaac D, de Wit K, Worster A, Costa AP, Griffith LE, Douma M, Nolan JP, Muscedere J, Couban R, Foroutan F. Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis. Resuscitation 2021; 167:242-250. [PMID: 34166743 DOI: 10.1016/j.resuscitation.2021.06.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/28/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To synthesize the current evidence examining the association between frailty and a series of post-arrest outcomes following the provision of cardiopulmonary resuscitation (CPR). DATA SOURCES We searched MEDLINE, PubMed (exclusive of MEDLINE), EMBASE, CINAHL, and Web of Science from inception to August 2020 for observational studies that examined an association between frailty and post-arrest health outcomes, including in-hospital and post-discharge mortality. We conducted citation tracking for all eligible studies. STUDY SELECTION Our search yielded 20,480 citations after removing duplicate records. We screened titles, abstracts and full-texts independently and in duplicate. DATA EXTRACTION The prognosis research strategy group (PROGRESS) and the critical appraisal and data extraction for systematic review of prediction modelling studies (CHARMS) guidelines were followed. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) instrument. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations for prognostic factor research. DATA SYNTHESIS Four studies were included in this review and three were eligible for statistical pooling. Our sample comprised 1,134 persons who experienced in-hospital cardiac arrest (IHCA). The mean age of the sample was 71 years. The study results were pooled according to the specific frailty instrument. Three studies used the Clinical Frailty Scale (CFS) and adjusted age (our minimum confounder); the presence of frailty was associated with an approximate three-fold increase in the odds of dying in-hospital after IHCA (aOR = 2.93; 95% CI = 2.43-3.53, high certainty). Frailty was also associated with decreased incidence of ROSC (return of spontaneous circulation) and discharge home following IHCA. One study with high risk of bias used the Hospital Frailty Risk Score and reported a 43% decrease in the odds of discharge home for patients with frailty following IHCA. CONCLUSION High certainty evidence was found for an association between frailty and in-hospital mortality following IHCA. Frailty is a robust prognostic factor that contributes valuable information and can inform shared-decision making and policies surrounding advance care directives. Registration: PROSPERO Registration # CRD42020212922.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada.
| | - Donna Manlongat
- College of Nursing, Wayne State University, 5557 Cass Ave, Detroit, MI 48202, USA.
| | - Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada.
| | - Ryan P Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada.
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, 451 Smyth Rd #2044, Ottawa, Ontario K1H 8M5, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, 451 Smyth Rd #2044, Ottawa, Ontario K1H 8M5, Canada.
| | - Daniel McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, 451 Smyth Rd #2044, Ottawa, Ontario K1H 8M5, Canada; The Ottawa Hospital School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cres, Rm 101, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Kerstin de Wit
- Division of Emergency Medicine, Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada; St. Joseph's Health System, 50 Charlton Ave. E, Hamilton, Ontario L8N 4A6, Canada.
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence and Impact, McMaster University, 175 Longwood Rd. S, Hamilton, Ontario L8P 0A1, Canada; McMaster Institute for Research on Aging, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Matthew Douma
- Department of Critical Care Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, Alberta T6G 2R3, Canada.
| | - Jerry P Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, Medical School Building, Coventry CV4 7HL, United Kingdom; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, United Kingdom.
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, 99 University Ave, Kingston, Ontario K7L 3N6, Canada.
| | - Rachel Couban
- Department of Anesthesia, McMaster University, 1280 Main St. W, Hamilton, Ontario L8S 4L8, Canada.
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, University Health Network, 661 University Ave, Toronto, Ontario M5G 1X8, Canada.
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Abstract
Background Little is known about the prognostic differences between older emergency department (ED) patients who present with different formal support requirements in the community. We set out to describe and compare the patient profiles and patterns of health service use among three older ED cohorts: home care clients, nursing home residents and those receiving no formal support. Methods We conducted a secondary analysis of the Canadian cohort from the interRAI multinational ED study. Data were collected using interRAI ED contact assessment on patients 75 years of age and older (n = 2,274), in eight ED sites across Canada. A series of descriptive statistics were reported. Adjusted associations were determined using logistic regression. Results Older adults receiving no formal support services were most stable. However, they were most likely to be hospitalized. Older home care clients were most likely to report depressive symptoms and distressed caregivers. They also had the greatest odds of frequent ED visitation post-discharge (OR=1.9; 95% CI=1.39–2.59). Older adults transferred from a nursing home were the frailest but had the lowest odds of hospital admission (OR=0.14; 95% CI=0.09–0.23). Conclusion We demonstrated the importance of inquiring about community-based formal support services and provide data to support decision-making in the ED.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
| | - Komal Aryal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
| | - Eric Mercier
- Département de Médecine Familiale et Médecine d'Urgence, Faculté de Médecine, Université Laval, Quebec City, QC.,Centre d'excellence sur le vieillissement, Centre de recherche sur les soins de première ligne de l'Université Laval, Quebec City, QC
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON
| | - Andrew P Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON.,Michael G. DeGroote School of Medicine, Waterloo Regional Campus, Waterloo, ON, Canada
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25
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El-Masri MM, Mowbray FI, Fox-Wasylyshyn SM, Kanters D. Multivariate Outliers: A Conceptual and Practical Overview for the Nurse and Health Researcher. Can J Nurs Res 2020; 53:316-321. [PMID: 32522115 DOI: 10.1177/0844562120932054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The presence of statistical outliers is a shared concern in research. If ignored or improperly handled, outliers have the potential to distort parameter estimates and possibly compromise the validity of research findings. The purpose of this paper is to provide a conceptual and practical overview of multivariate outliers with a focus on common techniques used to identify and manage multivariate outliers. Specifically, this paper discusses the use of Mahalanobis distance and residual statistics as common multivariate outlier identification techniques. It also discusses the use of leverage and Cook's distance as two common techniques to determine the influence that multivariate outliers may have on statistical models. Finally, this paper discusses techniques that are commonly used to handle influential multivariate outlier cases.
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Affiliation(s)
| | - Fabrice I Mowbray
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - David Kanters
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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26
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Mowbray FI, DeLaroche AM, Parker SJ, Jones A, Ravichandran Y. Examining the clinical management of asthma exacerbations by nurse practitioners in a pediatric emergency department. Int Emerg Nurs 2020; 50:100844. [PMID: 32205105 DOI: 10.1016/j.ienj.2020.100844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/17/2019] [Accepted: 01/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the clinical management or quality of asthma care provided by nurse practitioners (NP) in a pediatric emergency setting. OBJECTIVE To describe the clinical management of asthma by NPs in our institution's emergency department, and to compare the treatment strategies between NPs, pediatricians, and pediatric emergency physicians. METHODS We conducted a retrospective chart review at a level-one pediatric trauma center. Data were extracted from electronic medical records for all patients between 2 and 18 years of age presenting to the emergency department with an asthma exacerbation. Data were analyzed using binary logistic regression with generalized estimating equations. RESULTS NPs evaluated 18% of all children presenting for asthma care. When compared to pediatric emergency physicians, patients treated by NPs had approximately twice the odds of receiving a β2-agonist (OR = 2.02; 95% CI 1.02 - 3.99) or a systemic corticosteroid (OR = 2.31; 95% CI 1.35 - 3.95) within 60 minutes of clinical evaluation. Adherence rates were similar for the other asthma quality measures between these two clinician groups. CONCLUSIONS NPs were best able to meet time-sensitive asthma quality measures in the emergency department. The addition of NPs to emergency staffing models may improve access to timely care for children with asthma.
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Affiliation(s)
- Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. West., L8S 4L8 Hamilton, Ontario, Canada.
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien St., 48201 Detroit, Michigan, United States.
| | - Sarah J Parker
- Department of Family Medicine and Public Health Sciences, Wayne State University, 42 W Warren Avenue, 48202 Detroit, Michigan, United States.
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. West., L8S 4L8 Hamilton, Ontario, Canada.
| | - Yagnaram Ravichandran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien St., 48201 Detroit, Michigan, United States.
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27
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Mowbray FI, Omar AE, Pfaff K, El-Masri MM. Exploring the factors associated with non-urgent emergency department utilisation for mental health care. J Res Nurs 2019; 24:663-674. [PMID: 34394591 DOI: 10.1177/1744987119845020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Emergency department visits for mental health care are on the rise across North America. Patients with mental illness are at an increased risk for frequent and non-urgent emergency department visitation. Aims The purpose of this study was to examine the independent predictors of non-urgent emergency department use for mental health care. Methods A secondary data analysis was conducted with archived data provided by the Erie St. Clair Local Health Integration Network in Ontario. Results A total of 13,114 mental health-related emergency department visits were analysed using logistic regression with generalised estimating equations modelling. The findings suggest the following characteristics are predictive of non-urgent emergency department use for mental health care: age, season, time of day, access to primary health care, mode of arrival, hospital type, referral source and patient diagnosis. Conclusions The findings of this study can be utilised to assist clinicians and policy makers in identifying and managing patients using the emergency department for non-urgent mental health care.
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Affiliation(s)
- Fabrice I Mowbray
- PhD student, Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Abeer E Omar
- Research Associate, Faculty of Nursing, University of Windsor, Canada
| | - Kathyrn Pfaff
- Associate Professor, Faculty of Nursing, University of Windsor, Canada
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