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Davis VH, Dainty KN, Dhalla IA, Sheehan KA, Wong BM, Pinto AD. "Addressing the bigger picture": A qualitative study of internal medicine patients' perspectives on social needs data collection and use. PLoS One 2023; 18:e0285795. [PMID: 37285324 DOI: 10.1371/journal.pone.0285795] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/29/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND There is increasing interest in collecting sociodemographic and social needs data in hospital settings to inform patient care and health equity. However, few studies have examined inpatients' views on this data collection and what should be done to address social needs. This study describes internal medicine inpatients' perspectives on the collection and use of sociodemographic and social needs information. METHODS A qualitative interpretive description methodology was used. Semi-structured interviews were conducted with 18 patients admitted to a large academic hospital in Toronto, Canada. Participants were recruited using maximum variation sampling for diverse genders, races, and those with and without social needs. Interviews were coded using a predominantly inductive approach and a thematic analysis was conducted. RESULTS Patients expressed that sociodemographic and social needs data collection is important to offer actionable solutions to address their needs. Patients described a gap between their ideal care which would attend to social needs, versus the reality that hospital-based teams are faced with competing priorities and pressures that make it unfeasible to provide such care. They also believed that this data collection could facilitate more holistic, integrated care. Patients conveyed a need to have a trusting and transparent relationship with their provider to alleviate concerns surrounding bias, discrimination, and confidentiality. Lastly, they indicated that sociodemographic and social needs data could be useful to inform care, support research to inspire social change, and assist them with navigating community resources or creating in-hospital programs to address unmet social needs. CONCLUSIONS While the collection of sociodemographic and social needs information in hospital settings is generally acceptable, there were varied views on whether hospital staff should intervene, as their priority is medical care. The results can inform the implementation of social data collection and interventions in hospital settings.
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Affiliation(s)
- Victoria H Davis
- Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Katie N Dainty
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Irfan A Dhalla
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen A Sheehan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Brian M Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
| | - Andrew D Pinto
- Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Wei S, Bogoch II, Dhalla IA, Wong DKH. Forme grave d’hépatite C aiguë transmise sexuellement chez des hommes ayant des relations sexuelles avec d’autres hommes. CMAJ 2023; 195:E243-E246. [PMID: 36781192 PMCID: PMC9928437 DOI: 10.1503/cmaj.220757-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- Sunny Wei
- Département de médecine (Wei), Université McMaster, Hamilton, Ont.; Département de médecine (Bogoch, Dhalla, Wong), Université de Toronto; Divisions de médecine interne générale et d'infectiologie (Bogoch), Hôpital général de Toronto, Réseau universitaire de santé; Département de médecine (Dhalla, Wong), Hôpital St. Michael; Division de gastroentérologie et d'hépatologie (Wong), Université de Toronto, Toronto, Ont
| | - Isaac I Bogoch
- Département de médecine (Wei), Université McMaster, Hamilton, Ont.; Département de médecine (Bogoch, Dhalla, Wong), Université de Toronto; Divisions de médecine interne générale et d'infectiologie (Bogoch), Hôpital général de Toronto, Réseau universitaire de santé; Département de médecine (Dhalla, Wong), Hôpital St. Michael; Division de gastroentérologie et d'hépatologie (Wong), Université de Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Département de médecine (Wei), Université McMaster, Hamilton, Ont.; Département de médecine (Bogoch, Dhalla, Wong), Université de Toronto; Divisions de médecine interne générale et d'infectiologie (Bogoch), Hôpital général de Toronto, Réseau universitaire de santé; Département de médecine (Dhalla, Wong), Hôpital St. Michael; Division de gastroentérologie et d'hépatologie (Wong), Université de Toronto, Toronto, Ont
| | - David K H Wong
- Département de médecine (Wei), Université McMaster, Hamilton, Ont.; Département de médecine (Bogoch, Dhalla, Wong), Université de Toronto; Divisions de médecine interne générale et d'infectiologie (Bogoch), Hôpital général de Toronto, Réseau universitaire de santé; Département de médecine (Dhalla, Wong), Hôpital St. Michael; Division de gastroentérologie et d'hépatologie (Wong), Université de Toronto, Toronto, Ont.
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Wei S, Bogoch II, Dhalla IA, Wong DKH. Sexually acquired severe acute hepatitis C infection in men who have sex with men. CMAJ 2022; 194:E1537-E1540. [PMID: 36410757 PMCID: PMC9828952 DOI: 10.1503/cmaj.220757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sunny Wei
- Department of Medicine (Wei), McMaster University, Hamilton, Ont.; Department of Medicine (Bogoch, Dhalla, Wong), University of Toronto; Divisions of General Internal Medicine and Infectious Diseases (Bogoch), Toronto General Hospital, University Health Network; Department of Medicine (Dhalla, Wong), St. Michael's Hospital; Division of Gastroenterology and Hepatology (Wong), University of Toronto, Toronto, Ont
| | - Isaac I Bogoch
- Department of Medicine (Wei), McMaster University, Hamilton, Ont.; Department of Medicine (Bogoch, Dhalla, Wong), University of Toronto; Divisions of General Internal Medicine and Infectious Diseases (Bogoch), Toronto General Hospital, University Health Network; Department of Medicine (Dhalla, Wong), St. Michael's Hospital; Division of Gastroenterology and Hepatology (Wong), University of Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Department of Medicine (Wei), McMaster University, Hamilton, Ont.; Department of Medicine (Bogoch, Dhalla, Wong), University of Toronto; Divisions of General Internal Medicine and Infectious Diseases (Bogoch), Toronto General Hospital, University Health Network; Department of Medicine (Dhalla, Wong), St. Michael's Hospital; Division of Gastroenterology and Hepatology (Wong), University of Toronto, Toronto, Ont
| | - David K H Wong
- Department of Medicine (Wei), McMaster University, Hamilton, Ont.; Department of Medicine (Bogoch, Dhalla, Wong), University of Toronto; Divisions of General Internal Medicine and Infectious Diseases (Bogoch), Toronto General Hospital, University Health Network; Department of Medicine (Dhalla, Wong), St. Michael's Hospital; Division of Gastroenterology and Hepatology (Wong), University of Toronto, Toronto, Ont.
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Liu M, Richard L, Campitelli MA, Nisenbaum R, Dosani N, Dhalla IA, Wadhera RK, Shariff SZ, Hwang SW. Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals. Addiction 2022; 117:1692-1701. [PMID: 35129239 PMCID: PMC9111216 DOI: 10.1111/add.15823] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
AIMS To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and re-opening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. DESIGN Population-based retrospective cohort study conducted between September 30, 2018 and September 26, 2020. SETTING Ontario, Canada. PARTICIPANTS A total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden. MEASUREMENTS ED visits for drug overdoses of accidental and undetermined intent. FINDINGS Average rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7-153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7-24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re-opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44-1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08-1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02-1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period. CONCLUSIONS Recently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re-opening period of the COVID-19 pandemic compared with housed people.
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Affiliation(s)
- Michael Liu
- Harvard Medical SchoolBostonMAUSA,MAP Centre for Urban Health SolutionsLi Ka Shing Knowledge Institute, St. Michael's HospitalTorontoCanada,ICES CentralTorontoCanada
| | | | | | - Rosane Nisenbaum
- MAP Centre for Urban Health SolutionsLi Ka Shing Knowledge Institute, St. Michael's HospitalTorontoCanada,Division of Biostatistics, Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | - Naheed Dosani
- Division of Palliative CareMcMaster UniversityHamiltonCanada
| | - Irfan A. Dhalla
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada,Division of General Internal Medicine, Department of MedicineUniversity of TorontoTorontoCanada
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes ResearchBeth Israel Deaconess Medical CenterBostonMAUSA
| | | | - Stephen W. Hwang
- MAP Centre for Urban Health SolutionsLi Ka Shing Knowledge Institute, St. Michael's HospitalTorontoCanada,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada,Division of General Internal Medicine, Department of MedicineUniversity of TorontoTorontoCanada
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5
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Liu M, Richard L, Campitelli MA, Nisenbaum R, Dhalla IA, Wadhera RK, Shariff SZ, Hwang SW. Hospitalizations During the COVID-19 Pandemic Among Recently Homeless Individuals: a Retrospective Population-Based Matched Cohort Study. J Gen Intern Med 2022; 37:2016-2025. [PMID: 35396658 PMCID: PMC8992790 DOI: 10.1007/s11606-022-07506-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hospitalizations fell precipitously among the general population during the COVID-19 pandemic. It remains unclear whether individuals experiencing homelessness experienced similar reductions. OBJECTIVE To examine how overall and cause-specific hospitalizations changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. DESIGN Population-based cohort study conducted in Ontario, Canada, between September 30, 2018, and September 26, 2020. PARTICIPANTS In total, 38,617 IRHH, 15,022,368 housed individuals, and 186,858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden. MAIN MEASURES Primary outcomes included medical-surgical, non-elective (overall and cause-specific), elective surgical, and psychiatric hospital admissions. KEY RESULTS Average rates of medical-surgical (rate ratio: 3.8, 95% CI: 3.7-3.8), non-elective (10.3, 95% CI: 10.1-10.4), and psychiatric admissions (128.1, 95% CI: 126.1-130.1) between January and September 2020 were substantially higher among IRHH compared to housed individuals. During the peak period (March 17 to June 16, 2020), rates of medical-surgical (0.47, 95% CI: 0.47-0.47), non-elective (0.80, 95% CI: 0.79-0.80), and psychiatric admissions (0.86, 95% CI: 0.84-0.88) were significantly lower among housed individuals relative to equivalent weeks in 2019. No significant changes were observed among IRHH. During the re-opening period (June 17-September 26, 2020), rates of non-elective hospitalizations for liver disease (1.41, 95% CI: 1.23-1.69), kidney disease (1.29, 95% CI: 1.14-1.47), and trauma (1.19, 95% CI: 1.07-1.32) increased substantially among IRHH but not housed individuals. Distinct hospitalization patterns were observed among IRHH even in comparison with more medically and socially vulnerable matched housed individuals. CONCLUSIONS Persistence in overall hospital admissions and increases in non-elective hospitalizations for liver disease, kidney disease, and trauma indicate that the COVID-19 pandemic presented unique challenges for recently homeless individuals. Health systems must better address the needs of this population during public health crises.
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Affiliation(s)
- Michael Liu
- Harvard Medical School, Boston, MA, USA. .,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada. .,ICES Central, Toronto, Ontario, Canada.
| | | | | | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Irfan A Dhalla
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
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6
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Tran K, Webster F, Ivers NM, Laupacis A, Dhalla IA. Are quality improvement plans perceived to improve the quality of primary care in Ontario? Qualitative study. Can Fam Physician 2021; 67:759-766. [PMID: 34649902 DOI: 10.46747/cfp.6710759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To explore primary care administrators' perceptions of provincially mandated quality improvement plans, and barriers to and facilitators of using quality improvement plans as tools for improving the quality of primary care. DESIGN Qualitative descriptive study using semistructured interviews. SETTING Ontario. PARTICIPANTS Eleven primary care administrators (ie, executive directors, director of clinical services, office administrators) at 7 family health teams and 4 community health centres. METHODS All interviews were audiotaped and transcribed verbatim. Data were analyzed deductively to generate a framework based on a conceptual model of structural, organizational, individual, and innovation-related factors that influence the success of improvement initiatives and, inductively, to generate additional themes. MAIN FINDINGS Provincially mandated quality improvement plans seem to have raised awareness of and provided an overall focus on quality improvement, and have contributed to primary care organizations implementing initiatives to address quality gaps. Four factors that have contributed to the success of quality improvement plans relate to attributes of the quality improvement plans (adaptability and compatibility) and contextual factors (leadership and organizational culture). However, participants expressed that the use of quality improvement plans have not yet led to substantial improvements in the quality of primary care in Ontario, which may be owing to several challenges: poor data quality, lack of staff and physician engagement and buy-in, and lack of resources to support measurement and quality improvement. CONCLUSION Awareness of and focused attention on the need for high-quality patient care may have increased, but participants expressed that substantial improvements in quality care have yet to be achieved in Ontario. The lack of perceived improvements is likely the result of multifaceted and complex challenges primary care organizations face when trying to improve patient care. To effect positive change, organization- and health system-level efforts are needed to improve measurement capabilities, improve staff and physician engagement, and increase capacity for quality improvement among organizations.
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Affiliation(s)
- Kim Tran
- First Nations, Inuit and Métis Lead for System Performance at the Canadian Partnership Against Cancer in Toronto, Ont
| | - Fiona Webster
- Associate Professor in the Arthur Labatt Family School of Nursing at Western University in London, Ont
| | - Noah M Ivers
- Scientist in the Women's College Research Institute in Toronto and Associate Professor in the Department of Family and Community Medicine at the University of Toronto
| | - Andreas Laupacis
- Professor in the Department of Medicine and the Institute of Health Policy, Management and Evaluation at the University of Toronto
| | - Irfan A Dhalla
- Vice President of Physician Quality and Director of the Care Experience Institute at Unity Health Toronto, and Associate Professor in the Department of Medicine and the Institute of Health Policy, Management and Evaluation at the University of Toronto
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7
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Naeh A, Berezowsky A, Yudin MH, Dhalla IA, Berger H. Preeclampsia-Like Syndrome in a Pregnant Patient With Coronavirus Disease 2019 (COVID-19). J Obstet Gynaecol Can 2021; 44:193-195. [PMID: 34648956 PMCID: PMC8505022 DOI: 10.1016/j.jogc.2021.09.015] [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: 06/22/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Hypertension, proteinuria, and hepatic dysfunction have been described as manifestations of coronavirus disease 2019 (COVID-19) and are generally accepted as poor prognostic factors. However, these same findings can also occur in pregnant women with preeclampsia, thus creating a diagnostic challenge. CASE We report a case of COVID-19 infection in an otherwise healthy pregnant patient with secondary hypertension, proteinuria, and significant hepatic dysfunction. Maternal placental growth factor (PlGF) testing was used to rule out preeclampsia. The patient received supportive care and improved significantly. She went on to have a spontaneous vaginal term delivery of a healthy male baby. CONCLUSION COVID-19 infection in pregnancy may present as preeclampsia-like syndrome. PlGF testing can be used to differentiate preeclampsia from COVID-19 and facilitate appropriate management.
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Affiliation(s)
- Amir Naeh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON.
| | - Alexandra Berezowsky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON
| | - Mark H Yudin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON
| | - Irfan A Dhalla
- Division of General Internal Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON
| | - Howard Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON
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Liu M, Maxwell CJ, Armstrong P, Schwandt M, Moser A, McGregor MJ, Bronskill SE, Dhalla IA. La COVID-19 dans les foyers de soins de longue durée en Ontario et en Colombie-Britannique. CMAJ 2021; 193:E263-E269. [PMID: 33593958 PMCID: PMC8034325 DOI: 10.1503/cmaj.201860-f] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Michael Liu
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Colleen J Maxwell
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Pat Armstrong
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Michael Schwandt
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Andrea Moser
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Margaret J McGregor
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Susan E Bronskill
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
| | - Irfan A Dhalla
- Faculté de médecine de Harvard (Liu), Boston, Mass.; Département de politiques et d'interventions sociales (Liu), Université d'Oxford, Oxford, R.-U.; Écoles de pharmacie, de santé publique et de système de santé (Maxwell), Université de Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Département de sociologie (Armstrong), Université York; Département de médecine familiale et communautaire (Moser); Institut de politiques, de gestion et d'évaluation de la santé (Bronskill, Dhalla), École de santé publique Dalla Lana, et Département de médecine (Dhalla), Université de Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculté de médecine (Schwandt), École de la santé publique et des populations, et Département de pratique familiale (McGregor), Université de la Colombie-Britannique; Vancouver Coastal Health (Schwandt); Vancouver, C.-B
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9
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Affiliation(s)
- Larissa M Matukas
- Départements de médecine de laboratoire et pathobiologie et de médecine (Matukas), Université de Toronto; Division de microbiologie (Matukas), Départements de médecine de laboratoire et de médecine, Hôpital St. Michael's, Unity Health Toronto, Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Dhalla), Université de Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; rédacteur en chef (Laupacis), CMAJ
| | - Irfan A Dhalla
- Départements de médecine de laboratoire et pathobiologie et de médecine (Matukas), Université de Toronto; Division de microbiologie (Matukas), Départements de médecine de laboratoire et de médecine, Hôpital St. Michael's, Unity Health Toronto, Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Dhalla), Université de Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; rédacteur en chef (Laupacis), CMAJ
| | - Andreas Laupacis
- Départements de médecine de laboratoire et pathobiologie et de médecine (Matukas), Université de Toronto; Division de microbiologie (Matukas), Départements de médecine de laboratoire et de médecine, Hôpital St. Michael's, Unity Health Toronto, Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Dhalla), Université de Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; rédacteur en chef (Laupacis), CMAJ
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Liu M, Maxwell CJ, Armstrong P, Schwandt M, Moser A, McGregor MJ, Bronskill SE, Dhalla IA. COVID-19 in long-term care homes in Ontario and British Columbia. CMAJ 2020; 192:E1540-E1546. [PMID: 32998943 DOI: 10.1503/cmaj.201860] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Michael Liu
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Colleen J Maxwell
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Pat Armstrong
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Michael Schwandt
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Andrea Moser
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Margaret J McGregor
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Susan E Bronskill
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
| | - Irfan A Dhalla
- Harvard Medical School (Liu), Boston, Mass.; Department of Social Policy and Intervention (Liu), University of Oxford, Oxford, UK; Schools of Pharmacy and Public Health and Health Systems (Maxwell), University of Waterloo, Waterloo, Ont.; ICES Central (Maxwell, Bronskill); Department of Sociology (Armstrong), York University; Department of Family and Community Medicine (Moser); Institute of Health Policy, Management and Evaluation (Bronskill, Dhalla), Dalla Lana School of Public Health, and Department of Medicine (Dhalla), University of Toronto; Baycrest Health Sciences (Moser); Unity Health Toronto (Dhalla), Toronto, Ont.; Faculty of Medicine (Schwandt), School of Population and Public Health, and Department of Family Practice (McGregor), University of British Columbia; Vancouver Coastal Health (Schwandt); Vancouver, BC
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Affiliation(s)
- Larissa M Matukas
- Departments of Laboratory Medicine and Pathobiology, and Medicine (Matukas), University of Toronto; Division of Microbiology (Matukas), Department of Lab Medicine, and Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Department of Medicine and Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; editor-in-chief (Laupacis), CMAJ
| | - Irfan A Dhalla
- Departments of Laboratory Medicine and Pathobiology, and Medicine (Matukas), University of Toronto; Division of Microbiology (Matukas), Department of Lab Medicine, and Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Department of Medicine and Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; editor-in-chief (Laupacis), CMAJ
| | - Andreas Laupacis
- Departments of Laboratory Medicine and Pathobiology, and Medicine (Matukas), University of Toronto; Division of Microbiology (Matukas), Department of Lab Medicine, and Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Department of Medicine and Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto; Unity Health Toronto (Dhalla), Toronto, Ont.; editor-in-chief (Laupacis), CMAJ
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12
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Xie X, Wang M, Goh ESY, Ungar WJ, Little J, Carroll JC, Okun N, Huang T, Rousseau F, Dougan SD, Tu HA, Higgins C, Holubowich C, Sikich N, Dhalla IA, Ng V. Noninvasive Prenatal Testing for Trisomies 21, 18, and 13, Sex Chromosome Aneuploidies, and Microdeletions in Average-Risk Pregnancies: A Cost-Effectiveness Analysis. J Obstet Gynaecol Can 2020; 42:740-749.e12. [PMID: 32008974 DOI: 10.1016/j.jogc.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 09/12/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The cost effectiveness of noninvasive prenatal testing (NIPT) has been established for high-risk pregnancies but remains unclear for pregnancies at other risk levels. The aim was to assess the cost effectiveness of NIPT in average-risk pregnancies from the perspective of a provincial public payer in Canada. METHODS A model was developed to compare traditional prenatal screening (TPS), NIPT as a second-tier test (performed only after a positive TPS result), and NIPT as a first-tier test (performed instead of TPS) for trisomies 21, 18, and 13; sex chromosome aneuploidies; and microdeletions in a hypothetical annual population cohort of average-risk pregnancies (142 000 to 148,000) in Ontario, Canada. A probabilistic analysis was conducted with 5000 repetitions. RESULTS Compared with TPS, NIPT as a second-tier test detected more affected fetuses with trisomies 21, 18, and 13 (188 vs. 158), substantially reduced the number of diagnostic tests (i.e., chorionic villus sampling and amniocentesis) performed (660 vs. 3107), and reduced the cost of prenatal screening ($26.7 million vs. $27.6 million) annually. Compared with second-tier NIPT, first-tier NIPT detected an additional 80 cases of trisomies 21, 18, and 13 at an additional cost of $33 million. The incremental cost per additional affected fetus detected was $412 411. Extending first-tier NIPT to include testing for sex chromosome aneuploidies and 22q11.2 deletion would increase the total screening cost. CONCLUSIONS NIPT as a second-tier test is cost-saving compared with TPS alone. Compared with second-tier NIPT, first-tier NIPT detects more cases of chromosomal anomalies but at a substantially higher cost.
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Affiliation(s)
| | | | - Elaine Suk-Ying Goh
- Laboratory Medicine and Genetics Program, Trillium Health Partners, Mississauga, ON
| | - Wendy J Ungar
- Program of Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON
| | - June C Carroll
- Department of Family and Community Medicine, Sinai Health System, University of Toronto, Toronto, ON
| | - Nan Okun
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON
| | - Tianhua Huang
- Prenatal Screening Ontario, Better Outcomes Registry and Network (BORN) Ontario, Ottawa, ON; Genetics Program, North York General Hospital, Toronto, ON
| | - François Rousseau
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Québec City, QC
| | - Shelley D Dougan
- Prenatal Screening Ontario, Better Outcomes Registry and Network (BORN) Ontario, Ottawa, ON
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13
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Affiliation(s)
- Irfan A Dhalla
- Health Quality Ontario (Dhalla, Tepper); Department of Medicine (Dhalla) and Department of Family and Community Medicine (Tepper) and Institute of Health Policy, Management and Evaluation (Dhalla, Tepper), University of Toronto; St. Michael's Hospital (Dhalla, Tepper), Toronto, Ont.
| | - Joshua Tepper
- Health Quality Ontario (Dhalla, Tepper); Department of Medicine (Dhalla) and Department of Family and Community Medicine (Tepper) and Institute of Health Policy, Management and Evaluation (Dhalla, Tepper), University of Toronto; St. Michael's Hospital (Dhalla, Tepper), Toronto, Ont
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Gajic-Veljanoski O, Sanyal C, McMartin K, Xie X, Walter M, Higgins C, Sikich N, Dhalla IA, Ng V. Economic evaluations of commonly used structured psychotherapies for major depressive disorder and generalized anxiety disorder: A systematic review. Canadian Psychology/Psychologie canadienne 2018. [DOI: 10.1037/cap0000155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kolhatkar A, Cheng L, Morgan SG, Goldsmith LJ, Dhalla IA, Holbrook AM, Law MR. Patterns of borrowing to finance out-of-pocket prescription drug costs in Canada: a descriptive analysis. CMAJ Open 2018; 6:E544-E550. [PMID: 30459172 PMCID: PMC6276978 DOI: 10.9778/cmajo.20180063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Out-of-pocket drug costs lead many Canadians to engage in cost-related nonadherence to prescription medications, but our understanding of other consequences such as borrowing money remains incomplete. In this descriptive study, we sought to quantify the frequency of borrowing to pay for prescription drugs in Canada and characteristics of Canadians who borrowed money for this purpose. METHODS In partnership with Statistics Canada, we designed and administered a cross-sectional rapid-response module in the Canadian Community Health Survey administered by telephone to Canadians aged 12 years or more between January and June 2016. We restricted our analyses to participants who responded to the question regarding borrowing money to pay for prescription drugs and used logistic regression to identify characteristics associated with borrowing. RESULTS A total of 28 091 Canadians responded to the survey (overall response rate 61.8%). The weighted proportion of respondents who reported having borrowed money to pay for prescription drugs in the previous year was 2.5% (95% confidence interval 2.2%-2.8%), an estimated 731 000 Canadians. The odds of borrowing were higher among younger adults, people in poor health and people lacking prescription drug insurance. Other factors associated with increased adjusted odds of borrowing were having 2 or more chronic conditions, low household income and higher out-of-pocket prescription drug costs. INTERPRETATION Many Canadians reported borrowing money to pay for out-of-pocket prescription drug costs, and borrowing was more prevalent among already vulnerable groups that also report other compensatory behaviours to address challenges in paying for prescription drugs. Future research should investigate policy responses intended to increase equity in access to prescription drugs.
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Affiliation(s)
- Ashra Kolhatkar
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Lucy Cheng
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Steven G Morgan
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Laurie J Goldsmith
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Irfan A Dhalla
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Anne M Holbrook
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont
| | - Michael R Law
- Centre for Health Services and Policy Research (Kolhatkar, Cheng, Law), School of Population and Public Health; School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.
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Law MR, Cheng L, Kolhatkar A, Goldsmith LJ, Morgan SG, Holbrook AM, Dhalla IA. The consequences of patient charges for prescription drugs in Canada: a cross-sectional survey. CMAJ Open 2018; 6:E63-E70. [PMID: 29440236 PMCID: PMC5878943 DOI: 10.9778/cmajo.20180008] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many Canadians face substantial out-of-pocket charges for prescription drugs. Prior work suggests that this causes some patients to not take their medications as prescribed; however, we have little understanding of whether charges for prescription medicines lead patients to forego basic needs or to use more health care services. Our study aimed to quantify the consequences of patient charges for medicines in Canada. METHODS As part of the 2016 Canadian Community Health Survey, we designed and fielded cross-sectional questions to 28 091 Canadians regarding prescription drug affordability, consequent use of health care services and trade-offs with other expenditures. We calculated weighted population estimates and proportions, and used logistic regression to determine which patient characteristics were associated with these behaviours. RESULTS Overall, 5.5% (95% confidence interval 5.1%-6.0%) of Canadians reported being unable to afford 1 or more drugs in the prior year, representing 8.2% of those with at least 1 prescription. Drugs for mental health conditions were the most commonly reported drug class for cost-related nonadherence. About 303 000 Canadians had additional doctor visits, about 93 000 sought care in the emergency department, and about 26 000 were admitted to hospital at the population level. Many Canadians forewent basic needs such as food (about 730 000 people), heat (about 238 000) and other health care expenses (about 239 000) because of drug costs. These outcomes were more common among females, younger adults, Aboriginal peoples, those with poorer health status, those lacking drug insurance and those with lower income. INTERPRETATION Out-of-pocket charges for medicines for Canadians are associated with foregoing prescription drugs and other necessities as well as use of additional health care services. Changes to protect vulnerable populations from drug costs might reduce these negative outcomes.
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Affiliation(s)
- Michael R Law
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Lucy Cheng
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Ashra Kolhatkar
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Laurie J Goldsmith
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Steven G Morgan
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Anne M Holbrook
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Irfan A Dhalla
- Affiliations: Centre for Health Services and Policy Research (Law, Cheng, Kolhatkar); School of Population and Public Health (Law, Cheng, Kolhatkar, Morgan), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Goldsmith), Simon Fraser University, Burnaby, BC; Division of Clinical Pharmacology and Toxicology (Holbrook), Department of Medicine, McMaster University, Hamilton, Ont.; Health Quality Ontario (Dhalla); Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
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Dhalla IA, Sikich N. Inaccuracies and omissions in editorial about robotic-assisted prostatectomy. Can Urol Assoc J 2018; 12:10-11. [PMID: 29381454 DOI: 10.5489/cuaj.5099] [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: 11/19/2022]
Affiliation(s)
- Irfan A Dhalla
- Health Quality Ontario; Toronto, ON, Canada.,Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto; Toronto, ON, Canada.,Department of Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital; Toronto, ON, Canada
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Verma AA, Guo Y, Kwan JL, Lapointe-Shaw L, Rawal S, Tang T, Weinerman A, Cram P, Dhalla IA, Hwang SW, Laupacis A, Mamdani MM, Shadowitz S, Upshur R, Reid RJ, Razak F. Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: the General Medicine Inpatient Initiative (GEMINI) retrospective cohort study. CMAJ Open 2017; 5:E842-E849. [PMID: 29237706 PMCID: PMC5741428 DOI: 10.9778/cmajo.20170097] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The precise scope of hospital care delivered under general internal medicine services remains poorly quantified. The purpose of this study was to describe the demographic characteristics, medical conditions, health outcomes and resource use of patients admitted to general internal medicine at 7 hospital sites in the Greater Toronto Area. METHODS This was a retrospective cohort study involving all patients who were admitted to or discharged from general internal medicine at the study sites between Apr. 1, 2010, and Mar. 31, 2015. Clinical data from hospital electronic information systems were linked to administrative data from each hospital. We examined trends in resource use and patient characteristics over the study period. RESULTS There were 136 208 admissions to general internal medicine involving 88 121 unique patients over the study period. General internal medicine admissions accounted for 38.8% of all admissions from the emergency department and 23.7% of all hospital bed-days. Over the study period, the number of admissions to general internal medicine increased by 32.4%; there was no meaningful change in the median length of stay or cost per hospital stay. The median patient age was 73 (interquartile range [IQR] 57-84) years, and the median number of coexisting conditions was 6 (IQR 3-9). The median acute length of stay was 4.6 (IQR 2.5-8.6) days, and the median total cost per hospital stay was $5850 (IQR $3915-$10 061). Patients received at least 1 computed tomography scan in 52.2% of admissions. The most common primary discharge diagnoses were pneumonia (5.0% of admissions), heart failure (4.7%), chronic obstructive pulmonary disease (4.1%), urinary tract infection (4.0%) and stroke (3.6%). INTERPRETATION Patients admitted to general internal medicine services represent a large, heterogeneous, resource-intensive and growing population. Understanding and improving general internal medicine care is essential to promote a high-quality, sustainable health care system.
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Affiliation(s)
- Amol A Verma
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Yishan Guo
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Janice L Kwan
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Lauren Lapointe-Shaw
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Shail Rawal
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Terence Tang
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Adina Weinerman
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Peter Cram
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Irfan A Dhalla
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Stephen W Hwang
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Andreas Laupacis
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Muhammad M Mamdani
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Steven Shadowitz
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Ross Upshur
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Robert J Reid
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
| | - Fahad Razak
- Affiliations: Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass
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Xie X, Lambrinos A, Chan B, Dhalla IA, Krings T, Casaubon LK, Lum C, Sikich N, Bharatha A, Pereira VM, Stotts G, Saposnik G, O'Callaghan C, Kelloway L, Hill MD. Mechanical thrombectomy in patients with acute ischemic stroke: a cost-utility analysis. CMAJ Open 2016; 4:E316-25. [PMID: 27398380 PMCID: PMC4933608 DOI: 10.9778/cmajo.20150088] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The beneficial effects of endovascular treatment with new-generation mechanical thrombectomy devices compared with intravenous thrombolysis alone to treat acute large-artery ischemic stroke have been shown in randomized controlled trials (RCTs). This study aimed to estimate the cost utility of mechanical thrombectomy compared with the established standard of care. METHODS We developed a Markov decision process analytic model to assess the cost-effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis versus treatment with intravenous thrombolysis alone from the public payer perspective in Canada. We conducted comprehensive literature searches to populate model inputs. We estimated the efficacy of mechanical thrombectomy plus intravenous thrombolysis from a meta-analysis of 5 RCTs, and we used data from the Oxford Vascular Study to model long-term clinical outcomes. We calculated incremental cost-effectiveness ratios (ICER) using a 5-year time horizon. RESULTS The base case analysis showed the cost and effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis to be $126 939 and 1.484 quality-adjusted life-years (QALYs), respectively, and the cost and effectiveness of treatment with intravenous thrombolysis alone to be $124 419 and 1.273 QALYs, respectively. The mechanical thrombectomy plus intravenous thrombolysis strategy was associated with an ICER of $11 990 per QALY gained. Probabilistic sensitivity analysis showed that the probability of treatment with mechanical thrombectomy plus intravenous thrombolysis being cost-effective was 57.5%, 89.7% and 99.6% at thresholds of $20 000, $50 000 and $100 000 per QALY gained, respectively. The main factors influencing the ICER were time horizon, extra cost of mechanical thrombectomy treatment and age of the patient. INTERPRETATION Mechanical thrombectomy as an adjunct therapy to intravenous thrombolysis is cost-effective compared with treatment with intravenous thrombolysis alone for patients with acute large-artery ischemic stroke.
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Affiliation(s)
- Xuanqian Xie
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Anna Lambrinos
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Brian Chan
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Irfan A Dhalla
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Timo Krings
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Leanne K Casaubon
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Cheemun Lum
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Nancy Sikich
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Aditya Bharatha
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Vitor Mendes Pereira
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Grant Stotts
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Gustavo Saposnik
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Christina O'Callaghan
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Linda Kelloway
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Michael D Hill
- Health Quality Ontario (Xie, Lambrinos, Chan, Dhalla, Sikich); Toronto Health Economics and Technology Assessment Collaborative (Xie), Leslie Dan Pharmacy, University of Toronto; Departments of Medical Imaging and Surgery (Krings, Pereira), University of Toronto; University Health Network - Toronto Western Hospital (Krings, Casaubon); Department of Medicine (Casaubon), Division of Neurology, University of Toronto; Stroke Outcomes Research Centre (Saposnik), St. Michael's Hospital, University of Toronto; Division of Neuroradiology (Bharatha), Department of Medical Imaging, St. Michael's Hospital, University of Toronto; Ontario Stroke Network (O'Callaghan, Kelloway), Toronto, Ont.; Ottawa Hospital Research Institute and Diagnostic Imaging - Interventional Neuroradiology (Lum), The Ottawa Hospital, University of Ottawa; Division of Neurology (Stotts), The Ottawa Hospital, Ottawa, Ont.; Department of Clinical Neurosciences (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
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Weinerman AS, Dhalla IA, Kiss A, Etchells EE, Wu RC, Wong BM. Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med 2015; 10:491-6. [PMID: 25851257 DOI: 10.1002/jhm.2348] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 01/13/2015] [Accepted: 01/19/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Accurate and complete documentation of hospitalized patients' code status is important to ensure that healthcare providers take appropriate action in the event of a cardiac arrest. OBJECTIVE Determine the frequency and clinical relevance of incomplete and inconsistent code status documentation. DESIGN Point-prevalence study. SETTING Academic medical centers. PATIENTS Patients admitted to general internal medicine wards. MEASUREMENTS Frequency and clinical relevance of inconsistent code status documentation across 5 documentation sources. RESULTS Thirty-eight (20%; 95% confidence interval [CI], 14%-26%) of 187 patients had complete and consistent code status documentation. Another 27 (14%; 95% CI, 9%-19%) patients had no code status documentation. The remaining 122 (65%; 95% CI, 58%-72%) patients had at least 1 code status documentation inconsistency. Of these, 38 (20%; 95% CI, 14%-26%) patients had a clinically relevant code status documentation inconsistency. Multivariate logistic regression analysis demonstrated that increased age (odds ratio [OR] = 1.07 [95% CI, 1.05-1.10] for every 1-year increase in age, P < 0.001) and patients receiving comfort measures (OR = 9.39 [95% CI, 1.35-65.19], P = 0.02) were independently associated with a clinically relevant code status documentation inconsistency. CONCLUSIONS Incomplete and inconsistent documentation of code status occurred frequently in hospitalized patients, especially elderly patients and patients receiving comfort measures. Having multiple, poorly integrated code status documentation sources leads to a significant number of concerning inconsistencies that create opportunities for healthcare providers to inappropriately deliver or withhold resuscitative measures that conflict with patients' expressed wishes. Institutions need to be aware of this potential documentation hazard and take steps to minimize code status documentation inconsistencies.
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Affiliation(s)
- Adina S Weinerman
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irfan A Dhalla
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Edward E Etchells
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert C Wu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
| | - Brian M Wong
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Pattani R, Wu PE, Dhalla IA. Other consequences of reduced duty hours. The authors respond. CMAJ 2015; 187:207. [PMID: 25691795 PMCID: PMC4330147 DOI: 10.1503/cmaj.115-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Reena Pattani
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital; Department of Medicine, (Pattani, Wu, Dhalla), University of Toronto; Department of Medicine (Wu), Toronto General Hospital; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital; Department of Medicine, (Pattani, Wu, Dhalla), University of Toronto; Department of Medicine (Wu), Toronto General Hospital; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital; Department of Medicine, (Pattani, Wu, Dhalla), University of Toronto; Department of Medicine (Wu), Toronto General Hospital; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
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Abstract
BACKGROUND The incidence of neonatal opioid withdrawal is increasing in both Canada and the United States. However, the degree to which the treatment of pain with opioids, rather than the misuse of prescription opioids or heroin, contributes to the prevalence of neonatal opioid withdrawal remains unknown. METHODS We conducted a retrospective, population-based, cross-sectional study between 1992 and 2011 in Ontario with 2 objectives. First, we determined the annual incidence of neonatal abstinence syndrome. Second, using data from a subset of women eligible for publicly funded prescription drugs, we determined what proportion of women who deliver an infant with neonatal abstinence syndrome were given a prescription for an opioid before and during pregnancy. RESULTS The incidence of neonatal abstinence syndrome in Ontario increased 15-fold during the study period, from 0.28 per 1000 live births in 1992 to 4.29 per 1000 live births in 2011. During the final 5 years of the study, we identified 927 deliveries of infants with neonatal abstinence syndrome to mothers who were public drug plan beneficiaries. Of these mothers, 67% had received an opioid prescription in the 100 days preceding delivery, including 53.3% who received methadone, an increase from 28.6% in the interval spanning 1 to 2 years before delivery (p < 0.001). Prescription for nonmethadone opioids decreased from 38% to 17% (p < 0.001). INTERPRETATION The incidence of neonatal opioid withdrawal in Ontario has increased substantially over the last 20 years. Most of the women in this cohort who delivered an infant with neonatal abstinence syndrome had received a prescription for an opioid both before and during their pregnancy.
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Affiliation(s)
- Suzanne D Turner
- Department of Family and Community Medicine, St. Michael's Hospital
| | - Tara Gomes
- Li KaShing Knowledge Institute, St. Michael's Hospital ; Leslie Dan Faculty of Pharmacy, University of Toronto
| | | | - Zhan Yao
- Institute for Clinical Evaluative Sciences
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences ; Division of Paediatric Medicine, Hospital for Sick Children ; Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Muhammad M Mamdani
- Li KaShing Knowledge Institute, St. Michael's Hospital ; Leslie Dan Faculty of Pharmacy, University of Toronto
| | - David N Juurlink
- Institute for Clinical Evaluative Sciences ; Department of Medicine, University of Toronto ; Sunnybrook Research Institute, Toronto, Ont
| | - Irfan A Dhalla
- Institute for Clinical Evaluative Sciences ; Department of Medicine, University of Toronto ; Department of Medicine, St. Michael's Hospital
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Abstract
BACKGROUND Harms associated with prescription opioids are a major and increasing public health concern. Prescribing of opioids for inpatients may contribute to the problem, especially if primary care practitioners continue opioid therapy that is initiated in hospital. OBJECTIVES To describe the extent and nature of opioid prescribing for opioid-naive patients (i.e., no use of opioids within 2 weeks before admission) on an internal medicine unit. METHODS This single-centre study involved chart review for opioid-naive patients admitted to the internal medicine unit of a large academic health sciences centre in Toronto, Ontario. Over 12 weeks, patients were prospectively identified for the study, and charts were later reviewed to characterize opioid use during the hospital stay and upon discharge. The primary outcomes were the proportions of opioid-naive patients for whom opioids were prescribed in hospital and upon discharge. Data on serious adverse events related to opioid use (e.g., need for naloxone or occurrence of falls) were also collected through chart review. RESULTS From July 4 to September 22, 2011, a total of 721 patients were admitted to the study unit, of whom 381 (53%) were classified as opioid-naive. Opioids were prescribed for 82 (22%) of these opioid-naive patients while they were in hospital. Among the opioid-naive patients, there were a total of 247 opioid prescriptions, with hydromorphone (110 prescriptions) and morphine (92 prescriptions) being the drugs most commonly prescribed. For 23 (28%) of the patients with a prescription for opioids in hospital (6% of all opioid-naive patients), an opioid was also prescribed upon discharge. The indication for opioids was documented in 16 (70%) of the 23 discharge prescriptions. No adverse events or deaths related to opioid use were identified during the hospital stays. CONCLUSIONS Among opioid-naive patients admitted to the internal medicine unit, opioids were prescribed for about 1 in 5 patients, and less than one-third of these patients were continued on opioids at the time of discharge. These results, if replicated elsewhere, suggest that efforts to improve opioid prescribing and reduce attendant harm should be focused primarily on the outpatient setting.
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Affiliation(s)
- Sharan Lail
- BScPhm, ACPR, is with the General Internal Medicine Unit and Department of Pharmacy, St Michael's Hospital, Toronto, Ontario
| | - Kelly Sequeira
- BScPhm, is with the General Internal Medicine Unit and Department of Pharmacy, St Michael's Hospital, Toronto, Ontario
| | - Jenny Lieu
- BScPhm, ACPR, is with the Department of Clinical Informatics and Department of Pharmacy, St Michael's Hospital, Toronto, Ontario
| | - Irfan A Dhalla
- MD, MSc, is with the Department of Medicine, University of Toronto, and the Department of Medicine and the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario
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Affiliation(s)
- Irfan A Dhalla
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada,
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Dhalla IA, O'Brien T, Morra D, Thorpe KE, Wong BM, Mehta R, Frost DW, Abrams H, Ko F, Van Rooyen P, Bell CM, Gruneir A, Lewis GH, Daub S, Anderson GM, Hawker GA, Rochon PA, Laupacis A. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial. JAMA 2014; 312:1305-12. [PMID: 25268437 DOI: 10.1001/jama.2014.11492] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated. OBJECTIVE To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital. DESIGN, SETTING, AND PATIENTS High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014. INTERVENTIONS Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year. RESULTS There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups. CONCLUSIONS AND RELEVANCE In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01108172.
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Affiliation(s)
- Irfan A Dhalla
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto3Department of Medicine, St Michael's Hospital, Toronto4Li Ka Shing Knowledge Institute of St Mich
| | - Tara O'Brien
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada6Department of Medicine, Women's College Hospital, Toronto
| | - Dante Morra
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada7Trillium Health Partners, Mississauga, Ontario
| | - Kevin E Thorpe
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto8Dalla Lana School of Public Health, University of Toronto, Toronto
| | - Brian M Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada9Department of Medicine, Sunnybrook Health Sciences Centre, Toronto10Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto
| | - Rajin Mehta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada9Department of Medicine, Sunnybrook Health Sciences Centre, Toronto
| | - David W Frost
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada11Department of Medicine, University Health Network, Toronto
| | - Howard Abrams
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada11Department of Medicine, University Health Network, Toronto
| | | | | | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada5Institute for Clinical Evaluative Sciences, Toronto, 13Department of Medicine, Mount Sinai Hospital, Toronto
| | - Andrea Gruneir
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto5Institute for Clinical Evaluative Sciences, Toronto, 14Women's College Research Institute, Women's College Hospital, Toronto
| | | | - Stacey Daub
- Toronto Central Community Care Access Centre, Toronto
| | - Geoff M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto
| | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada5Institute for Clinical Evaluative Sciences, Toronto, 6Department of Medicine, Women's College Hospital, Toronto
| | - Paula A Rochon
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto5Institute for Clinical Evaluative Sciences, Toronto, 6Department of Medicine, Women's College Hos
| | - Andreas Laupacis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto4Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto5Institute for Clinical Evaluati
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Affiliation(s)
- Michael R Law
- Centre for Health Services and Policy Research (Law, Kratzer), School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, BC; Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital, Toronto, Ont.; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.
| | - Jillian Kratzer
- Centre for Health Services and Policy Research (Law, Kratzer), School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, BC; Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital, Toronto, Ont.; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
| | - Irfan A Dhalla
- Centre for Health Services and Policy Research (Law, Kratzer), School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, BC; Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; Li Ka Shing Knowledge Institute (Dhalla), St. Michael's Hospital, Toronto, Ont.; Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont
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Gomes T, Mamdani MM, Paterson JM, Dhalla IA, Juurlink DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician 2014; 60:826-832. [PMID: 25217680 PMCID: PMC4162700] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To describe trends in rates of prescribing of high-dose opioid formulations and variations in opioid product selection across Canada. DESIGN Population-based, cross-sectional study. SETTING Canada. PARTICIPANTS Retail pharmacies dispensing opioids between January 1, 2006, and December 31, 2011. MAIN OUTCOME MEASURES Opioid dispensing rates, reported as the number of units dispensed per 1000 population, stratified by province and opioid type. RESULTS The rate of dispensing high-dose opioid formulations increased 23.0%, from 781 units per 1000 population in 2006 to 961 units per 1000 population in 2011. Although these rates remained relatively stable in Alberta (6.3% increase) and British Columbia (8.4% increase), rates in Newfoundland and Labrador (84.7% increase) and Saskatchewan (54.0% increase) rose substantially. Ontario exhibited the highest annual rate of high-dose oxycodone and fentanyl dispensing (756 tablets and 112 patches per 1000 population, respectively), while Alberta's rate of high-dose morphine dispensing was the highest in Canada (347 units per 1000 population). Two of the highest rates of high-dose hydromorphone dispensing were found in Saskatchewan and Nova Scotia (258 and 369 units per 1000 population, respectively). Conversely, Quebec had the lowest rate of high-dose oxycodone and morphine dispensing (98 and 53 units per 1000 population, respectively). CONCLUSION We found marked interprovincial variation in the dispensing of high-dose opioid formulations in Canada, emphasizing the need to understand the reasons for these differences, and to consider developing a national strategy to address opioid prescribing.
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Affiliation(s)
- Tara Gomes
- Scientist at the Institute for Clinical Evaluative Sciences; Assistant Professor at the Institute for Health Policy, Management and Evaluation and the Leslie Dan Faculty of Pharmacy at the University of Toronto; and Scientist at the Li Ka Shing Knowledge Institute at St Michael's Hospital in Toronto, Ont.
| | - Muhammad M Mamdani
- Scientist at the Institute for Clinical Evaluative Sciences; Professor at the Institute for Health Policy, Management and Evaluation, the Department of Medicine, and the Leslie Dan Faculty of Pharmacy at the University of Toronto; and Scientist at the Li Ka Shing Knowledge Institute and the Department of Medicine at St Michael's Hospital
| | - J Michael Paterson
- Scientist at the Institute for Clinical Evaluative Sciences and Assistant Professor in the Institute for Health Policy, Management and Evaluation at the University of Toronto and the Department of Family Medicine at McMaster University in Hamilton, Ont
| | - Irfan A Dhalla
- Scientist at the Institute for Clinical Evaluative Sciences; Assistant Professor at the Institute for Health Policy, Management and Evaluation and the Department of Medicine at the University of Toronto; and Associate Scientist at the Li Ka Shing Knowledge Institute and the Department of Medicine at St Michael's Hospital
| | - David N Juurlink
- Scientist at the Institute for Clinical Evaluative Sciences; Scientist at the Sunnybrook Research Institute; and Professor at the Institute for Health Policy, Management and Evaluation, the Department of Medicine, and the Department of Pediatrics at the University of Toronto
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Gomes T, Mamdani MM, Dhalla IA, Cornish S, Paterson JM, Juurlink DN. The burden of premature opioid-related mortality. Addiction 2014; 109:1482-8. [PMID: 25041316 PMCID: PMC4171750 DOI: 10.1111/add.12598] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 03/31/2014] [Accepted: 04/17/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The burden of premature mortality due to opioid-related death has not been fully characterized. We calculated temporal trends in the proportion of deaths attributable to opioids and estimated years of potential life lost (YLL) due to opioid-related mortality in Ontario, Canada. DESIGN Cross-sectional study. SETTING Ontario, Canada. PARTICIPANTS Individuals who died of opioid-related causes between January 1991 and December 2010. MEASUREMENTS We used the Registered Persons Database and data abstracted from the Office of the Chief Coroner to measure annual rates of opioid-related mortality. The proportion of all deaths related to opioids was determined by age group in each of 1992, 2001 and 2010. The YLL due to opioid-related mortality were estimated, applying the life expectancy estimates for the Ontario population. FINDINGS We reviewed 5935 opioid-related deaths in Ontario between 1991 and 2010. The overall rate of opioid-related mortality increased by 242% between 1991 (12.2 per 1 000 000 Ontarians) and 2010 (41.6 per 1 000 000 Ontarians; P < 0.0001). Similarly, the annual YLL due to premature opioid-related death increased threefold, from 7006 years (1.3 years per 1000 population) in 1992 to 21 927 years (3.3 years per 1000 population) in 2010. The proportion of deaths attributable to opioids increased significantly over time within each age group (P < 0.05). By 2010, nearly one of every eight deaths (12.1%) among individuals aged 25-34 years was opioid-related. CONCLUSIONS Rates of opioid-related deaths are increasing rapidly in Ontario, Canada, and are concentrated among the young, leading to a substantial burden of disease.
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Affiliation(s)
- Tara Gomes
- Institute for Clinical and Evaluative SciencesToronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of TorontoToronto, ON, Canada,Leslie Dan Faculty of PharmacyToronto, ON, Canada,Sunnybrook Research InstituteToronto, ON, Canada
| | - Muhammad M Mamdani
- Institute for Clinical and Evaluative SciencesToronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of TorontoToronto, ON, Canada,Leslie Dan Faculty of PharmacyToronto, ON, Canada,Li Ka Shing Knowledge Institute, St. Michael's HospitalToronto, ON, Canada,Applied Health Research Centre (AHRC), St Michael's HospitalToronto, ON, Canada
| | - Irfan A Dhalla
- Institute for Clinical and Evaluative SciencesToronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of TorontoToronto, ON, Canada,Li Ka Shing Knowledge Institute, St. Michael's HospitalToronto, ON, Canada,Department of Medicine, University of TorontoToronto, ON, Canada
| | - Stephen Cornish
- Schulich School of Medicine, University of Western ONLondon, ON, Canada
| | - J Michael Paterson
- Institute for Clinical and Evaluative SciencesToronto, ON, Canada,Department of Family Medicine, McMaster UniversityHamilton, ON, Canada
| | - David N Juurlink
- Institute for Clinical and Evaluative SciencesToronto, ON, Canada,Institute of Health Policy, Management and Evaluation, University of TorontoToronto, ON, Canada,Sunnybrook Research InstituteToronto, ON, Canada,Department of Medicine, University of TorontoToronto, ON, Canada
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Affiliation(s)
- Reena Pattani
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont.
| | - Peter E Wu
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
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Balaban DY, Dhalla IA, Law MR, Bell CM. Private expenditures on brand name prescription drugs after generic entry. Appl Health Econ Health Policy 2013; 11:523-529. [PMID: 23979876 DOI: 10.1007/s40258-013-0052-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Generic drugs offer a less expensive and therapeutically equivalent alternative to brand name drugs. Nevertheless, many Canadian private drug plans continue to pay for brand name drugs even after generics become available. OBJECTIVE The objective of this study was to quantify the excess spending resulting from this practice. METHODS We used the IMS Brogan PharmaStat database to study private-plan drug spending in Ontario from 2000 to 2009. We focused on three widely used drug classes: proton pump inhibitors (PPIs), selective serotonin reuptake inhibitors (SSRIs), and angiotensin-converting enzyme (ACE) inhibitors. For each specific molecule, we determined the difference between what private plans spent on the brand name version and what would have been spent if an available generic version of the same molecule had been purchased instead. RESULTS We found that prescriptions paid for by private drug plans were often filled with brand name drugs after generics became available. This led to excess private spending of more than Can$107.8 million for these three drug classes over our study period: Can$54.4 million for PPIs, Can$32.4 million for SSRIs and Can$21.0 million for ACE inhibitors. INTERPRETATION Brand name drugs continue to be reimbursed by Canadian private drug plans at higher prices even after less expensive generic alternatives are available. By mandating generic substitution, substantial cost savings on benefit plans could be achieved.
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Affiliation(s)
- Dahlia Y Balaban
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada,
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Fallis BA, Dhalla IA, Klemensberg J, Bell CM. Primary medication non-adherence after discharge from a general internal medicine service. PLoS One 2013; 8:e61735. [PMID: 23658698 PMCID: PMC3642181 DOI: 10.1371/journal.pone.0061735] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 03/14/2013] [Indexed: 11/18/2022] Open
Abstract
Background Medication non-adherence frequently leads to suboptimal patient outcomes. Primary non-adherence, which occurs when a patient does not fill an initial prescription, is particularly important at the time of hospital discharge because new medications are often being prescribed to treat an illness rather than for prevention. Methods We studied older adults consecutively discharged from a general internal medicine service at a large urban teaching hospital to determine the prevalence of primary non-adherence and identify characteristics associated with primary non-adherence. We reviewed electronic prescriptions, electronic discharge summaries and pharmacy dispensing data from April to August 2010 for drugs listed on the public formulary. Primary non-adherence was defined as failure to fill one or more new prescriptions after hospital discharge. In addition to descriptive analyses, we developed a logistical regression model to identify patient characteristics associated with primary non-adherence. Results There were 493 patients eligible for inclusion in our study, 232 of whom were prescribed new medications. In total, 66 (28%) exhibited primary non-adherence at 7 days after discharge and 55 (24%) at 30 days after discharge. Examples of medications to which patients were non-adherent included antibiotics, drugs for the management of coronary artery disease (e.g. beta-blockers, statins), heart failure (e.g. beta-blockers, angiotensin converting enzyme inhibitors, furosemide), stroke (e.g. statins, clopidogrel), diabetes (e.g. insulin), and chronic obstructive pulmonary disease (e.g. long-acting bronchodilators, prednisone). Discharge to a nursing home was associated with an increased risk of primary non-adherence (OR 2.25, 95% CI 1.01–4.95). Conclusions Primary non-adherence after medications are newly prescribed during a hospitalization is common, and was more likely to occur in patients discharged to a nursing home.
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Affiliation(s)
- Brooks A. Fallis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Irfan A. Dhalla
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jason Klemensberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
- * E-mail:
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Kahan M, Gomes T, Juurlink DN, Manno M, Wilson L, Mailis-Gagnon A, Srivastava A, Reardon R, Dhalla IA, Mamdani MM. Effect of a course-based intervention and effect of medical regulation on physicians' opioid prescribing. Can Fam Physician 2013; 59:e231-e239. [PMID: 23673603 PMCID: PMC3653672] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To examine the effects of an intensive 2-day course on physicians' prescribing of opioids. DESIGN Population-based retrospective observational study. SETTING College of Physicians and Surgeons of Ontario (CPSO) in Toronto. PARTICIPANTS Ontario physicians who took the course between April 1, 2000, and May 30, 2008. INTERVENTION A 2-day opioid-prescribing course with a maximum of 12 physician participants. Educational methods included didactic presentations, case discussions, and standardized patients. A detailed syllabus and office materials were provided. MAIN OUTCOME MEASURES Participants were matched with control physicians using specific variables. The primary outcome was the rate of opioid prescribing, expressed as milligrams of morphine equivalent per quarter. RESULTS One hundred thirty-eight course participants (120 family physicians, 15 specialists, and 3 physicians whose status was uncertain) were eligible for analysis. Of these, 68.1% were self-referred and 31.9% were referred by the CPSO. Overall, among physicians referred by the CPSO, the rate of opioid prescribing decreased dramatically in the year before course participation compared with matched control physicians. The course had no added effect on the rate of physicians' opioid prescribing in the subsequent 2 years. There was no statistically significant effect on the rate of opioid prescribing observed among the self-referred physicians. Among 15 of the self-referred physicians who, owing to the high quantities of opioids they prescribed, were not matched with control physicians, the rate of opioid prescribing decreased by 43.9% in the year following course completion. CONCLUSION Physicians markedly reduced the quantities of opioids they prescribed after medical regulators referred them to an opioid-prescribing course. The course itself did not lead to significant additional reductions; however, a subgroup of physicians who prescribed high quantities of opioids might have responded to what was taught in the course.
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Affiliation(s)
- Meldon Kahan
- Department of Family and Community Medicine, University of Toronto (U of T), Ontario, Canada.
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Dhalla IA, Gomes T, Yao Z, Nagge J, Persaud N, Hellings C, Mamdani MM, Juurlink DN. Chlorthalidone versus hydrochlorothiazide for the treatment of hypertension in older adults: a population-based cohort study. Ann Intern Med 2013; 158:447-55. [PMID: 23552325 DOI: 10.7326/0003-4819-158-6-201303190-00004] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Some evidence suggests that chlorthalidone may be superior to hydrochlorothiazide for the treatment of hypertension. OBJECTIVE To compare the effectiveness and safety of chlorthalidone and hydrochlorothiazide in older adults. DESIGN Propensity score-matched observational cohort study with up to 5 years of follow-up. SETTING Ontario, Canada. PATIENTS All individuals aged 66 years or older who were newly treated with chlorthalidone or hydrochlorothiazide and were not hospitalized for heart failure, stroke, or myocardial infarction in the prior year were eligible for inclusion. Each chlorthalidone recipient was matched to up to 2 hydrochlorothiazide recipients on the basis of age, sex, year of treatment initiation, and propensity score. MEASUREMENTS The primary outcome was a composite of death or hospitalization for heart failure, stroke, or myocardial infarction. Safety outcomes included hospitalization with hypokalemia or hyponatremia. RESULTS A total of 29 873 patients were studied. During follow-up, chlorthalidone recipients (n = 10 384) experienced the primary outcome at a rate of 3.2 events per 100 person-years of follow-up, and hydrochlorothiazide recipients experienced 3.4 events per 100 person-years of follow-up (adjusted hazard ratio, 0.93 [95% CI, 0.81 to 1.06]). Patients treated with chlorthalidone were more likely to be hospitalized with hypokalemia (adjusted hazard ratio, 3.06 [CI, 2.04 to 4.58]) or hyponatremia (adjusted hazard ratio, 1.68 [CI, 1.24 to 2.28]). In 9 post hoc analyses comparing patients initially prescribed 12.5, 25, or 50 mg of chlorthalidone per day with those prescribed 12.5, 25, or 50 mg of hydrochlorothiazide per day, the former were more likely to be hospitalized with hypokalemia for all 6 comparisons in which a statistically significant association was found. The results of other effectiveness and safety outcomes were also consistent with those of the main analysis. LIMITATION Unmeasured differences in baseline characteristics or physician treatment approaches or an insufficiently large sample may have limited the ability to detect small differences in the comparative effectiveness of the drugs. CONCLUSION As typically prescribed, chlorthalidone in older adults was not associated with fewer adverse cardiovascular events or deaths than hydrochlorothiazide. However, it was associated with a greater incidence of electrolyte abnormalities, particularly hypokalemia. PRIMARY FUNDING SOURCE Ontario Ministry of Health and Long-Term Care.
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Affiliation(s)
- Irfan A Dhalla
- St. Michael’s Hospital and Institute for Clinical Evaluative Sciences, Toronto, Ontario M5B 1W8, Canada.
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Affiliation(s)
- David N Juurlink
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Abstract
BACKGROUND Use of opioids may predispose drivers to road trauma, yet the effect of opioid dose on this association is unknown. METHODS We conducted a population-based nested case-control study of patients aged 18 to 64 years who received at least 1 publicly funded prescription for an opioid from April 1, 2003, through March 31, 2011. Cases were defined as having an emergency department visit related to road trauma. Patients without road trauma served as a control group matched to cases by age, sex, index year, prior road trauma, and a disease risk index. We compared the risk of road trauma among patients treated with doses of opioids ranging from very low to very high (<20 to ≥200 morphine equivalents daily). In a subgroup analysis, we stratified our analysis by driver status. RESULTS Among 549 878 eligible adults, we identified 5300 cases with road trauma and matched an equal number of controls. Multivariate adjustment yielded no significant association between escalating opioid dose and odds of road trauma (adjusted odds ratio ranged between 1.00 and 1.09). However, a significant association between opioid dose and road trauma was observed among drivers. Compared with very low opioid doses, drivers prescribed low doses had a 21% increased odds of road trauma (adjusted odds ratio, 1.21 [95% CI, 1.02-1.42]); those prescribed moderate doses, 29% increased odds (1.29 [1.06-1.57]); those prescribed high doses, 42% increased odds (1.42 [1.15-1.76]); and those prescribed very high doses, 23% increased odds (1.23 [1.02-1.49]). CONCLUSIONS Among drivers prescribed opioids, a significant relationship exists between drug dose and risk of road trauma. This association is distinct and does not appear with passengers, pedestrians, and others injured in road trauma.
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Affiliation(s)
- Tara Gomes
- Institute for Clinical Evaluative Sciences, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Affiliation(s)
- Irfan A Dhalla
- Department of Medicine, University of Toronto, Toronto, Ontario
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Lam K, Hwang SW, Dhalla IA, Hota S, Thorpe K, Palda VA, Brown A, Klein DJ. Creating the right evidence for system change. Healthc Q 2013; 16:22-26. [PMID: 24034773 DOI: 10.12927/hcq.2013.23496] [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] [Indexed: 06/02/2023]
Abstract
Most evaluative research is focused on assessing new technologies at the patient level. Comparatively little is focused on assessing how system changes could improve the delivery of healthcare. In this article, the authors describe an opportunity to conduct evaluative trials of system changes affordably and efficiently by using a cluster randomized design and mandatory reporting data, using the prevention of Clostridium difficile infection as an example. They then describe what must be done to make similar trials a regular tool of healthcare policy.
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Affiliation(s)
- Kenneth Lam
- Kenneth Lam, BSc, is a Keenan research summer student at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, in Toronto, Ontario; and a medical student at Western University, in London, Ontario
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Ivers N, Dhalla IA, Allan GM. Opioids for osteoarthritis pain: benefits and risks. Can Fam Physician 2012; 58:e708. [PMID: 23242901 PMCID: PMC3520677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
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Petch J, Dhalla IA, Henry DA, Schultz SE, Glazier RH, Bhatia S, Laupacis A. Public payments to physicians in Ontario adjusted for overhead costs. Healthc Policy 2012; 8:30-36. [PMID: 23968613 PMCID: PMC3517870] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
We used data collected in the 2010 National Physician Survey and public payment data published in the Institute for Clinical and Evaluative Sciences report Payments to Ontario Physicians from Ministry of Health and Long-Term Care Sources 1992/93 to 2009/10 to estimate 2009/2010 net physician income from public payments for Ontario physicians by specialty. Incorporating overhead substantially affects estimates of physician income and changes relative position. For example, ophthalmologists were ranked second when only public payments were considered but eighth when overhead was included. Conversely, hospital-based specialties such as anaesthesia, radiation oncology and emergency medicine rank significantly higher after overhead is included.
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Affiliation(s)
- Jeremy Petch
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON.
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Dhalla IA. Not as good as we need it to be. CMAJ 2012. [DOI: 10.1503/cmaj.121191] [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] [Indexed: 11/01/2022] Open
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Affiliation(s)
- Robert J Campbell
- Department of Ophthalmology, Hotel Dieu Hospital and Queen's University, 166 Brock Street, Kingston, Ontario, Canada K7L 5G2.
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Dhalla IA, Juurlink DN, Gomes T, Granton JT, Zheng H, Mamdani MM. Selective Serotonin Reuptake Inhibitors and Pulmonary Arterial Hypertension. Chest 2012; 141:348-353. [DOI: 10.1378/chest.11-0426] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
BACKGROUND Many patients do not adhere to treatment because they cannot afford their prescription medications, putting them at increased risk of adverse health outcomes. We determined the prevalence of cost-related nonadherence and investigated its associated characteristics, including whether a person has drug insurance. METHODS Using data from the 2007 Canada Community Health Survey, we analyzed the responses of 5732 people who answered questions about cost-related nonadherence to treatment. We determined the national prevalence of cost-related nonadherence and used logistic regression to evaluate the association between cost-related nonadherence and a series of demographic and socioeconomic variables, including province of residence, age, sex, household income, health status and having drug insurance. RESULTS Cost-related nonadherence was reported by 9.6% (95% confidence interval [CI] 8.5%-10.6%) of Canadians who had received a prescription in the past year. In our adjusted model, we found that people in poor health (odds ratio [OR] 2.64, 95% CI 1.77-3.94), those with lower income (OR 3.29, 95% CI 2.03-5.33), those without drug insurance (OR 4.52, 95% CI 3.29-6.20) and those who live in British Columbia (OR 2.56, 95% CI 1.49-4.42) were more likely to report cost-related nonadherence. Predicted rates of cost-related nonadherence ranged from 3.6% (95% CI 2.4-4.5) among people with insurance and high household incomes to 35.6% (95% CI 26.1%-44.9%) among people with no insurance and low household incomes. INTERPRETATION About 1 in 10 Canadians who receive a prescription report cost-related nonadherence. The variability in insurance coverage for prescription medications appears to be a key reason behind this phenomenon.
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Affiliation(s)
- Michael R Law
- The Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC.
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Dhalla IA, Gomes T, Mamdani MM, Juurlink DN. Opioids versus nonsteroidal anti-inflammatory drugs in noncancer pain. Can Fam Physician 2012; 58:30. [PMID: 22267615 PMCID: PMC3264005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Affiliation(s)
- Irfan A Dhalla
- Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
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Gruneir A, Dhalla IA, van Walraven C, Fischer HD, Camacho X, Rochon PA, Anderson GM. Unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm. Open Med 2011; 5:e104-11. [PMID: 21915234 PMCID: PMC3148002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 10/30/2010] [Accepted: 10/30/2010] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unplanned hospital readmissions are common, expensive and often preventable. Strategies designed to reduce readmissions should target patients at high risk. The purpose of this study was to describe medical patients identified using a recently published and validated algorithm (the LACE index) as being at high risk for readmission and to examine their actual hospital readmission rates. METHODS We used population-based administrative data to identify adult medical patients discharged alive from 6 hospitals in Toronto, Canada, during 2007. A LACE index score of 10 or higher was used to identify patients at high risk for readmission. We described patient and hospitalization characteristics among both the high-risk and low-risk groups as well as the 30-day readmission rates. RESULTS Of 26 045 patients, 12.6% were readmitted to hospital within 30 days and 20.9% were readmitted within 90 days of discharge. High-risk patients (LACE ≥ 10) accounted for 34.0% of the sample but 51.7% of the patients who were readmitted within 30 days. High-risk patients were readmitted with twice the frequency as other patients, had longer lengths of stay and were more likely to die during the readmission. INTERPRETATION Using a LACE index score of 10, we identified patients with a high rate of readmission who may benefit from improved post-discharge care. Our findings suggest that the LACE index is a potentially useful tool for decision-makers interested in identifying appropriate patients for post-discharge interventions.
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Affiliation(s)
- Irfan A Dhalla
- Department of Medicine and the Keenan Research Centre of the Li Ka Shing KnowledgeInstitute, St. Michael’s Hospital, Toronto, Ont.
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