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Boozary A, Varner C, Laupacis A. Homelessness is a health crisis: why hospitals are resorting to building housing. CMAJ 2024; 196:E666-E667. [PMID: 38772600 DOI: 10.1503/cmaj.240649] [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: 05/23/2024] Open
Affiliation(s)
- Andrew Boozary
- Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; executive director, Gattuso Centre for Social Medicine (Boozary), University Health Network, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; Harvard T.H. Chan School of Public Health (Boozary), Boston, Mass.; deputy editor, CMAJ (Varner); Schwartz/Reisman Emergency Medicine Institute (Varner); Department of Emergency Medicine, Sinai Health, Department of Family & Community Medicine (Varner), University of Toronto, Toronto, Ont.; consulting editor, CMAJ (Laupacis)
| | - Catherine Varner
- Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; executive director, Gattuso Centre for Social Medicine (Boozary), University Health Network, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; Harvard T.H. Chan School of Public Health (Boozary), Boston, Mass.; deputy editor, CMAJ (Varner); Schwartz/Reisman Emergency Medicine Institute (Varner); Department of Emergency Medicine, Sinai Health, Department of Family & Community Medicine (Varner), University of Toronto, Toronto, Ont.; consulting editor, CMAJ (Laupacis)
| | - Andreas Laupacis
- Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; executive director, Gattuso Centre for Social Medicine (Boozary), University Health Network, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; Harvard T.H. Chan School of Public Health (Boozary), Boston, Mass.; deputy editor, CMAJ (Varner); Schwartz/Reisman Emergency Medicine Institute (Varner); Department of Emergency Medicine, Sinai Health, Department of Family & Community Medicine (Varner), University of Toronto, Toronto, Ont.; consulting editor, CMAJ (Laupacis)
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Varner C, Boozary A, Laupacis A. "Social admissions" to hospital are not personal failures but policy ones. CMAJ 2024; 196:E597-E598. [PMID: 38719224 PMCID: PMC11073831 DOI: 10.1503/cmaj.240577] [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: 05/12/2024] Open
Affiliation(s)
- Catherine Varner
- Deputy editor, CMAJ (Varner); Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; executive director, Gattuso Centre for Social Medicine (Boozary), University Health Network, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; Harvard T.H. Chan School of Public Health ( Boozary), Boston, Mass.; Schwartz/Reisman Emergency Medicine Institute (Varner); Department of Emergency Medicine, Sinai Health, Department of Family & Community Medicine (Varner), University of Toronto, Toronto, Ont.; senior deputy editor, CMAJ (Laupacis)
| | - Andrew Boozary
- Deputy editor, CMAJ (Varner); Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; executive director, Gattuso Centre for Social Medicine (Boozary), University Health Network, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; Harvard T.H. Chan School of Public Health ( Boozary), Boston, Mass.; Schwartz/Reisman Emergency Medicine Institute (Varner); Department of Emergency Medicine, Sinai Health, Department of Family & Community Medicine (Varner), University of Toronto, Toronto, Ont.; senior deputy editor, CMAJ (Laupacis)
| | - Andreas Laupacis
- Deputy editor, CMAJ (Varner); Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; executive director, Gattuso Centre for Social Medicine (Boozary), University Health Network, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; Harvard T.H. Chan School of Public Health ( Boozary), Boston, Mass.; Schwartz/Reisman Emergency Medicine Institute (Varner); Department of Emergency Medicine, Sinai Health, Department of Family & Community Medicine (Varner), University of Toronto, Toronto, Ont.; senior deputy editor, CMAJ (Laupacis)
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Laupacis A, Patrick K. De nouveaux articles du JAMC sur la confiance envers le milieu de la santé. CMAJ 2024; 196:E272-E273. [PMID: 38438147 PMCID: PMC10911868 DOI: 10.1503/cmaj.231712-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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
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Persaud N, Azarpazhooh A, Keown-Stoneman C, Birken CS, Isaranuwatchai W, Maguire JL, Mamdani M, Allen C, Mason D, Kowal C, Jaleel M, Bazeghi F, Thorpe KE, Laupacis A, Parkin PC. Xylitol for the prevention of acute otitis media episodes in children aged 1-5 years: a randomised controlled trial. Arch Dis Child 2024; 109:121-124. [PMID: 37890960 PMCID: PMC10850643 DOI: 10.1136/archdischild-2023-325565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE To investigate the regular use of xylitol, compared with sorbitol, to prevent acute otitis media (AOM), upper respiratory tract infections (URTIs) and dental caries. DESIGN Blinded randomised controlled trial with a 6-month study period. SETTING Enrolment took place at 11 primary care practices in Ontario, Canada. PATIENTS Children aged 1-5 years who did not use xylitol or sorbitol at enrolment. INTERVENTIONS Children were randomly assigned to use a placebo syrup with sorbitol or xylitol syrup two times per day for 6 months. MAIN OUTCOME MEASURES Primary outcome was the number of clinician-diagnosed AOM episodes over 6 months. Secondary outcomes were caregiver-reported URTIs and dental caries. RESULTS Among the 250 randomised children, the mean (SD) age was 38±14 months and there were 124 girls (50%). There were three clinician-diagnosed AOM episodes in the 125 placebo group participants and six in the 125 xylitol group participants (OR 2.04; 95% CI 0.43, 12.92; p=0.50). There was no difference in number of caregiver-reported URTI episodes (rate ratio (RR) 0.88; 95% CI 0.70, 1.11) between the placebo (4.2 per participant over 6 months; 95% CI 3.6, 5.0) and xylitol (3.7; 95% CI 3.2, 4.4) groups. Dental caries were reported for four participants in the placebo group and two in the xylitol group (OR 0.42; 95% CI 0.04, 3.05; p=0.42). In a post-hoc analysis of URTIs during the COVID-19 pandemic, the rate among the 59 participants receiving placebo was 2.3 per participant over 6 months (95% CI 1.8, 3.0) and for the 55 receiving xylitol, 1.3 over 6 months (95% CI 0.92, 1.82; RR 0.56; 95% CI 0.36, 0.87). The most common adverse event was diarrhoea (28% with placebo; 34% with xylitol). CONCLUSIONS Regular use of xylitol did not prevent AOM, URTIs or dental caries in a trial with limited statistical power. A post-hoc analysis indicated that URTIs were less common with xylitol exposure during the COVID-19 pandemic, but this finding could be spurious. TRIAL REGISTRATION NUMBER NCT03055091.
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Affiliation(s)
- Navindra Persaud
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Amir Azarpazhooh
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Charles Keown-Stoneman
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- The Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Catherine S Birken
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jonathon L Maguire
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Pediatrics, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- The Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Allen
- The Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Dalah Mason
- SickKids Research Institute, Toronto, Ontario, Canada
| | | | | | | | - Kevin E Thorpe
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- The Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Andreas Laupacis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patricia C Parkin
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Laupacis A, Saigle V. Du nouveau au JAMC: ajout d’un type d’article pour aider les médecins à soutenir leur patientèle. CMAJ 2024; 196:E26-E27. [PMID: 38228348 PMCID: PMC10803000 DOI: 10.1503/cmaj.231549-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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Affiliation(s)
- Andreas Laupacis
- Institut de recherche de l'Hôpital d'Ottawa (Saigle), Ottawa, Ont.; Rédacteur adjoint, JAMC (Laupacis)
| | - Victoria Saigle
- Institut de recherche de l'Hôpital d'Ottawa (Saigle), Ottawa, Ont.; Rédacteur adjoint, JAMC (Laupacis)
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Laupacis A. L’identité de chaque personne doit être respectée : l’expérience d’un homme transgenre. CMAJ 2024; 196:E28. [PMID: 38228340 PMCID: PMC10803001 DOI: 10.1503/cmaj.231476-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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
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Laupacis A, Patrick K. New CMAJ articles to explore trust in health care. CMAJ 2023; 195:E1723-E1724. [PMID: 38110215 PMCID: PMC10727796 DOI: 10.1503/cmaj.231712] [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: 12/20/2023] Open
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Shickh S, Mighton C, Clausen M, Kodida R, Adi-Wauran E, Hirjikaka D, Krishnapillai S, Reble E, Sam J, Baxter NN, Laupacis A, Bombard Y. "I don't need any more unknowns hanging over my head": Views of patients with cancer on variants of uncertain significance and low/moderate risk results from genomic sequencing. Genet Med 2023; 25:100960. [PMID: 37577963 DOI: 10.1016/j.gim.2023.100960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023] Open
Abstract
PURPOSE We sought to explore patient-reported utility of all types of cancer results from genomic sequencing (GS). METHODS Qualitative study, using semi-structured interviews with patients who underwent GS within a trial. Thematic analysis employing constant comparison was used. Two coders coded transcripts, with use of a third coder to resolve conflicts. RESULTS 25 patients participated: female (22), >50 years (18), European (12), Ashkenazi Jewish (5), Middle Eastern (3), or other ethnicity (5), with breast cancer history (20). Patients' perceptions of the utility of cancer GS results hinged on whether they triggered clinical action. For example, when patients were enrolled into high-risk breast cancer surveillance programs for low/moderate risk breast cancer genes, they perceived the results to be very "useful" and of moderate-high utility. In contrast, patients receiving low/moderate risk or primary variants of uncertain significance results without clinical action perceived results as "concerning," leading to harms, such as hypervigilance about cancer symptoms. Overall, having supportive relatives or providers enhanced perceptions of utility. CONCLUSION Patients' perceptions of cancer GS results hinged on whether they triggered clinical management. Consequently, patients who received results without clinical action became hypervigilant, experiencing harms. Our findings call for a need to develop practice interventions to support patients with cancer undergoing GS.
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Affiliation(s)
- Salma Shickh
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Chloe Mighton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Marc Clausen
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Rita Kodida
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Ella Adi-Wauran
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Daena Hirjikaka
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Suvetha Krishnapillai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Emma Reble
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Jordan Sam
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nancy N Baxter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Yvonne Bombard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research, Toronto, ON, Canada.
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Laupacis A. Le point de vue de l’épouse et de la fille d’un patient atteint de délirium. CMAJ 2023; 195:E1564. [PMID: 37984931 PMCID: PMC10662495 DOI: 10.1503/cmaj.230833-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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
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Affiliation(s)
- Andreas Laupacis
- Ottawa Hospital Research Institute (Saigle), Ottawa, Ont.; Senior Deputy Editor, CMAJ (Laupacis)
| | - Victoria Saigle
- Ottawa Hospital Research Institute (Saigle), Ottawa, Ont.; Senior Deputy Editor, CMAJ (Laupacis)
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Rani S, Laupacis A. Le message à transmettre : « Boire moins, c’est mieux ». CMAJ 2023; 195:E1494-E1495. [PMID: 37931945 PMCID: PMC10627567 DOI: 10.1503/cmaj.231238-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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
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Rani S, Laupacis A. "Less is better" is the best message when talking to patients about alcohol. CMAJ 2023; 195:E1232-E1233. [PMID: 37722747 PMCID: PMC10506506 DOI: 10.1503/cmaj.231238] [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: 09/20/2023] Open
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Laupacis A. Delirium: perspectives of a patient's wife and daughter. CMAJ 2023; 195:E1043. [PMID: 37580074 PMCID: PMC10426350 DOI: 10.1503/cmaj.230833] [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: 08/16/2023] Open
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Persaud N, Bedard M, Boozary A, Glazier RH, Gomes T, Hwang SW, Jüni P, Law MR, Mamdani M, Manns B, Martin D, Morgan SG, Oh P, Pinto AD, Shah BR, Sullivan F, Umali N, Thorpe KE, Tu K, Wu F, Laupacis A. Effect of Free Medicine Distribution on Health Care Costs in Canada Over 3 Years: A Secondary Analysis of the CLEAN Meds Randomized Clinical Trial. JAMA Health Forum 2023; 4:e231127. [PMID: 37234014 DOI: 10.1001/jamahealthforum.2023.1127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Importance Few interventions are proven to reduce total health care costs, and addressing cost-related nonadherence has the potential to do so. Objective To determine the effect of eliminating out-of-pocket medication fees on total health care costs. Design, Setting, and Participants This secondary analysis of a multicenter randomized clinical trial using a prespecified outcome took place across 9 primary care sites in Ontario, Canada (6 in Toronto and 3 in rural areas), where health care services are generally publicly funded. Adult patients (≥18 years old) reporting cost-related nonadherence to medicines in the past 12 months were recruited between June 1, 2016, and April 28, 2017, and followed up until April 28, 2020. Data analysis was completed in 2021. Interventions Access to a comprehensive list of 128 medicines commonly prescribed in ambulatory care with no out-of-pocket costs for 3 years vs usual medicine access. Main Outcome and Measures Total publicly funded health care costs over 3 years, including costs of hospitalizations. Health care costs were determined using administrative data from Ontario's single-payer health care system, and all costs are reported in Canadian dollars with adjustments for inflation. Results A total of 747 participants from 9 primary care sites were included in the analysis (mean [SD] age, 51 [14] years; 421 [56.4%] female). Free medicine distribution was associated with a lower median total health care spending over 3 years of $1641 (95% CI, $454-$2792; P = .006). Mean total spending was $4465 (95% CI, -$944 to $9874) lower over the 3-year period. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, eliminating out-of-pocket medication expenses for patients with cost-related nonadherence in primary care was associated with lower health care spending over 3 years. These findings suggest that eliminating out-of-pocket medication costs for patients could reduce overall costs of health care. Trial Registration ClinicalTrials.gov Identifier: NCT02744963.
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Affiliation(s)
- Nav Persaud
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael Bedard
- Department of Family Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Andrew Boozary
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Richard H Glazier
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tara Gomes
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Jüni
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Healthcare Analytics Research and Training at St Michael's Hospital, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
| | - Braden Manns
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Danielle Martin
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Steven G Morgan
- School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Oh
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew D Pinto
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Sullivan
- North York General Hospital, Toronto Western Family Health Team, University Health Network, Toronto, Ontario, Canada
- Division of Population and Behavioral Science, School of Medicine, University of St Andrews, St Andrews, Scotland, United Kingdom
| | - Norman Umali
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Karen Tu
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- North York General Hospital, Toronto Western Family Health Team, University Health Network, Toronto, Ontario, Canada
| | - Fangyun Wu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Andreas Laupacis
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Patrick K, Laupacis A. Le sujet de l’heure : l’accès aux soins de santé au Canada. CMAJ 2023; 195:E317-E318. [PMID: 36849172 PMCID: PMC9970631 DOI: 10.1503/cmaj.230040-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: 03/01/2023] Open
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Patrick K, Laupacis A. A focus on access to health care in Canada. CMAJ 2023; 195:E123-E124. [PMID: 36690361 PMCID: PMC9876585 DOI: 10.1503/cmaj.230040] [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: 01/24/2023] Open
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Laupacis A. Soins palliatifs à domicile au Canada: Il est temps que cette option soit offerte à toute la population. CMAJ 2022; 194:E1527-E1528. [DOI: 10.1503/cmaj.221332-f] [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: 01/09/2023] Open
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Laupacis A. Home-based palliative care in Canada: time for this to be an option for everyone. CMAJ 2022; 194:E1290-E1291. [PMID: 36162838 PMCID: PMC9512166 DOI: 10.1503/cmaj.221332] [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: 11/18/2022] Open
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Chin-Yee N, Gomes T, Tanuseputro P, Talarico R, Laupacis A. Anticoagulant use and associated outcomes in older patients receiving home palliative care: a retrospective cohort study. CMAJ 2022; 194:E1198-E1208. [PMID: 36096505 PMCID: PMC9477253 DOI: 10.1503/cmaj.220919] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/08/2022] Open
Abstract
Background: The benefits and harms of anticoagulants for people near the end of life are not well understood, nor is it known what proportion of patients discontinue these medications. We aimed to characterize anticoagulant use in older recipients of home palliative care and describe patient and provider characteristics, as well as outcomes associated with anticoagulant discontinuation in this group. Methods: Using linked administrative health databases, we conducted a population-based cohort study of patients aged 66 years and older who initiated home palliative care in Ontario from 2010 to 2018. We calculated the prevalence of anticoagulant use. We used multilevel logistic regression models to assess patient (e.g., sociodemographic, comorbidities) and physician (e.g., demographic, training, practice) factors associated with anticoagulant discontinuation after initiation of home palliative care. We defined discontinuation as either primary (no anticoagulant claim within 1.5 times the days’ supply of the previous prescription) or secondary (no subsequent anticoagulant claim at any time after the index date). In secondary analyses, we used cause-specific hazards regression to explore subsequent thrombotic and bleeding events associated with anticoagulant discontinuation, and multivariable logistic regression for location of death. Results: We identified 98 089 recipients of home palliative care, of whom 15.5% were taking anticoagulants at the time of the first palliative care visit. Depending on the definition of discontinuation, 18.0% to 24.4% of patients discontinued anticoagulants after the first home palliative care visit. Compared with warfarin, use of a direct oral anticoagulant (adjusted odds ratio [OR] 0.49, 95% confidence interval [CI] 0.43–0.56) and low-molecular-weight heparin (adjusted OR 0.56, 95% CI 0.47–0.66) were associated with a lower likelihood of discontinuation. Few patient or physician characteristics — and no comorbidities or indications for therapeutic anticoagulation — were associated with discontinuation. Anticoagulant discontinuation after beginning home palliative care was associated with similar rates of thrombosis (adjusted hazard ratio [HR] 1.06, 95% CI 0.81–1.39), lower rates of bleeding (adjusted HR 0.75, 95% CI 0.62–0.90) and a higher likelihood of a home death (adjusted OR 1.22, 95% CI 1.09–1.36) compared with continuing anticoagulation. Interpretation: Among recipients of home palliative care in Ontario, anticoagulant use is common, and discontinuation is not influenced by comorbidities or indication for anticoagulation. Physician preference may play an important role; patients should be made aware of their options toward the end of life and supported in shared decision-making.
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Affiliation(s)
- Nicolas Chin-Yee
- St. Michael's Hospital (Chin-Yee, Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Chin-Yee, Gomes, Laupacis), University of Toronto; ICES Central (Chin-Yee, Gomes); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; ICES uOttawa (Tanuseputro, Talarico); The Ottawa Hospital Research Institute (Tanuseputro, Talarico), Ottawa, Ont.; Senior Deputy Editor (Laupacis), CMAJ
| | - Tara Gomes
- St. Michael's Hospital (Chin-Yee, Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Chin-Yee, Gomes, Laupacis), University of Toronto; ICES Central (Chin-Yee, Gomes); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; ICES uOttawa (Tanuseputro, Talarico); The Ottawa Hospital Research Institute (Tanuseputro, Talarico), Ottawa, Ont.; Senior Deputy Editor (Laupacis), CMAJ
| | - Peter Tanuseputro
- St. Michael's Hospital (Chin-Yee, Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Chin-Yee, Gomes, Laupacis), University of Toronto; ICES Central (Chin-Yee, Gomes); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; ICES uOttawa (Tanuseputro, Talarico); The Ottawa Hospital Research Institute (Tanuseputro, Talarico), Ottawa, Ont.; Senior Deputy Editor (Laupacis), CMAJ
| | - Robert Talarico
- St. Michael's Hospital (Chin-Yee, Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Chin-Yee, Gomes, Laupacis), University of Toronto; ICES Central (Chin-Yee, Gomes); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; ICES uOttawa (Tanuseputro, Talarico); The Ottawa Hospital Research Institute (Tanuseputro, Talarico), Ottawa, Ont.; Senior Deputy Editor (Laupacis), CMAJ
| | - Andreas Laupacis
- St. Michael's Hospital (Chin-Yee, Gomes), Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Chin-Yee, Gomes, Laupacis), University of Toronto; ICES Central (Chin-Yee, Gomes); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; ICES uOttawa (Tanuseputro, Talarico); The Ottawa Hospital Research Institute (Tanuseputro, Talarico), Ottawa, Ont.; Senior Deputy Editor (Laupacis), CMAJ
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Laupacis A. “I thought everybody bled like that”: a patient’s experience with von Willebrand disease. CMAJ 2022; 194:E1137. [PMID: 36302108 PMCID: PMC9435535 DOI: 10.1503/cmaj.221102] [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: 11/14/2022] Open
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Shickh S, Mighton C, Clausen M, Adi-Wauran E, Hirjikaka D, Kodida R, Krishnapillai S, Reble E, Sam J, Shaw A, Lerner-Ellis J, Baxter NN, Laupacis A, Bombard Y. "Doctors shouldn't have to cheat the system": Clinicians' real-world experiences of the utility of genomic sequencing. Genet Med 2022; 24:1888-1898. [PMID: 35612591 DOI: 10.1016/j.gim.2022.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Emerging genetic tests such as genomic sequencing (GS) can generate a broad range of benefits, but funding criteria only prioritize diagnosis and clinical management. There is limited evidence on all types of benefits obtained from GS in practice. We aimed to explore real-world experiences of Canadian clinicians across specialties on the full range of benefits obtained from the results from GS. METHODS We conducted a qualitative study using semistructured interviews with Canadian clinicians. Transcripts were thematically analyzed using constant comparison. RESULTS In total, 25 clinicians participated, including 12 geneticists, 7 genetic counselors, 4 oncologists, 1 neurologist, and 1 family physician. Although diagnoses and management were the most valued benefits of GS, clinicians also prioritized nontraditional utility, such as access to community supports. However, clinicians felt "restricted" by funding bodies, which only approved funding when GS would inform diagnoses and management. Consequently, clinicians sought ways to "cheat the system" to access GS (eg, research testing) but acknowledged workarounds were burdensome, drove inequity, and undermined patient care. CONCLUSION Current governance structures undervalue real-world benefits of GS leading clinicians to adopt workarounds, which jeopardize patient care. These results support calls for the expansion of the definition of clinical utility and research to quantify the additional benefits.
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Affiliation(s)
- Salma Shickh
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Chloe Mighton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Marc Clausen
- Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ella Adi-Wauran
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Daena Hirjikaka
- Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rita Kodida
- Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Suvetha Krishnapillai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Emma Reble
- Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jordan Sam
- Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Angela Shaw
- Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jordan Lerner-Ellis
- Lunenfeld Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada; Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Yvonne Bombard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Genomics Health Services and Policy Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Ontario Institute for Cancer Research, Toronto, Ontario, Canada.
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Laupacis A. How a powdered fentanyl program has improved a client’s quality of life. CMAJ 2022; 194:E681. [PMID: 35577375 PMCID: PMC9438732 DOI: 10.1503/cmaj.220649] [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: 11/08/2022] Open
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Laupacis A. Long road to recovery after complications of sickle cell disease. CMAJ 2022; 194:E617. [PMID: 35500917 PMCID: PMC9067385 DOI: 10.1503/cmaj.220573] [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: 11/06/2022] Open
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Laupacis A. Perspectives of a patient and a physiatrist on neuralgic amyotrophy. CMAJ 2022; 194:E502-E503. [DOI: 10.1503/cmaj.220382] [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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Shickh S, Mighton C, Clausen M, Lerner-Ellis J, Baxter NN, Laupacis A, Bombard Y. eP513: “Doctors shouldn’t have to cheat the system”: Clinicians’ real-world experiences of the utility of genomic sequencing. Genet Med 2022. [DOI: 10.1016/j.gim.2022.01.545] [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: 10/18/2022] Open
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Bayoumi A, Laupacis A. Des critères d’assurance désuets empêchent le remboursement de soins fondés sur des données probantes. CMAJ 2021; 193:E1826-E1827. [PMID: 34844946 PMCID: PMC8654894 DOI: 10.1503/cmaj.211617-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: 11/25/2022] Open
Affiliation(s)
- Ahmed Bayoumi
- Centre for Urban Health Solutions (Bayoumi), Hôpital St. Michael, Unity Health Toronto, Toronto, Ont.; rédacteur adjoint principal, CMAJ (Laupacis)
| | - Andreas Laupacis
- Centre for Urban Health Solutions (Bayoumi), Hôpital St. Michael, Unity Health Toronto, Toronto, Ont.; rédacteur adjoint principal, CMAJ (Laupacis)
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McRae AD, Laupacis A. SARS-CoV-2 vaccination should be required to practise medicine in Canada. CMAJ 2021; 193:E1816-E1817. [PMID: 34753806 PMCID: PMC8654896 DOI: 10.1503/cmaj.211839] [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: 11/16/2022] Open
Affiliation(s)
- Andrew D McRae
- Editorial Fellow, CMAJ (McRae); Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Senior Deputy Editor, CMAJ (Laupacis)
| | - Andreas Laupacis
- Editorial Fellow, CMAJ (McRae); Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Senior Deputy Editor, CMAJ (Laupacis)
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Vyas MV, Fang J, Austin PC, Laupacis A, Cheung MC, Silver FL, Kapral MK. Importance of accounting for loss to follow-up when comparing mortality between immigrants and long-term residents: a population-based retrospective cohort. BMJ Open 2021; 11:e046377. [PMID: 34728439 PMCID: PMC8565574 DOI: 10.1136/bmjopen-2020-046377] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To evaluate the association between immigration status and all-cause mortality in different disease cohorts, and the impact of loss to follow-up on the observed associations. DESIGN Population-based retrospective cohort study using linked administrative health data in Ontario, Canada. SETTING We followed adults with a first-ever diagnosis of ischaemic stroke, cancer or schizophrenia between 2002 and 2013 from index event to death, loss to follow-up, or end of follow-up in 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Our outcomes of interest were all-cause mortality and loss to follow-up. For each disease cohort, we calculated adjusted HRs of death in immigrants compared with long-term residents, adjusting for demographic characteristics and comorbidities, with and without censoring for those who were lost to follow-up. We calculated the ratio of two the HRs and the respective CL using bootstrapping methods. RESULTS Immigrants were more likely to be lost to follow-up than long-term residents in all disease cohorts. Not accounting for this loss to follow-up overestimated the magnitude of the association between immigration status and mortality in those with ischaemic stroke (HR of death before vs after accounting for censoring: 0.78 vs 0.83, ratio=0.95; 95% CL 0.93 to 0.97), cancer (0.74 vs 0.78, ratio=0.96; 0.95 to 0.96), and schizophrenia (0.54 vs 0.56, ratio=0.97; 0.96 to 0.98). CONCLUSIONS Immigrants to Canada have a survival advantage that varies by the disease studied. The magnitude of this advantage is modestly overestimated by not accounting for the higher loss to follow-up in immigrants.
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Affiliation(s)
- Manav V Vyas
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | - Andreas Laupacis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Matthew C Cheung
- Division of Haematology & Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank L Silver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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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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Affiliation(s)
- Ahmed Bayoumi
- Centre for Urban Health Solutions (Bayoumi), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Senior Deputy Editor, CMAJ (Laupacis)
| | - Andreas Laupacis
- Centre for Urban Health Solutions (Bayoumi), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Senior Deputy Editor, CMAJ (Laupacis)
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Vyas MV, Austin PC, Pequeno P, Fang J, Silver FL, Laupacis A, Kapral MK. Incidence of Stroke in Immigrants to Canada: A Province-wide Retrospective Analysis. Neurology 2021; 97:e1192-e1201. [PMID: 34408071 DOI: 10.1212/wnl.0000000000012555] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/25/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To evaluate the association between immigration status and stroke incidence. METHODS We conducted a retrospective cohort study of 8 million adults (15% immigrants) residing in Ontario, Canada, on January 1, 2003, with no history of stroke or TIA. Participants were followed up until March 31, 2018, to identify incident stroke or TIA, defined as hospitalization or emergency room visit. We calculated adjusted hazard ratios (HRs) of stroke or TIA in immigrants compared to long-term residents using cause-specific hazard models, adjusting for demographics and comorbid conditions. We evaluated whether the association varied by age, stroke type, or country of origin of immigrants. RESULTS During 109 million person-years of follow-up, we observed 235,336 incident stroke or TIA events. Compared to long-term residents, immigrants had a lower rate of stroke or TIA (10.9 vs 23.4 per 10,000 person-years, HR 0.67, 95% confidence interval [CI] 0.66-0.68). This was true across all age groups and stroke types, with an HR in immigrants vs long-term residents for ischemic stroke of 0.71 (95% CI 0.69-0.72), for intracerebral hemorrhage of 0.89 (95% CI 0.85-0.93), for subarachnoid hemorrhage of 0.85 (95% CI 0.81-0.91), and for TIA of 0.53 (95% CI 0.51-0.54). The magnitude of the reduction in stroke risk associated with immigration status was less pronounced in immigrants from the Caribbean (HR 0.95, 95% CI 0.91-1.00), Latin America (HR 0.85, 95% CI 0.82-0.91), and Africa (HR 0.80, 95% CI 0.74-0.85) than in those from other world regions. DISCUSSION Immigrants have a lower rate of stroke or TIA than long-term residents with variation by age, stroke type, and country of origin. This knowledge may be useful for developing targeted primary stroke prevention strategies.
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Affiliation(s)
- Manav V Vyas
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada.
| | - Peter C Austin
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada
| | - Priscila Pequeno
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada
| | - Jiming Fang
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada
| | - Frank L Silver
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada
| | - Andreas Laupacis
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada
| | - Moira K Kapral
- From the Division of Neurology (M.V.V., F.L.S.) and Division of General Internal Medicine (M.K.K.), Department of Medicine, and Institute of Health Policy Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.); and ICES (M.V.V., P.C.A., P.P., J.F., F.L.S., A.L., M.K.K.), Toronto, Ontario, Canada
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Dainty K, Seaton M, Cowan K, Laupacis A, Dorian P, Douma M, Garner J, Goldstein J, Shire D, Sinclair D, Thurlow C, Vaillancourt C. Partnering with survivors & families to determine research priorities for adult out-of-hospital cardiac arrest: A James Lind Alliance Priority Setting Partnership. Resusc Plus 2021; 7:100148. [PMID: 34286310 PMCID: PMC8274337 DOI: 10.1016/j.resplu.2021.100148] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 03/02/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Research priority setting in health care has historically been done by expert health care providers and researchers and has not involved patients, family or the public. Survivors & family members have been particularly absent from this process in the field of resuscitation research and specifically adult out of hospital cardiac arrest (OHCA). As such, we sought to conduct a priority setting exercise in partnership with survivors, lay responders and their families in order to ensure that their priorities were visible. We partnered with the James Lind Alliance (UK) and used their commonly used consensus methodology for Public Priority Setting Partnerships (PSPs) to identify research priorities that reflected the perspectives of all stakeholders. METHODS We used two rounds of public and health care professional surveys to create the initial priority lists. The initial survey collected open-ended questions while the second round consolidated the list of initial questions into a refined list for prioritization. This was done by reviewing existing evidence and thematic categorization by the multi-disciplinary steering committee. An in-person consensus workshop was conducted to come to consensus on the top ten priorities from all perspectives. The McMaster PPEET tool was used to measure engagement. RESULTS The initial survey yielded more than 425 responses and 1450 "questions" from survivors and family members (18%), lay responders, health care providers and others. The second survey asked participants to rank a short list of 125 questions. The final top 25 questions were brought to the in-person meeting, and a top ten were selected through the JLA consensus process. The final list of top ten questions included how to improve the rate of lay responder CPR, what interventions used at the scene of an arrest can improve resuscitation and survival, how survival can be improved in rural areas of Canada, what resuscitation medications are most effective, what care patient's family members need, what post-discharge support is needed for survivors, how communication should work for everyone involved with a cardiac arrest, what factors best predict neurologically intact survival, whether biomarkers/genetic tests are effective in predicting OHCA and more research on the short and long-term psycho-social impacts of OHCA on survivors. The PPEET showed overwhelmingly positive results for the patient and family engagement experience during the final workshop. CONCLUSIONS This inclusive research priority setting provides essential information for those doing resuscitation research internationally. The results provide a guide for priority areas of research and should drive our community to focus on questions that matter to survivors and their families in our work. In particular the Canadian Resuscitation Outcomes Consortium will be incorporating the top ten list into its strategic plan for the future.
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Affiliation(s)
- K.N. Dainty
- North York General Hospital and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - M.B. Seaton
- North York General Hospital, Toronto, Ontario, Canada
| | | | - A. Laupacis
- Li Ka Shing Knowledge Institute and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Dorian
- Unity Health Toronto and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M. Douma
- University of Dublin, Dublin, Ireland
| | - J. Garner
- Family member, Toronto, Ontario, Canada
| | - J. Goldstein
- Dalhousie Emergency Health Service, Halifax, Nova Scotia, Canada
| | - D. Shire
- Survivor, Toronto, Ontario, Canada
| | - D. Sinclair
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - C. Thurlow
- Survivor, Vancouver, British Columbia, Canada
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Rawal S, Rinkel GJE, Fang J, Washington CW, Macdonald RL, Victor JC, Krings T, Kapral MK, Laupacis A. External Validation and Modification of Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Score. Neurosurgery 2021; 89:591-596. [PMID: 34271587 DOI: 10.1093/neuros/nyab237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 05/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Nationwide Inpatient Sample Subarachnoid Hemorrhage (SAH) Severity Score (NIS-SSS) was developed as a measure of SAH severity for use in administrative databases. The NIS-SSS consists of International Classification of Diseases Ninth Revision (ICD-9) diagnostic and procedure codes derived from the SAH inpatient course and has been validated against the Hunt-Hess score (HH). OBJECTIVE To externally validate both the NIS-SSS and a modified version of the NIS-SSS (m-NIS-SSS) consisting of codes present only on admission, against the HH in a Canadian province-wide registry and administrative database of SAH patients. METHODS A total of 1467 SAH patients admitted to Ontario stroke centers between 2003 and 2013 with recorded HH were included. The NIS-SSS and m-NIS-SSS were validated against the HH by testing correlation between the NIS-SSS/m-NIS-SSS and HH, comparing discriminative ability of the NIS-SSS/m-NIS-SSS vs HH for poor outcome by calculating area under the curve (AUC), and comparing calibration of the NIS-SSS, m-NIS-SSS, and HH by plotting predicted vs observed outcome. RESULTS Correlation with HH was 0.417 (P ≤ .001) for NIS-SSS, and 0.403 (P ≤ .001) for m-NIS-SSS. AUC for prediction of poor outcome was 0.786 (0.764-0.808) for HH, 0.771 (0.748-0.793) for NIS-SSS, and 0.744 (0.721-0.767) for m-NIS-SSS. Calibration plots demonstrated that HH had the most accurate prediction of outcome, whereas the NIS-SSS and m-NIS-SSS did not accurately predict low risk of poor outcome. CONCLUSION The NIS-SSS and m-NIS-SSS have good external validity, and therefore, may be suitable to approximate traditional clinical scores of disease severity in SAH research using administrative data.
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Affiliation(s)
- Sapna Rawal
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | | | - Chad W Washington
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - J Charles Victor
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Timo Krings
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada.,Division of General Internal Medicine and Toronto General Research Institute, University Health Network, Toronto, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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Affiliation(s)
- Michelle Sholzberg
- Départements de médecine, de médecine de laboratoire et de pathobiologie (Sholzberg), Hôpital St. Michael's, Université de Toronto; Département de médecine (Arnold), Université McMaster, Toronto, Ont.; rédacteur adjoint principal (Laupacis), CMAJ, Ottawa, Ont.
| | - Donald M Arnold
- Départements de médecine, de médecine de laboratoire et de pathobiologie (Sholzberg), Hôpital St. Michael's, Université de Toronto; Département de médecine (Arnold), Université McMaster, Toronto, Ont.; rédacteur adjoint principal (Laupacis), CMAJ, Ottawa, Ont
| | - Andreas Laupacis
- Départements de médecine, de médecine de laboratoire et de pathobiologie (Sholzberg), Hôpital St. Michael's, Université de Toronto; Département de médecine (Arnold), Université McMaster, Toronto, Ont.; rédacteur adjoint principal (Laupacis), CMAJ, Ottawa, Ont
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Affiliation(s)
- Michelle Sholzberg
- Departments of Medicine, and Laboratory Medicine and Pathobiology (Sholzberg), St. Michael's Hospital, University of Toronto; Department of Medicine (Arnold), McMaster University, Toronto, Ont.; Senior Deputy Editor (Laupacis), CMAJ, Ottawa, Ont.
| | - Donald M Arnold
- Departments of Medicine, and Laboratory Medicine and Pathobiology (Sholzberg), St. Michael's Hospital, University of Toronto; Department of Medicine (Arnold), McMaster University, Toronto, Ont.; Senior Deputy Editor (Laupacis), CMAJ, Ottawa, Ont
| | - Andreas Laupacis
- Departments of Medicine, and Laboratory Medicine and Pathobiology (Sholzberg), St. Michael's Hospital, University of Toronto; Department of Medicine (Arnold), McMaster University, Toronto, Ont.; Senior Deputy Editor (Laupacis), CMAJ, Ottawa, Ont
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Persaud N, Bedard M, Boozary A, Glazier RH, Gomes T, Hwang SW, Juni P, Law MR, Mamdani M, Manns B, Martin D, Morgan SG, Oh P, Pinto AD, Shah BR, Sullivan F, Umali N, Thorpe KE, Tu K, Laupacis A. Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial. PLoS Med 2021; 18:e1003590. [PMID: 34019540 PMCID: PMC8139488 DOI: 10.1371/journal.pmed.1003590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/19/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted. METHODS AND FINDINGS We randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports. CONCLUSIONS In this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years. TRIAL REGISTRATION ClinicalTrials.gov NCT02744963.
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Affiliation(s)
- Nav Persaud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael Bedard
- Department of Family Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Andrew Boozary
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Richard H Glazier
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tara Gomes
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Juni
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Healthcare Analytics Research and Training at St Michael's Hospital and Vector Institute, Toronto, Ontario, Canada
| | - Braden Manns
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Danielle Martin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Steven G Morgan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Oh
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew D Pinto
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R Shah
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Sullivan
- Department of Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Division of Population and Behavioral Science, University of St Andrews, Scotland
| | - Norman Umali
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Karen Tu
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- 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
| | - Andreas Laupacis
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Vyas MV, Austin PC, Fang J, Laupacis A, Silver FL, Kapral MK. Immigration Status, Ethnicity, and Long-term Outcomes Following Ischemic Stroke. Neurology 2021; 96:e1145-e1155. [PMID: 33472924 DOI: 10.1212/wnl.0000000000011451] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 09/30/2020] [Accepted: 10/28/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the association between immigration status and ethnicity and the outcomes of mortality and vascular event recurrence following ischemic stroke in Ontario, Canada. METHODS We conducted a retrospective cohort study using linked administrative and clinical registry-based data from 2002 to 2018 and compared hazards of all-cause mortality and vascular event recurrence in immigrants and long-term residents using inverse probability of treatment weighting accounting for age, sex, income, and comorbidities. We stratified analyses by age (≤75 and >75 years) and used interaction terms to evaluate whether the association between immigration status and outcomes varied with age or ethnicity. RESULTS We followed 31,918 adult patients, of whom 2,740 (8.6%) were immigrants, for a median follow-up of 5 years. Immigrants had lower mortality than long-term residents (46.1% vs 64.5%), which was attenuated after adjustment (hazard ratio [HR] 0.94; 95% confidence interval [CI] 0.88-1.00), but persisted in those younger than 75 years (HR 0.82; 0.74-0.91). Compared to their respective ethnic long-term resident counterparts, the adjusted hazard of death was higher in South Asian immigrants, similar in Chinese immigrants, and lower in other immigrants (p value for interaction = 0.003). The adjusted hazard of vascular event recurrence (HR 1.01; 0.92-1.11) was similar in immigrants and long-term residents, and this observation persisted across all age and ethnic groups. CONCLUSIONS Long-term mortality following ischemic stroke is lower in immigrants than in long-term residents, but is similar after adjustment for baseline characteristics, and it is modified by age at the time of stroke and by ethnicity.
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Affiliation(s)
- Manav V Vyas
- From the Divisions of Neurology (M.V.V., F.L.S.) and General Internal Medicine (A.L., M.K.K.), Department of Medicine, and Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto; ICES (M.V.V., P.C.A., J.F., A.L., F.L.S., M.K.K.), Toronto, Canada; and Institute of Health Equity (M.V.V.), University College London, UK
| | - Peter C Austin
- From the Divisions of Neurology (M.V.V., F.L.S.) and General Internal Medicine (A.L., M.K.K.), Department of Medicine, and Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto; ICES (M.V.V., P.C.A., J.F., A.L., F.L.S., M.K.K.), Toronto, Canada; and Institute of Health Equity (M.V.V.), University College London, UK
| | - Jiming Fang
- From the Divisions of Neurology (M.V.V., F.L.S.) and General Internal Medicine (A.L., M.K.K.), Department of Medicine, and Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto; ICES (M.V.V., P.C.A., J.F., A.L., F.L.S., M.K.K.), Toronto, Canada; and Institute of Health Equity (M.V.V.), University College London, UK
| | - Andreas Laupacis
- From the Divisions of Neurology (M.V.V., F.L.S.) and General Internal Medicine (A.L., M.K.K.), Department of Medicine, and Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto; ICES (M.V.V., P.C.A., J.F., A.L., F.L.S., M.K.K.), Toronto, Canada; and Institute of Health Equity (M.V.V.), University College London, UK
| | - Frank L Silver
- From the Divisions of Neurology (M.V.V., F.L.S.) and General Internal Medicine (A.L., M.K.K.), Department of Medicine, and Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto; ICES (M.V.V., P.C.A., J.F., A.L., F.L.S., M.K.K.), Toronto, Canada; and Institute of Health Equity (M.V.V.), University College London, UK
| | - Moira K Kapral
- From the Divisions of Neurology (M.V.V., F.L.S.) and General Internal Medicine (A.L., M.K.K.), Department of Medicine, and Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto; ICES (M.V.V., P.C.A., J.F., A.L., F.L.S., M.K.K.), Toronto, Canada; and Institute of Health Equity (M.V.V.), University College London, UK.
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Abstract
BACKGROUND AND PURPOSE We evaluated the influence of age on the association between sex and the incidence of stroke or transient ischemic attack (TIA) using a population-based cohort from Ontario, Canada. METHODS We followed a cohort of adults (≥18 years) without prior stroke from January 1, 2003 (cohort start date) to March 31, 2018, to identify incident events. We calculated hazard ratios (HRs), in women compared to men, of incident stroke or TIA, adjusted for demographics and comorbidities, overall and stratified by stroke type. We calculated piecewise adjusted HRs for each decade of age to evaluate the effect of age on sex differences in stroke incidence. RESULTS We followed 9.2 million adults for a median of 15 years and observed 280,197 incident stroke or TIA events. Compared with men, women had an overall lower adjusted hazard of stroke or TIA (HR, 0.82 [95% CI, 0.82-0.83]), with similar findings across all stroke types except for subarachnoid hemorrhage (HR, 1.29 [95% CI, 1.24-1.33]). We found a U-shaped association between age and sex differences in the incidence of stroke or TIA: compared with men, the hazard of stroke was higher in women among those aged ≤30 years (HR, 1.26 [95% CI, 1.10-1.45]), lower among those between ages 40 and 80 years (eg, age 50-59, HR, 0.69 [95% CI, 0.68-0.70]), and similar among those aged ≥80 years (HR, 0.99 [95% CI, 0.98-1.01]). CONCLUSIONS Overall, women have a lower hazard of stroke than men, but this association varies by age and across stroke types. Recognition of age-sex variations in stroke incidence can help guide prevention efforts to reduce stroke incidence in both men and women.
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Affiliation(s)
- Manav V Vyas
- Division of Neurology, Department of Medicine (M.V.V., F.L.S., A.Y.X.Y.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Frank L Silver
- Division of Neurology, Department of Medicine (M.V.V., F.L.S., A.Y.X.Y.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Amy Y X Yu
- Division of Neurology, Department of Medicine (M.V.V., F.L.S., A.Y.X.Y.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Priscila Pequeno
- ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada.,Division of General Internal Medicine, and Department of Medicine (M.K.K.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
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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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Murthy S, Fowler RA, Laupacis A. Intégration des essais randomisés dans les soins cliniques : comment le Canada peut faire mieux. CMAJ 2020; 192:E1834-E1835. [DOI: 10.1503/cmaj.201764-f] [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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Holroyd-Leduc JM, Laupacis A. Soins continus et COVID-19 : Qu’une telle tragédie ne se reproduise plus au Canada! CMAJ 2020; 192:E1389-E1390. [DOI: 10.1503/cmaj.201017-f] [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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Patrick K, Stanbrook MB, Laupacis A. Éloignement social pour lutter contre la COVID-19: nous sommes tous en première ligne. CMAJ 2020; 192:E1294-E1295. [PMID: 33077530 PMCID: PMC7588207 DOI: 10.1503/cmaj.200606-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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kirsten Patrick
- Directrice de la rédaction, CMAJ (Patrick); rédacteur adjoint, CMAJ (Stanbrook); Département de médecine (Stanbrook), Université de Toronto, Toronto, Ont.; rédacteur en chef, CMAJ (Laupacis)
| | - Matthew B Stanbrook
- Directrice de la rédaction, CMAJ (Patrick); rédacteur adjoint, CMAJ (Stanbrook); Département de médecine (Stanbrook), Université de Toronto, Toronto, Ont.; rédacteur en chef, CMAJ (Laupacis)
| | - Andreas Laupacis
- Directrice de la rédaction, CMAJ (Patrick); rédacteur adjoint, CMAJ (Stanbrook); Département de médecine (Stanbrook), Université de Toronto, Toronto, Ont.; rédacteur en chef, CMAJ (Laupacis)
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Laupacis A. Travailler ensemble à contenir et gérer la COVID-19. CMAJ 2020; 192:E1248-E1249. [DOI: 10.1503/cmaj.200428-f] [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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Laupacis A. Le gouvernement du Canada doit continuer à jouer de prudence dans le dossier de l’aide médicale à mourir. CMAJ 2020; 192:E1187-E1188. [DOI: 10.1503/cmaj.200213-f] [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)
- 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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Affiliation(s)
- Srinivas Murthy
- Department of Pediatrics (Murthy), University of British Columbia, Vancouver, BC; Interdepartmental Division of Critical Care Medicine (Fowler), Department of Medicine, and Institute of Health Policy, Management and Evaluation (Fowler), University of Toronto; Sunnybrook Health Sciences Centre (Fowler), Toronto, Ont.; editorin-chief, CMAJ (Laupacis)
| | - Robert A Fowler
- Department of Pediatrics (Murthy), University of British Columbia, Vancouver, BC; Interdepartmental Division of Critical Care Medicine (Fowler), Department of Medicine, and Institute of Health Policy, Management and Evaluation (Fowler), University of Toronto; Sunnybrook Health Sciences Centre (Fowler), Toronto, Ont.; editorin-chief, CMAJ (Laupacis)
| | - Andreas Laupacis
- Department of Pediatrics (Murthy), University of British Columbia, Vancouver, BC; Interdepartmental Division of Critical Care Medicine (Fowler), Department of Medicine, and Institute of Health Policy, Management and Evaluation (Fowler), University of Toronto; Sunnybrook Health Sciences Centre (Fowler), Toronto, Ont.; editorin-chief, CMAJ (Laupacis)
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Affiliation(s)
- Andrew Boozary
- Editor-in-Chief, CMAJ (Laupacis); Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; and Harvard T.H. Chan School of Public Health (Boozary), Boston, Mass
| | - Andreas Laupacis
- Editor-in-Chief, CMAJ (Laupacis); Dalla Lana School of Public Health (Boozary), University of Toronto, Toronto, Ont.; Health and Social Policy (Boozary), University Health Network, Toronto, Ont.; and Harvard T.H. Chan School of Public Health (Boozary), Boston, Mass
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