Responsiveness of the anxiety/depression dimension of the 3- and 5-level versions of the EQ-5D in assessing mental health.

BACKGROUND: Anxiety and depression disorders are associated with significantly lower health-related quality of life (HRQL). The EQ-5D is a commonly used generic measure of HRQL; it captures mental health through a single domain-the anxiety/depression dimension. Evidence on the responsiveness of this measure in assessing changes in mental health changes is limited. OBJECTIVE: To examine the performance of the anxiety/depression dimension (A/D) of the 3- and 5-level (3L and 5L) versions of the EQ-5D in assessing changes in mental health. METHODS: Data from two patient populations were used: 495 adults post-discharge from general internal medicine ward (EQ-5D-3L), and 225 type 2 diabetes patients who screened positive for depressive symptoms (EQ-5D-5L). Anchor-based approach along with effect sizes (ES) and ROC analysis was used. Anchors included patient health questionnaire 9-items "PHQ9" and generalized anxiety disorder 2-item questionnaire "GAD2" for EQ-5D-3L, and PHQ9 and SF-12 mental composite summary scores (MCS) for EQ-5D-5L. A/D change was quantified as the difference between follow-up and baseline levels. RESULTS: The A/D dimension of the EQ-5D-3L showed limited responsiveness to changes in depressive symptoms measured by PHQ9 and for anxiety symptoms measured by GAD2, whereby in those who improved or deteriorated in either symptom, more than half of the patients did not have an A/D change. In the ROC analysis, the A/D dimension of the EQ-5D-3L showed weak performance with C-indices ranging from 0.58 to 0.63 and probability of detection of depressive or anxiety symptoms ranging between 20 and 40%, which are all well below acceptable ranges. Similar results were observed for the A/D dimension of the EQ-5D-5L; although the performance was slightly better, it was still below acceptable range. In patients who improved or deteriorated based on the PHQ9 or MCS, around a third had no changes on the A/D dimension. The performance of the A/D dimension of the EQ-5D-5L was also very limited with C-indices ranging between 0.67 and 0.76, and probability of detection between 50 and 67%, slightly better than that of the 3L, yet unsatisfactory. CONCLUSIONS: Although the A/D of both EQ-5D-3L and 5L was limited in capturing changes in mental health in these populations, the 5L was slightly more responsive than the 3L. While the performance was better for depressive than anxiety symptoms, it varied by the direction of change. Further research using other measures of mental health in other populations is warranted.

Descriptive analysis of cochrane child-relevant systematic reviews: an update and comparison between 2009 and 2013.

BACKGROUND: Systematic reviews support health systems and clinical decision-making by identifying and summarizing all existing studies on a particular topic. In 2009, a comprehensive description of child-relevant systematic reviews published in the Cochrane Database of Systematic Reviews was compiled. This study aims to provide an update, and to describe these systematic reviews according to their content and methodological approaches. METHODS: All child-relevant systematic reviews published by the Cochrane Collaboration in the Cochrane Database of Systematic Reviews (CDSR) as of March, 2013 were identified and described in relation to their content and methodological approaches. This step equated to an update of the Child Health Field Review Register (CHFRR). The content of the updated CHFRR was compared to the published 2009 CHFRR description regarding clinical and methodological characteristics, using bivariate analyses. As the Cochrane Collaboration has recognized that disease burden should guide research prioritization, we extracted data from the Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013 study in order to map the distribution of the burden of disease in child health to the distribution of evidence across Review Groups in the CHFRR. RESULTS: Of the 5,520 potential Cochrane systematic reviews identified, 1,293 (23.4%) were child-relevant (an increase of 24% since 2009). Overall, these reviews included 16,738 primary studies. The most commonly represented Review Groups were Airways (11.5%), Cystic Fibrosis and Genetic Diseases (7.9%), Acute Respiratory Infections (7.8%), Developmental, Psychological and Learning Problems (6.7%), and Infectious Diseases (6.2%). Corresponding authors were most often from Europe (51%), North America (15%), and Australia (15%). The majority of systematic reviews examined pharmacological interventions alone (52% compared to 59% in 2009). Out of 611 reviews that were assessed as up-to-date, GRADE was used in 204 (35%) reviews to assess the overall quality of the evidence, which was often moderate (35.6%) or low (37.8%) for primary outcomes. Ninety percent of reviews that were assessed as up to date used the Cochrane Risk of Bias tool, or a modified version, to assess methodological quality. Most reviews conducted one or more meta-analyses (73%). Among the 25 leading causes of death globally, the Review Groups associated with the largest number of causes were: 1) Infectious Diseases, 2) Anaesthesia, Critical, and Emergency Care, 3) Injuries, 4) Pregnancy and Childbirth (PC), and 5) Neonatal. There were large discrepancies between the number of causes of mortality that each Review Group was associated with and the total amount of evidence each Review Group contributed to the CHFRR. Ninety-eight percent of the causes of mortality in 2013 were from developing nations, but only 224 (17.3%) reviews had corresponding authors from developing countries. CONCLUSION: The content and methodological characteristics of child-relevant systematic reviews in the Cochrane CHFRR have been described in detail. There were modest advances in methods between 2009 and 2013. Systematic reviews contained in the CDSR offer an important resource for researcher's, clinicians and policy makers by synthesizing an extensive body of primary research. Further content analysis will allow the identification of clinical topics of greatest priority for future systematic reviews in child health.

Low-acuity presentations to the emergency department in Canada: exploring the alternative attempts to avoid presentation.

OBJECTIVE: ED visits have been rising year on year worldwide. It has been suggested that some of these visits could be avoided if low-acuity patients had better primary care access. This study explored patients' efforts to avoid ED presentation and alternative care sought prior to presentation. METHODS: Consecutive adult patients presenting to three urban EDs in Edmonton, Canada, completed a questionnaire collecting demographics, actions attempted to avoid presentation and reasons for presentation. Survey data were cross-referenced to a minimal patient dataset containing ED and demographic information. RESULTS: A total of 1402 patients (66.5%) completed the survey. Although 89.3% of the patients felt that the ED was their best care option, the majority of patients (60.1%) sought alternative care or advice prior to presentation. Men, individuals who presented with injury only, and individuals with less than a high school education were all less likely to seek alternative care. Alternative care actions included visiting a physician (54.1%) or an alternative healthcare professional (eg, chiropractor, physiotherapist, etc; 21.2%), calling physician offices (47%) or the regional health information line (13%). Of those who called their physicians, the majority received advice to present to the ED (67.5%). CONCLUSIONS: Most low-acuity patients attempt to avoid ED presentation by seeking alternative care. This analysis identifies groups of individuals in the study region who are less likely to seek alternative care first and may benefit from targeted interventions/education. Other regions may wish to complete a similar profile to determine which patients are less likely to seek alternative care first.

An evaluation of harvest plots to display results of meta-analyses in overviews of reviews: a cross-sectional study.

BACKGROUND: Harvest plots are used to graphically display evidence from complex and diverse studies or results. Overviews of reviews bring together evidence from two or more systematic reviews. Our objective was to determine the feasibility of using harvest plots to depict complex results of overviews of reviews. METHODS: We conducted a survey of 279 members of Cochrane Child Health to determine their preferences for graphical display of data, and their understanding of data presented in the form of harvest plots. Preferences were rated on a scale of 0-100 (100 most preferred) and tabulated using descriptive statistics. Knowledge and accuracy were assessed by tabulating the number of correctly answered questions for harvest plots and traditional data summary tables; t-tests were used to compare responses between formats. RESULTS: 53 individuals from 7 countries completed the survey (19%): 60% were females; the majority had an MD (38%), PhD (47%), or equivalent. Respondents had published a median of 3 systematic reviews (inter-quartile range 1 to 8). There were few differences between harvest plots and tables in terms of being: well-suited to summarize and display results from meta-analysis (52 vs. 56); easy to understand (53 vs. 51); and, intuitive (49 vs. 44). Harvest plots were considered more aesthetically pleasing (56 vs. 44, p = 0.03). 40% felt the harvest plots could be used in conjunction with tables to display results from meta-analyses; additionally, 45% felt the harvest plots could be used with some improvement. There was no statistically significant difference in percentage of knowledge questions answered correctly for harvest plots compared with tables. When considering both types of data display, 21% of knowledge questions were answered incorrectly. CONCLUSIONS: Neither harvest plots nor standard summary tables were ranked highly in terms of being easy to understand or intuitive, reflecting that neither format is ideal to summarize the results of meta-analyses in overviews of reviews. Responses to knowledge questions showed some misinterpretation of results of meta-analyses. Reviewers should ensure that messages are clearly articulated and summarized in the text to avoid misinterpretation.

Gastroscopy for dyspeptic symptoms in patients <65 years has a low yield of clinically important findings: a retrospective study.

Background: Dyspepsia is a common, generally low-risk gastrointestinal condition. The American College of Gastroenterology and Canadian Association of Gastroenterology recommend avoiding gastroscopy in healthy patients <60 years old. Many dyspeptic patients can be effectively managed in primary care. This study aimed to determine: (1) the proportion of gastroscopies performed for dyspepsia among patients <65 years old with no alarm symptoms or clinically appropriate indications and (2) to determine the frequency of clinically actionable findings and dyspepsia-related healthcare utilization in the year following gastroscopy. Methods: Outpatient endoscopy reports were sampled and reviewed retrospectively from 2019 to -2021 in Edmonton, Alberta to identify gastroscopies performed for the indication of dyspepsia. Gastroscopies were considered low-risk for significant endoscopic findings if age <65, no alarm symptoms or other concerning indications, and insufficient evidence that first-line treatments and diagnostic approaches had been tried prior to gastroscopy. Clinically important findings were defined as those impacting management, not otherwise identifiable non-invasively. Results: Of the 358 reviewed gastroscopies for dyspepsia, 293 (81.8%) had no alarm symptoms, and 130 (36.3%) had no alarm symptoms or other appropriate indications. Clinically important findings were identified in 9 (6.9%) of the 130 low-risk cases. In the year following, one patient (1/130) visited the emergency department 3 times for their symptoms and no patients required hospital admission. No malignancies were detected. Conclusions: Many gastroscopies are performed on patients <65 years old with dyspepsia, even when they lack alarm symptoms or other clinical indications, despite recommendations against this practice and low procedure yield. Strategies to improve the uptake of current guidelines may optimize endoscopy resource utilization.

Gastroscopy for dyspepsia: Understanding primary care and gastroenterologist mental models of practice: A cognitive task analysis approach.

Background: Gastroscopy to investigate dyspepsia without alarm symptoms rarely results in clinically actionable findings or sustained health-related quality-of-life improvements among patients aged 18-60 years and is, therefore, not recommended. Despite this, referrals for and performance of gastroscopy among this patient population remain high. The purpose of this study was to understand family physicians' and gastroenterologists' mental models of dyspepsia and the drivers behind referring or performing gastroscopy. Methods: Cognitive task analysis routine critical decision method interviews with family physicians (n = 8) and gastroenterologists (n = 4). Results: Family physicians and gastroenterologists hold rich mental models of dyspepsia that rely on sensemaking; however, gaps in information continuity affect their ability to plan and coordinate patient care. Drivers behind decisions to refer or perform gastroscopy were: eliminating risk for serious pathology, providing reassurance, perceived preference by patients to receive information and reassurance from gastroenterologists, maintaining relationships with patients, and saving costs to the health system. Conclusions: Family physicians refer for dyspepsia when they are seeking support from gastroenterologists, they believe that alternative factors may be impacting the patient's health or view it as a cost-saving measure. Likewise, gastroenterologists perform gastroscopy for dyspepsia when they perceive it as a cost-saving measure, they want to support their primary care colleagues and provide their colleagues and patients with reassurance. An improved degree of communication between speciality and primary care could allow for continuity in the transfer of information about patients and reduce referrals for dyspepsia.

Antimicrobial stewardship, procalcitonin testing, and rapid blood-culture identification to optimize sepsis care in critically ill adult patients: A quality improvement initiative.

We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.

Understanding challenges of using routinely collected health data to address clinical care gaps: a case study in Alberta, Canada.

High-quality data are fundamental to healthcare research, future applications of artificial intelligence and advancing healthcare delivery and outcomes through a learning health system. Although routinely collected administrative health and electronic medical record data are rich sources of information, they have significant limitations. Through four example projects from the Physician Learning Program in Edmonton, Alberta, Canada, we illustrate barriers to using routinely collected health data to conduct research and engage in clinical quality improvement. These include challenges with data availability for variables of clinical interest, data completeness within a clinical visit, missing and duplicate visits, and variability of data capture systems. We make four recommendations that highlight the need for increased clinical engagement to improve the collection and coding of routinely collected data. Advancing the quality and usability of health systems data will support the continuous quality improvement needed to achieve the quintuple aim.

Adrenal Insufficiency: Investigating Prevalence and Healthcare Utilization Using Administrative Data.

Context: Adrenal insufficiency (AI) is an uncommon, life-threatening disorder requiring lifelong treatment with steroid therapy and special attention to prevent adrenal crisis. Little is known about the prevalence of AI in Canada or healthcare utilization rates by these patients. Objective: We aimed to assess the prevalence and healthcare burden of AI in Alberta, Canada. Methods: This study used a population-based, retrospective administrative health data approach to identify patients with a diagnosis of AI over a 5-year period and evaluated emergency and outpatient healthcare utilization rates, steroid dispense records, and visit reasons. Results: The period prevalence of AI was 839 per million adults. Patients made an average of 2.3 and 17.8 visits per year in the emergency department and outpatient settings, respectively. This was 3 to 4 times as frequent as the average Albertan, and only 5% were coded as visits for AI. The majority of patients were dispensed glucocorticoid medications only. Conclusion: The prevalence of AI in Alberta is higher than published data in other locations. The frequency of visits suggests a significant healthcare burden and emphasizes the need for a strong understanding of this condition across all clinical settings. Our most concerning finding is that 94.3% of visits were not labeled with AI, even though many of the top presenting complaints were consistent with adrenal crisis. Several data limitations were discovered that suggest improvements in the standardization of data submission and coding can expand the yield of future studies using this method.

Adherence to a Nurse-Driven Feeding Protocol in a Pediatric Intensive Care Unit.

BACKGROUND: Patients admitted to pediatric intensive care units (PICUs) often experience prolonged periods without nutrition support, which may result in hospital-induced malnutrition and longer length of stay. Nurse-driven feeding protocols have been developed to prevent unnecessary interruptions or delays to nutrition support. The primary objective of this study was to identify compliance and reasons for noncompliance to a feeding protocol at a tertiary care hospital PICU in Canada. The secondary aim was to determine the mean time (hours) spent without any form of nutrition and to identify reasons for time spent without nutrition. MATERIALS AND METHODS: This was a prospective cohort audit, consisting of 150 consecutive PICU admissions (January-February 2016). Exclusion criteria consisted of patient mortality within 48 hours (n = 1) and patients who were still admitted at the end of the data collection timeframe (n = 7). The remaining cohort consisted of 142 consecutive admissions. Data collection took place in real time and included patient demographics, diagnostic categories, time spent without nutrition, reasons for interruptions to nutrition support, and reasons for noncompliance to the protocol. Observations were obtained through paper and computer charts and conversing with clinicians. RESULTS: There was a 95% compliance rate to the protocol and an average of 25.6 hours spent without nutrition per patient. The most prevalent reason for noncompliance was an avoidable delay to restart feeds before/after procedures or after surgery. CONCLUSIONS: A nurse-driven feeding protocol may reduce time spent without nutrition. Future research is required to examine the relationship between adherence to feeding protocols and clinical outcomes.

Check the score: Field validation of Street Smart Walk Score in Alberta, Canada.

Walk Score® is a proprietary walkability metric that ranks locations by proximity to destinations, with emerging health promotion applications for increasing walking as physical activity. Currently, field validations of Walk Score® have only occurred in metropolitan regions of the United States; moreover, many studies employ an earlier Walk Score® version utilizing straight line distance. To address this gap, we conducted a field validation of the newest, network-based metric for three municipal types along a rural-urban continuum in Alberta, Canada. In 2015, using street-level systematic observations collected in Bonnyville, Medicine Hat, and North Central Edmonton in 2008 (part of the Community Health and the Built Environment (CHBE) project), we reverse engineered 2181 scores with the network Walk Score® algorithm. We computed means, 95% confidence intervals, and t-tests (α = 0.05) for both sets of scores. Applying the Clifford-Richardson adjustment for spatial autocorrelation, we calculated Spearman's Rank Correlation Coefficients (rho, rs) and adjusted p-values to measure the strength of association between the derived scores and original network scores provided by Walk Score®. Spearman's rho for scores were very high for Bonnyville (rs = 0.950, adjusted p < 0.001), and high for Medicine Hat (rs = 0.790, adjusted p < 0.001) and North Central Edmonton (rs = 0.763, adjusted p < 0.001). High to very high correlations between derived scores and Walk Scores® field validated this metric across small, medium, and large population centres in Alberta, Canada. However, we suggest caution in interpreting Walk Score® for planning and evaluating health promotion interventions, since the strength of association between destinations and walking may vary across different municipal types.

Preferences of Knowledge Users for Two Formats of Summarizing Results from Systematic Reviews: Infographics and Critical Appraisals.

OBJECTIVES: To examine and compare preferences of knowledge users for two different formats of summarizing results from systematic reviews: infographics and critical appraisals. DESIGN: Cross-sectional. SETTING: Annual members' meeting of a Network of Centres of Excellence in Knowledge Mobilization called TREKK (Translating Emergency Knowledge for Kids). TREKK is a national network of researchers, clinicians, health consumers, and relevant organizations with the goal of mobilizing knowledge to improve emergency care for children. PARTICIPANTS: Members of the TREKK Network attending the annual meeting in October 2013. OUTCOME MEASURES: Overall preference for infographic vs. critical appraisal format. Members' rating of each format on a 10-point Likert scale for clarity, comprehensibility, and aesthetic appeal. Members' impressions of the appropriateness of the two formats for their professional role and for other audiences. RESULTS: Among 64 attendees, 58 members provided feedback (91%). Overall, their preferred format was divided with 24/47 (51%) preferring the infographic to the critical appraisal. Preference varied by professional role, with 15/22 (68%) of physicians preferring the critical appraisal and 8/12 (67%) of nurses preferring the infographic. The critical appraisal was rated higher for clarity (mean 7.8 vs. 7.0; p = 0.03), while the infographic was rated higher for aesthetic appeal (mean 7.2 vs. 5.0; p<0.001). There was no difference between formats for comprehensibility (mean 7.6 critical appraisal vs. 7.1 infographic; p = 0.09). Respondents indicated the infographic would be most useful for patients and their caregivers, while the critical appraisal would be most useful for their professional roles. CONCLUSIONS: Infographics are considered more aesthetically appealing for summarizing evidence; however, critical appraisal formats are considered clearer and more comprehensible. Our findings show differences in terms of audience-specific preferences for presentation of research results. This study supports other research indicating that tools for knowledge dissemination and translation need to be targeted to specific end users' preferences and needs.