Hospital Staffing and Hospital Harm Trends Throughout the COVID-19 Pandemic.

Throughout the COVID-19 pandemic, delivery of care was exceedingly difficult for hospital healthcare teams. This analysis presents a high-level look at the available pan-Canadian data on hospital staffing - including sick time, overtime and agency use - and potential impacts on patient harm in acute care hospitals. In 2021-2022, nurses and other healthcare providers working in hospital in-patient units across Canada logged significantly more overtime and sick-time hours compared with the previous year, equating to a shortfall of almost 14,000 full-time positions. Concurrently, the pan-Canadian rate of unintentional hospital harm increased to 6% compared with pre-pandemic numbers. The Hospital Harm Improvement Resource (HEC 2023a) links harm measurement and improvement efforts by providing evidence-informed practices to support patient safety improvement efforts.

Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates.

QUESTION: Are there ways to mitigate the challenges associated with imperfect data validity in Patient Safety Indicator (PSI) report cards? FINDINGS: Applying a methodological framework on simulated PSI report card data, we compare the adjusted PSI rates of three hospitals with variable quality of data and coding. This framework combines (i) a measure of PSI rates using existing algorithms; (ii) a medical record review on a small random sample of charts to produce a measure of hospital-specific data validity and (iii) a simple Bayesian calculation to derive estimated true PSI rates. For example, the estimated true PSI rate, for a theoretical hospital with a moderately good quality of coding, could be three times as high as the measured rate (for example, 1.4% rather than 0.5%). For a theoretical hospital with relatively poor quality of coding, the difference could be 50-fold (for example, 5.0% rather than 0.1%). MEANING: Combining a medical chart review on a limited number of medical charts at the hospital level creates an approach to producing health system report cards with estimates of true hospital-level adverse event rates.

Measuring Access to Home and Community Care and to Mental Health and Addictions Services in Canada.

Federal, provincial and territorial governments endorsed agreements in August of 2017 to focus on the shared health priorities of home, community, mental health and addictions care (Government of Canada 2017). The related $11 billion federal investment over a 10-year period aims to improve access for Canadians to effective and appropriate services in these areas (Government of Canada 2019).

Measuring and Monitoring Healthcare-Associated Infections: A Canadian Collaboration to Better Understand the Magnitude of the Problem.

Patients should never have to worry about getting an infection while in hospital. Yet every year, many hospitalized Canadians continue to acquire an infection during their hospital stay and experience increased morbidity and mortality as a result of these healthcare-associated infections (HAIs) (PHAC 2019b). Measuring and monitoring HAIs provide key data to better understand the magnitude of the problem. In Canada, there are inconsistencies in the use of standardized HAI case definitions and surveillance practices. These inconsistencies make it difficult to provide benchmarks and set targets to help reduce the rate of HAIs in Canadian hospitals.

Clinical and Health System Determinants of Venous Thromboembolism Event Rates After Hip Arthroplasty: An International Comparison.

BACKGROUND: Routinely collected hospital data provide increasing opportunities to assess the performance of health care systems. Several factors may, however, influence performance measures and their interpretation between countries. OBJECTIVE: We compared the occurrence of in-hospital venous thromboembolism (VTE) in patients undergoing hip replacement across 5 countries and explored factors that could explain differences across these countries. METHODS: We performed cross-sectional studies independently in 5 countries: Canada; France; New Zealand; the state of California; and Switzerland. We first calculated the proportion of hospital inpatients with at least one deep vein thrombosis (DVT) or pulmonary embolism by using numerator codes from the corresponding Patient Safety Indicator. We then compared estimates from each country against a reference value (benchmark) that displayed the baseline risk of VTE in such patients. Finally, we explored length of stay, number of secondary diagnoses coded, and systematic use of ultrasound to detect DVT as potential factors that could explain between-country differences. RESULTS: The rates of VTE were 0.16% in Canada, 1.41% in France, 0.84% in New Zealand, 0.66% in California, and 0.37% in Switzerland, while the benchmark was 0.58% (95% confidence interval, 0.35-0.81). Factors that could partially explain differences in VTE rates between countries were hospital length of stay, number of secondary diagnoses coded, and proportion of patients who received lower limb ultrasound to screen for DVT systematically before hospital discharge. An exploration of the French data showed that the systematic use of ultrasound may be associated with over detection of DVT but not pulmonary embolism. CONCLUSIONS: In-hospital VTE rates after arthroplasty vary widely across countries, and a combination of clinical, data-related, and health system factors explain some of the variations in VTE rates across countries.

New mental health indicators provide a snapshot on performance of the mental health system in Canada.

Although the general hospital remains an important place for stabilizing crises, most services for mental illnesses are provided in outpatient/community settings. In the absence of comprehensive data at the community level, data that are routinely collected from general hospitals can provide insights on the performance of mental health services for people living with mental illness or poor mental health. This article describes three new indicators that provide a snapshot on the performance of the mental health system in Canada: self-injury hospitalization rate, 30-day readmission rate for mental illness and percentage of patients with repeat hospitalizations for mental illness. Findings suggest a need for the early detection and treatment of mental illnesses and for optimal transitions between general hospitals and community services.

Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.

With advances in the effectiveness of treatment and disease management, the contribution of chronic comorbid diseases (comorbidities) found within the Charlson comorbidity index to mortality is likely to have changed since development of the index in 1984. The authors reevaluated the Charlson index and reassigned weights to each condition by identifying and following patients to observe mortality within 1 year after hospital discharge. They applied the updated index and weights to hospital discharge data from 6 countries and tested for their ability to predict in-hospital mortality. Compared with the original Charlson weights, weights generated from the Calgary, Alberta, Canada, data (2004) were 0 for 5 comorbidities, decreased for 3 comorbidities, increased for 4 comorbidities, and did not change for 5 comorbidities. The C statistics for discriminating in-hospital mortality between the new score generated from the 12 comorbidities and the Charlson score were 0.825 (new) and 0.808 (old), respectively, in Australian data (2008), 0.828 and 0.825 in Canadian data (2008), 0.878 and 0.882 in French data (2004), 0.727 and 0.723 in Japanese data (2008), 0.831 and 0.836 in New Zealand data (2008), and 0.869 and 0.876 in Swiss data (2008). The updated index of 12 comorbidities showed good-to-excellent discrimination in predicting in-hospital mortality in data from 6 countries and may be more appropriate for use with more recent administrative data.

CD5 expression identifies a subset of splenic marginal zone lymphomas with higher lymphocytosis: a clinico-pathological, cytogenetic and molecular study of 24 cases.

BACKGROUND: Classically, splenic marginal zone B-cell lymphoma is characterized by the absence of CD5 expression. Cases of apparent splenic marginal zone B-cell lymphoma showing CD5 expression, as diagnosed by blood studies, have been described; however, in the absence of histological evidence, the correct diagnosis of these cases is controversial because of possible confusion with other CD5-positive small B-cell neoplasms. DESIGN AND METHODS: We report a series of 24 CD5-positive, t(11;14)-negative cases of splenic marginal zone B-cell lymphoma diagnosed by flow cytometry studies of blood and histologically proven on spleen sections. Clinical data as well as morphological, immunological, cytogenetic and molecular characteristics were assessed to evaluate the similarities and differences of these cases with those of classical CD5-negative splenic marginal zone B-cell lymphoma. RESULTS: The CD5 expression detected in blood by flow cytometry was confirmed in most cases by immunohistochemistry on spleen sections. In general, cases of CD5-positive and CD5-negative splenic marginal zone B-cell lymphoma did not appear different and, in particular, they showed similar karyotypic changes such as 7q deletion, trisomy 3, trisomy 18 and biased IGHV usage (i.e. VH1-2). The main differences were a higher lymphocyte count at diagnosis (8.15x10(9)/L versus 3.90x10(9)/L; P=0.005) and more frequent diffuse bone marrow infiltration (34% versus 8%; P=0.03) in the CD5-positive group. A tendency to a more mutated IGHV status in the CD5 positive cases was observed (80% versus 54.5%; (P=0.11). No significant differences in outcome were found in relation to CD5 expression. CONCLUSIONS: This study confirms the existence of cases of CD5-positive splenic marginal zone B-cell lymphoma and shows that these cases are closely related to classical splenic marginal zone lymphoma. Whether or not CD5-positive splenic marginal zone B-cell lymphoma constitutes a true subset obviously requires the study of more cases.

Safety, efficacy and predictive factors of efficacy of a single intra-articular injection of non-animal-stabilized-hyaluronic-acid in the hip joint: results of a standardized follow-up of patients treated for hip osteoarthritis in daily practice.

AIM: To evaluate, in daily clinical practice, the efficacy and tolerability of a single intra-articular injection of non-animal-stabilized hyaluronic acid (NASHA) in patients treated for symptomatic hip OA (HOA). METHODS: Standardized follow-up (FU). PATIENTS: forty patients suffering from HOA treated by a single intra-articular injection of NASHA in the painful hip under fluoroscopy. EVALUATION: patient global assessment (PGA) and walking pain (WP) on a 100 mm visual analogue scale, WOMAC index, Lequesne index at each visit. STATISTICS: last observation carried forward. Treatment efficacy was assessed using OMERACT-OARSI response criteria, minimal clinically important improvement (MCII), patient acceptable symptom state (PASS) obtained from PGA, WOMAC and WP. Predictive factors of efficacy were also studied. RESULTS: Efficacy evaluation: 34 patients were assessable (mean FU 159 days). All clinical variables (WP, PGA, WOMAC, Lequesne index) decreased significantly between baseline and last evaluation. Twenty-two patients (71%) were classified OMERACT-OARSI responders, 25 subjects (75.8%) were classified PASS+, and 19 (61.3%) fulfilled criteria for MCII. Out of clinical and radiological variables only Lequesne index (p = 0.04) and WOMAC (p = 0.04) at baseline were found to be predictive of treatment efficacy. Safety evaluation: the treatment was well tolerated. There were no severe adverse events related to the treatment or to the procedure. However 15 of the 28 assessable patients experienced transient increase of pain in the target hip during the first week after injection. CONCLUSION: Viscosupplementation of the hip with NASHA is easily feasible in daily clinical practice, safe and well tolerated despite a frequent increase of pain the days following injection. Prospective controlled trials are needed to confirm these data and to evaluate both safety and efficacy of a second course of treatment.

A seventy percent overestimation of the burden of hip fractures in women aged 85 and over.

BACKGROUND: Hip fractures are the most devastating result of osteoporosis and are common worldwide. Based on an exponential increase in incidence with age, many studies in the 1990s forecasted an epidemic of hip fracture in women in the next 15 years which is not currently being observed. Despite the ageing of the populations, accurate description of hip fracture incidence in women aged 85 or older are scarce. METHODS: All women aged 60 to 95, living in the Rhône-Alpes area of France, who were admitted to hospitals during 2001-2004 for treatment of hip fracture were selected from the French claims databases. An exponential model was tested to describe the increase in hip fracture incidence in women aged 60-84 and 60-95. The first model was used to predict annual hip fracture incidence in women aged 85-95 in the Rhône-Alpes area, in France and in Europe. RESULTS: An exponential model was adequate to describe the increase in incidence in women aged 60-84. Assuming an exponential increase in incidence in women aged 85-95, the predicted number of cases was overestimated by 70% in the Rhône-Alpes. In France and in Europe, the excess number of incident cases is believed to be respectively 16,000 and 85,965 a year. INTERPRETATION: The age-specific incidence estimates an average risk although the individual risks are heterogeneous throughout the population. The slower increase in incidence after age 85 might not be related to a decreasing individual risk with age but rather might indicate that women at higher risk have already experienced hip fracture or have died. After age 85, women who are still at risk may represent a population with a lower risk of hip fracture. Models adapted to the elderly population should be developed to improve the accuracy of predictions and optimise the health care system.

A Comparison of Administrative Data Versus Surveillance Data for Hospital-Associated Methicillin-Resistant Staphylococcus aureus Infections in Canadian Hospitals.

BACKGROUND In Canadian hospitals, clinical information is coded according to national coding standards and is routinely collected as administrative data. Administrative data may complement active surveillance programs by providing in-hospital MRSA infection data in a standardized and efficient manner, but only if infections are accurately captured. OBJECTIVE To assess the accuracy of administrative data regarding in-hospital bloodstream infections (BSIs) and all-body-site infections due to MRSA. METHODS A retrospective study of all (adult and pediatric) in-hospital MRSA infections was conducted by comparing administrative data against surveillance data from 217 acute Canadian hospitals (124 in Ontario, 93 in Alberta) over a 12-month period. Hospital-associated MRSA BSI cases in Ontario, and for all-body-site MRSA infections in Alberta were identified. Pearson correlation coefficients were used to compare the number of hospital-level MRSA cases within administrative versus surveillance datasets. The correlation of all-body-site MRSA infections versus MRSA BSIs was also assessed using the Ontario administrative data. RESULTS Strong correlations between hospital-level MRSA cases in administrative and surveillance datasets were identified for Ontario (r=0.79; 95% CI, 0.72-0.85) and Alberta (r=0.92; 95% CI, 0.88-0.94). A strong correlation between all-body-site and bloodstream-only MRSA infection rates was identified across Ontario hospitals (r=0.95; P<.0001; 95% CI, 0.93-0.96). CONCLUSIONS This study provides good evidence of the comparability of administrative and surveillance datasets in identifying in-hospital MRSA infections. With standard definitions, administrative data can provide estimates of in-hospital infections for monitoring and/or comparisons across hospitals. Infect Control Hosp Epidemiol 2017;38:436-443.

Factors predicting patient satisfaction 2 years after total knee arthroplasty for osteoarthritis.

OBJECTIVE: To identify factors predicting patient satisfaction 2 years after total knee arthroplasty (TKA) for osteoarthritis. METHODS: Prospective multicenter study of patients followed up for 2 years after TKA for osteoarthritis. We evaluated pain and function (Lequesne index and WOMAC) at baseline and after 2 years. After 2 years, the patients rated their satisfaction as a percentage, with values greater than 50% defining good satisfaction. Factors associated with good satisfaction were identified by univariate analyses followed by multivariate analysis. RESULTS: Of 299 patients, 264 completed the study (26 were lost to follow-up, six died, and three refused the 2-year evaluation), including 237 (89.8%) with satisfaction scores greater than 50%. Highly significant improvements were found after 2 years versus baseline in the Lequesne index (7.9 vs. 14.5, P<0.0001) and WOMAC index (26.3 vs. 51.3, P<0.0001). There were 26 (9.8%) complications. Factors significantly associated with good satisfaction in the multivariate model were absence of complications (P=0.004), body mass index less than 27 kg/m² (P=0.015), high radiological joint narrowing score (P=0.038), age greater or equal to 70 years (P=0.038), and absence of depression at the 2-year evaluation (P=0.002). CONCLUSION: We report the first prospective multicenter study done in France to assess pain and function in a large number of patients treated with TKA for osteoarthritis. Our results indicate a high success rate. We identified three factors that predict patient satisfaction and can be assessed before surgery (age greater than 70 years, absence of obesity, and severe joint space narrowing).

Breast cancer incidence using administrative data: correction with sensitivity and specificity.

OBJECTIVE: To estimate breast cancer incidence in the general population using a method that corrects for lack of sensitivity and specificity in the identification of incident breast cancer in inpatient claims data. STUDY DESIGN AND SETTINGS: Two-phase study: phase 1 to identify incident cases in claims data, and phase 2 to estimate sensitivity and specificity in a subset of the population. Two algorithms (1: principal diagnosis; 2: principal diagnosis+specific surgery procedures) were used to identify incident cases in claims of women aged 20 years or older, living in a French district covered by a cancer registry. Sensitivity and specificity were estimated in one district and used to correct incident cases identified. RESULTS: The sensitivity and specificity for algorithms 1 and 2 were 69.0% and 99.89%, and 64.4% and 99.93%, respectively. In contrast to specificity, the sensitivity for both algorithms was lower for women younger than 40 years and older than 65 years. Cases reported by cancer registries were closer to cases identified with algorithm 2 (-3.2% to +20.1%) and to corrected numbers with algorithm 1 (-1% to +15%). CONCLUSION: To obtain reliable estimates of breast cancer incidence in the general population, sensitivity and specificity, which reflect medical and coding practice variations, are necessary.

Estimating infra-national and national thyroid cancer incidence in France from cancer registries data and national hospital discharge database.

OBJECTIVE: As in many countries, cancer registries cover only part of the population in France. Incidence/mortality ratio observed in registries is usually extrapolated to produce national estimates of cancer incidence. District-level estimates are not currently available. For cancer sites such as thyroid, the incidence/mortality ratio widely varies between districts, and alternative indicators must be explored. This study aims to produce national and district-level estimations of thyroid cancer incidence in France, using the ratio between incidence and hospital-based incidence. METHODS: Analyses concerned population living in France and aged over 20, for the period 1998-2000. For each sex, number of incident cases were analysed according to number of surgery admissions for thyroid cancer (Poisson model) in the districts covered by a registry. Age was included in the model as fixed effect and district as random effect. The model's ability to predict incidence was tested through cross-validation. The model was then extrapolated to produce national incidence estimations, and for women, district-level estimations. RESULTS: The national estimations of incidence rate age-standardised on the world population were 3.1 [95% prediction interval: 2.8-3.4] for men and 10.6 [9.8-11.4] for women, corresponding respectively to 1,148 [1,042-1,264] and 4,104 [3,817-4,413] annual new cases. For women, district-level incidence rates presented wide geographical variations, ranging broadly from 5 to 20 per 100,000. These estimations were quite imprecise, but their imprecision was smaller than the extent of geographical disparities. CONCLUSION: National incidence estimations obtained are relatively precise. District-level estimations in women are imprecise and should be treated carefully. They are informative though regarding the extent of geographical disparities. The approach can be useful to improve national incidence estimates and to produce district-level estimates for cancer sites presenting a high variability of the incidence/mortality ratio.

Cross-sectional study of pain and disability at knee replacement surgery for osteoarthritis in 299 patients.

OBJECTIVE: To evaluate pain and disability at the time of knee replacement surgery for osteoarthritis. METHODS: In this multicenter cross-sectional study, 299 patients at 12 orthopedic surgery centers in Lyon, France were evaluated on the day before knee replacement surgery. Pain severity was assessed on a visual analog scale (VAS) and function using the Lequesne index and the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: There were 207 women and 92 men with a mean age of 73 years. Mean (+/-SD) VAS pain score upon walking was 55.8+/-24mm. Compared to patients with very severe disability (Lequesne index>12), those with mild-to-severe disability (Lequesne index27kg/m(2) (OR, 2.2; 95%CI, 1.3-3.3) and to engage in sporting activities (OR, 3.3; 95%CI, 1.4-10). CONCLUSION: Patients about to undergo knee replacement surgery had high levels of pain and disability, with little variation across centers. Nevertheless, the severity of pain and disability may depend in part on age, gender, body mass index, and sporting activities, which probably influence the decision to perform knee replacement surgery.

French claims data as a source of information to describe cancer incidence: predictive values of two identification methods of incident prostate cancers.

Claims data from the "Programme de Médicalisation du Système d'Information" (PMSI) have been commonly used for several years to complement cancer registries and describe cancer incidence in France. It is less clear whether or not it is possible to use these data as an independent source of information to assess cancer incidence, in the absence of a regional cancer registry. Following a similar study on breast cancer, we present a study which aimed to evaluate two methods of identifying incident prostate cancer using claims data. These methods were developed using claims data from the Hospices Civils de Lyon (HCL) and their validity was tested against medical records. The first method (M1) identified incident patients as those who had at least one stay with a principal diagnosis of prostate cancer. The second method (M2) had a prostate cancer treatment code in addition to the criteria for the first method. Both methods of identification had similar results, indicating a low rate of false negatives (negative predictive values: M1 = 100 [CI95: 93.8-100], M2 = 98.6 [CI95: 90.1-99.6]) and a high rate of false positives (positive predictive values: M1 = 33.3 [CI95: 23.2-42.1], M2 = 33.7 [CI95: 24.2-43.2]). The sample size did not allow us to produce consistent estimates of sensitivity and specificity. Our results showed that an estimation of the number of incident cases of prostate cancer using both methods of identification would be biased because of the high rate of false positives. Statistical methods that correct identification errors should be used.

[Analysis of the medical activity related to cancer in a network of multidisciplinary hospitals using claims databases, the reseau Concorde Oncology Network]. / Estimation et analyse de l'activité cancérologique d'un ensemble d'établissements participant à un réseau régional à partir des données du PMSI, le réseau Concorde.

Recently, to answer patients, caregivers and professionals needs, the "Plan Cancer" has been presented by the French Government. This plan is intended to improve quality of care in cancer patients and finally, patients' survival and quality of life. This planned strategy stresses the importance of organized interactions between hospitals and between the various health professionals. Measuring the number of patients with cancer and the activity related to cancer in large networks of multidisciplinary hospitals has became a real challenge in France for organizational, quality of care and economic reasons. Many University Hospitals in France have chosen to face this question by using the French DRG based information system called PMSI. It allows estimating the proportion of hospital stays concerned by cancers that are identified with algorithms based on ICD 10. However, French databases of hospital discharges do not allow patients identification. We collected data on hospital stays and patients in a subset of an organized network focused on cancer care and composed of 55 public or private hospitals in the Rhone-Alpes area. We used these data to estimate the number of patients who had been hospitalized within the network in 2000. Approximately 110,000 hospital stays were related with a diagnostic of cancer, corresponding to a number of patients within a range of 30345 to 35700. In absence of communicating files between hospitals, claims databases are an interesting source of information for cancer burden. The recent implementation of a procedure allowing the linkage of data concerning each patient should permit better estimates in the future. The main limitation will remain the possibility of a hospital to participate to more than one network.