Development and Usability of an Endoscopist Report Card Assessing ERCP Quality.

BACKGROUND AND AIMS: Audit and feedback (A&F) for endoscopic retrograde cholangiopancreatography (ERCP) is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist 'report cards' are one A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability and feasibility through usability testing. METHODS: A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AE). Exploratory analyses from a prospective multi-center registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semi-structured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated post-interview usability instruments were administered. Feedback was incorporated to create a final report card. RESULTS: The report card included domains of technical parameters, AE rates/prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Post-interview instruments revealed adequate appropriateness and acceptability. PREMs were felt by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation due to reliance on difficult-to-obtain granular intraprocedural data. CONCLUSIONS: We designed and tested an ERCP report card that has potential to be an effective A&F intervention for endoscopists in clinical practice. Though feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool.

Presentations for hypoglycemia associated with diabetes mellitus to emergency departments in a Canadian province: A database and epidemiological analysis.

AIMS: The prevalence of diabetes mellitus was reportedly 9% in 2014, making it one of the most common global chronic conditions. Hypoglycemia is an important complication of diabetes treatment. The objective of this study was to quantify and characterize hypoglycemia presentations associated with type 1 or 2 diabetes made to emergency departments (EDs) by adults in a Canadian province. METHODS: A retrospective cohort study was conducted using reliable administrative data from Alberta for a five-year period (2010/11-2014/15). Records of interest were those with an ICD-10-CA diagnosis of diabetes-associated hypoglycemia (e.g., E10.63). A descriptive analysis was conducted. RESULTS: Data extraction yielded 7835 presentations by 5884 patients. The majority (56.2%) of presentations were made by males, median patient age was 62, and 60.5% had type 2 diabetes. These episodes constituted 0.08% of presentations to Alberta EDs. The annual rate of presentations decreased by 11.8% during the five-year period. Most presentations (63.4%) involved transportation to ED via ambulance. Median length-of-stay was four hours. For 27.5% of presentations, an X-ray was obtained. Most hypoglycemic episodes (65.2%) were considered to be moderate, while 34.3% were considered to be severe. CONCLUSIONS: Diabetes-associated hypoglycemia presentations to Alberta EDs are more commonly made by patients with type 2 diabetes, who are more likely to be transported via ambulance and also admitted. Each year, approximately one percent of Albertans with diabetes presented with a hypoglycemia episode; however, knowledge of the variation across regions can guide a strategy for improved care.

The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: principal results.

BACKGROUND: In Canada, demand for multidisciplinary bariatric (obesity) care far outstrips capacity. Consequently, prolonged wait times exist that contribute to substantial health impairments. A supportive, educational, self-management intervention (with in-person and web-based versions) for patients wait-listed for bariatric care has already been implemented in Northern and Central Alberta, Canada, but its effectiveness is unknown. The objective of this trial is to evaluate the clinical and economic outcomes of two self-management programs of varying intensity that are currently in use. METHODS: We conducted a pragmatic, prospective, parallel-arm, randomized controlled trial of 651 wait-listed patients from two regional bariatric programs. Patients were randomized to (1) an in-person, group-based intervention (13 sessions; n = 215) or (2) a web-based intervention (13 modules; n = 225) or (3) control group (printed educational materials; n = 211). After randomization, subjects had 3 months to review the content assigned to them (the intervention period) prior to bariatric clinic entry. The primary outcome was the proportion of patients achieving 5% weight loss at 9 months. Intention-to-treat two-way comparisons were performed and adjusted for baseline age, sex, site and body mass index. RESULTS: At baseline, mean age was 40.4 ± 9.8 years, mean weight was 134.7 ± 25.2 kg, mean body mass index was 47.7 ± 7.0 kg/m2 and 83% of participants were female. A total of 463 patients (71%) completed 9 months follow-up. At least 5% weight loss was achieved by 24.2% of those in the in-person strategy, 24.9% for the web-based strategy and 21.3% for controls (adjusted p value = 0.26 for in-person vs. controls, 0.28 for web-based vs. controls, 0.96 for in-person vs. web-based). Absolute and relative (% of baseline) mean weight reductions were 3.7 ± 7.1 kg (2.7 ± 5.4%) for in-person strategy, 2.8 ± 6.7 kg (2.0 ± 4.8%) for web-based and 2.9 ± 8.8 kg (1.9 ± 5.9%) for controls (p > 0.05 for all comparisons). No between-group differences were apparent for any clinical or humanistic secondary outcomes. Total annual costs in Canadian dollars were estimated at $477,000.00 for the in-person strategy, $9456.78 for the web-based strategy and $2270.31 for provision of printed materials. DISCUSSION: Two different self-management interventions were no more effective and were more costly than providing printed education materials to severely obese patients. Our findings underscore the need to develop more potent interventions and the importance of comprehensively evaluating self-management strategies before widespread implementation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01860131 . Registered 17 May 2013.

Inter- and intratester reliability of anthropometric assessment of limb circumference in labrador retrievers.

OBJECTIVE: To report a standardized method of, and determine inter- and intratester reliability for, anthropometric assessment of limb circumference in dogs. STUDY DESIGN: Prospective blinded study. ANIMALS: Labrador Retrievers (n = 20). METHOD: Unsedated dogs were manually restrained in lateral recumbency and triplicate measurements of limb circumference at the level of the proximal antebrachium, mid brachium, proximal crus, and mid-thigh were made using the Gulick II tape measure in the morning and afternoon of the same day. Observers were blinded to measurements made during each occasion and those made by co-observers. Estimates of inter- and intratester reliability were made for first and mean measurements using intra-class correlation coefficients (ICC). RESULTS: Measurements of the proximal antebrachium were made with moderate to fair intratester reliability by all observers with ICC's ranging from 0.68-0.78 (1st measurement) and 0.67-0.78 (mean measurement), and moderate to fair intertester reliability with ICC's of 0.66-0.68 (1st measurement) and 0.70-0.72 (mean measurement). Measurements of the brachium, crus, and thigh typically had poor inter- and intratester reliability, ICC < 0.5. CONCLUSION: Using the described method of muscle measurement in Labrador Retrievers only measurement of the proximal antebrachium was reliable; a single (1st) measurement was as reliable as using the mean of triplicate measurements.

Living alone, patient sex and mortality after acute myocardial infarction.

BACKGROUND: Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear. OBJECTIVE: To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex. DESIGN: Historical cohort study. PARTICIPANTS/SETTING: All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998-1999 fiscal year. MEASUREMENTS: Patients' sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001. RESULTS: Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0-2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1-3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7-2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5-1.5). CONCLUSIONS: Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.

Factors associated with depression in patients referred to headache specialists.

OBJECTIVE: To evaluate the relationship between selected demographic characteristics and clinical features in patients with headache and depression. METHODS: We studied demographic and clinical data collected at the time of consultation for 712 new patients with headache referred to five headache specialty clinics in Canada. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The Beck Depression Inventory (BDI-II) was used to identify the presence of depression. Multivariable logistic regression analysis was employed to evaluate associations between age, gender, employment status, marital status, diagnosis, headache days per month, medication overuse, headache impact (HIT-6), and headache disability (MIDAS) and the presence of depression as measured by the BDI-II. RESULTS: Among the sample of patients with headache, 27% (n = 189) had moderate to severe depression. Factors independently associated with depression included age less than 50 years, being unemployed, being on disability pension or welfare, being widowed, separated, or divorced, a diagnosis of transformed migraine or headache associated with head trauma or cervical spine disorder, and showing severe headache impact as measured by the HIT-6, or severe disability as measured by the MIDAS. CONCLUSIONS: In patients with headache referred for specialist consultation, depression is strongly associated with being on disability or welfare, unemployment, age under 50 years, showing severe headache impact on the Headache Impact Test-6, and receiving a diagnosis of transformed migraine. The possibility of a concomitant depression should be strongly considered in patients with headache with any of these characteristics.

Demographics and clinical features of patients referred to headache specialists.

OBJECTIVE: To examine demographic characteristics and clinical features of headache patients referred to neurologists specializing in headache in Canada. METHODS: Demographic and clinical data were collected at the time of consultation for 865 new headache patients referred to five headache-specialty clinics in Canada. The Headache Impact Test (HIT-6) and Migraine Disability Questionnaire (MIDAS) were used to measure headache impact and disability. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. RESULTS: The average age of the patients was 40 years and the majority were female (78%). Most were employed either full time (49%) or part time (13%). The majority of patients were diagnosed with either migraine or tension-type headache (78%). Over a third of patients experienced headache every day, and half had experienced a headache in the previous month which was of severe intensity. Most (80%) scored in the "very severe" category of the HIT-6 and over half (55%) were severely disabled as measured by the MIDAS. CONCLUSION: Patients referred to headache specialists in Canada are severely disabled by their headache disorders. These patients are in the most productive phase of their lives in terms of age and employment. It is important to provide the best available treatment to headache patients in order to minimize the disability and impact of their headache disorders.

Pain free efficacy of sumatriptan in the early treatment of migraine.

BACKGROUND: There is evidence that headache response rates may be higher if triptans are used early when a migraine attack is still mild, as compared to when it is treated after pain has reached moderate or severe intensity. METHODS: In this randomized, double blind, placebo controlled, parallel group clinical trial, 361 patients took either placebo, sumatriptan 50 mg, or sumatriptan 100 mg in a single attack study. The primary outcome measure was pain-free status at two hours. RESULTS: In the intention to treat group, two hour pain free rates were 16%, 40%, and 50% in the placebo group, sumatriptan 50 mg group, and the sumatriptan 100 mg group respectively (p < 0.001, active treatment groups vs. placebo). CONCLUSIONS: Both sumatriptan 50 mg and 100 mg were significantly superior to placebo for the pain-free end point at two hours. The pain-free response rates in this trial where sumatriptan was taken while the headache was still mild were generally higher than in older clinical trials where headache was treated after reaching a moderate or severe intensity.

The influence of breast self-examination on subsequent mammography participation.

OBJECTIVES: We evaluated whether breast self-examination (BSE) influences subsequent mammography participation. METHODS: We evaluated associations between BSE and subsequent mammography participation, adjusting for baseline screening behaviors and sociodemographic, health, and lifestyle characteristics, among women aged 40 years and older using data from the longitudinal Canadian National Population Health Survey. RESULTS: Regular performance of BSE at baseline was not associated with receipt of a recent mammogram at follow-up among all women (adjusted odds ratio [OR]=1.01; 95% confidence interval [CI]= 0.75, 1.35) or with mammography uptake among the subgroup of women reporting never use at baseline (adjusted OR=0.78; 95% CI=0.50, 1.22). CONCLUSIONS: The lack of association between performance of BSE and subsequent mammography participation suggests that not recommending BSE is unlikely to influence mammography participation.

Absence of sex differences in pharmacotherapy for acute myocardial infarction.

BACKGROUND: Previous studies have indicated that sex differences may exist in the pharmacological management of acute myocardial infarction (AMI), with female patients being treated less aggressively. OBJECTIVES: To determine if previously reported sex differences in AMI medication use were also evident among all AMI patients treated at hospitals in an urban Canadian city. METHODS: All patients who had a primary discharge diagnosis of AMI from all three adult care hospitals in Calgary, Alberta, in the 1998/1999 fiscal year were identified from hospital administrative records (n=914). A standardized, detailed chart review was conducted. Information collected from the medical charts included sociodemographic and clinical characteristics, comorbid conditions, and cardiovascular medication use during hospitalization and at discharge. RESULTS: Similar proportions of female and male patients were treated with thrombolytics, beta-blockers, angiotensin-converting enzyme inhibitors, nitrate, heparin, diuretics and digoxin. Among patients aged 75 years and over, a smaller proportion of female patients received acetylsalicylic acid in hospital than did male patients (87% versus 95%; P=0.026). Multivariable logistic regression analysis revealed that, after correction for age, use of other anticoagulants/antiplatelets and death within 24 h of admission, sex was no longer an independent predictor for receipt of acetylsalicylic acid in hospital. Medications prescribed at discharge were similar between male and female patients. CONCLUSION: The results from this Canadian chart review study, derived from detailed clinical data, indicate that the pattern of pharmacological treatment of female and male AMI patients during hospitalization and at discharge was very similar. No sex differences were evident in the treatment of AMI among patients treated in an urban Canadian centre.