Postdischarge opioid use after lumbar spine surgery among older adults in Ontario: a population-based cohort study.

BACKGROUND: Prescription opioid use places a considerable economic burden on health care systems. Older patients undergoing surgical procedures for painful conditions commonly receive opioids pre- and postoperatively, and are susceptible to adverse reactions. This study explores predictors of prolonged postoperative opioid use among older patients after lumbar spine surgery and the consequences in terms of health care utilization and costs. METHODS: We conducted a retrospective population-based cohort study using Ontario administrative data from older adults undergoing spine surgery between 2006 and 2017. Data were analyzed from 90 days preoperatively to 1 year after hospital discharge, with last postoperative opioid prescriptions stratified into 90-day increments. We used multivariable ordinal logistic regression to identify predictors of long-term opioid use and generalized linear modelling to examine resource utilization and health care costs (2021 Canadian dollars). RESULTS: Of 15 109 patients included, 40.8% received preoperative opioid prescriptions. Preoperative opioid use strongly predicted prolonged postoperative use (odds ratio [OR] 4.47, 95% confidence interval [CI] 4.16-4.79), with 48.3% of patients who received preoperative opioids continuing to use opioids for longer than 9 months, relative to 12.7% of those without preoperative use. Several other risk factors for prolonged use were identified. Patients receiving long-term postoperative opioids incurred greater health care costs relative to those with opioids prescribed for fewer than 90 days (OR 1.49, 95% CI 1.44-1.54). CONCLUSION: Among older adults undergoing spine surgery, preoperative opioid use was a strong predictor of prolonged postoperative use, which was associated with increased health care costs. These results form an important baseline for future studies evaluating strategies to reduce opioid use targeting older surgical populations.

Feasibility and Cost Analysis of Portable MRI Implementation in a Remote Setting in Canada.

OBJECTIVE: To conduct feasibility and cost analysis of portable MRI implementation in a remote setting where MRI access is otherwise unavailable. METHODS: Portable MRI (ultra-low field, 0.064T) was installed in Weeneebayko General Hospital, Moose Factory, Ontario. Adult patients, presenting with any indication for neuroimaging, were eligible for study inclusion. Scanning period was from November 14, 2021, to September 6, 2022. Images were sent via a secure PACS network for Neuroradiologist interpretation, available 24/7. Clinical indications, image quality, and report turnaround time were recorded. A cost analysis was conducted from a healthcare system's perspective in 2022 Canadian dollars, comparing cost of portable MRI implementation to transporting patients to a center with fixed MRI. RESULTS: Portable MRI was successfully implemented in a remote Canadian location. Twenty-five patients received a portable MRI scan. All studies were of diagnostic quality. No clinically significant pathologies were identified on any of the studies. However, based on clinical presentation and limitations of portable MRI resolution, it is estimated that 11 (44%) of patients would require transfer to a center with fixed MRI for further imaging workup. Cost savings were $854,841 based on 50 patients receiving portable MRI over 1 year. Five-year budget impact analysis showed nearly $8 million dollars saved. CONCLUSIONS: Portable MRI implementation in a remote setting is feasible, with significant cost savings compared to fixed MRI. This study may serve as a model to democratize MRI access, offer timely care and improved triaging in remote areas where conventional MRI is unavailable.

Chronic opioid use after joint replacement surgery in seniors is associated with increased healthcare utilization and costs: a historical cohort study.

PURPOSE: Postoperative opioid use may be associated with increased healthcare utilization and costs. We sought to examine the relationship between duration of postoperative opioid prescriptions and healthcare costs and resource utilization in senior patients following hip and knee replacement. METHODS: We conducted a historical cohort study evaluating postoperative opioid use and healthcare costs in patients over the age of 65 yr undergoing primary total hip or knee arthroplasty over a ten-year period from 1 April 2006 to 31 March 2016. The last follow-up date was 31 March 2017. We identified preoperative and postoperative opioid prescriptions, patient characteristics, and healthcare costs using deidentified Ontario administrative databases (Institute of Clinical Evaluative Sciences). Duration of postoperative opioid use was divided into four categories: short-term (1-90 days), prolonged (91-180 days), chronic (181-365 days), and undocumented. RESULTS: The study included 49,638 hip and 85,558 knee replacement patients. Although the initial hospitalization accounted for the greatest cost in all patients, over the following year patients in the short-term opioid use group incurred the lowest average costs, and those in the chronic group incurred the highest (hip, CAD 17,528 vs CAD 26,736; knee, CAD 16,043 vs CAD 23,007), driven by increased healthcare resource utilization. CONCLUSION: Chronic opioid use after arthroplasty was associated with higher resource utilization and healthcare costs during the year following surgery. These results can be used to develop predictors of longer opioid use and higher costs. Further research is planned to determine whether recently implemented opioid reduction strategies can reduce healthcare resource utilization.

RéSUMé: OBJECTIF: L'utilisation postopératoire d'opioïdes peut être associée à une augmentation de l'utilisation et des coûts des soins de santé. Nous avons cherché à examiner la relation entre la durée des ordonnances d'opioïdes postopératoires, les coûts des soins de santé et l'utilisation des ressources chez les patients âgés après une arthroplastie de la hanche et du genou. MéTHODE: Nous avons réalisé une étude de cohorte historique évaluant la consommation postopératoire d'opioïdes et les coûts des soins de santé chez les patients de plus de 65 ans subissant une arthroplastie totale primaire de la hanche ou du genou sur une période de dix ans allant du 1er avril 2006 au 31 mars 2016. La dernière date de suivi était le 31 mars 2017. Nous avons identifié les ordonnances pré- et postopératoires d'opioïdes, les caractéristiques des patients et les coûts des soins de santé à l'aide de bases de données administratives de l'Ontario désidentifiées (ICES). La durée de la consommation d'opioïdes postopératoires était divisée en quatre catégories : à court terme (1 à 90 jours), prolongée (91 à 180 jours), chronique (181 à 365 jours) et non documentée. RéSULTATS: L'étude a porté sur 49 638 patients ayant subi une arthroplastie de la hanche et 85 558 patients une arthroplastie du genou. Bien que l'hospitalisation initiale ait représenté le coût le plus élevé chez tous les patients, au cours de l'année suivante, les patients du groupe de consommation d'opioïdes à court terme ont encouru les coûts moyens les plus bas et ceux du groupe chronique les coûts les plus élevés (hanche, 17 528 CAD vs 26 736 CAD; genou, 16 043 CAD vs 23 007 CAD) en raison de l'utilisation accrue des ressources de soins de santé. CONCLUSION: La consommation chronique d'opioïdes après une arthroplastie a été associée à une augmentation de l'utilisation des ressources et des coûts des soins de santé au cours de l'année suivant la chirurgie. Ces résultats peuvent être utilisés pour développer des modèles de prédiction d'une consommation prolongée d'opioïdes et de coûts plus élevés. D'autres recherches sont prévues pour déterminer si les stratégies de réduction de la consommation d'opioïdes récemment mises en œuvre pourront réduire l'utilisation des ressources en soins de santé.

Long-term opioid use in seniors following hip and knee arthroplasty in Ontario: a historical cohort study.

PURPOSE: Canadian seniors who undergo hip and knee arthroplasty often experience significant postoperative pain, which could result in persistent opioid use. We aimed to document the impact of preoperative opioid use and other characteristics on postoperative opioid prescriptions in elderly patients following hip and knee replacement before widespread dissemination of opioid reduction strategies. METHODS: We conducted a historical cohort study to evaluate postoperative opioid use in patients over 65 yr undergoing primary total hip and knee replacement over a ten-year period from 1 April 2006 to 31 March 2016, using linked de-identified Ontario administrative data. We determined the use of preoperative opioids and the duration of postoperative opioid prescriptions (short-term [1-90 days], prolonged [91-180 days], chronic [181-365 days], or undocumented). RESULTS: The study included 49,638 hip and 85,558 knee replacement patients. Eighteen percent of hip and 21% of knee replacement patients received an opioid prescription within 90 days before surgery. Postoperatively, 51% of patients filled opioid prescriptions for 1-90 days, while 24% of hip and 29% of knee replacement patients filled prescriptions between 6 and 12 months, with no impact of preoperative opioid use. Residence in long-term care was a significant predictor of chronic opioid use (hip: odds ratio [OR], 2.64; 95% confidence interval [CI], 1.93 to 3.59; knee: OR, 2.46; 95% CI, 1.75 to 3.45); other risk factors included female sex and increased comorbidities. CONCLUSION: Despite a main goal of joint arthroplasty being relief of pain, seniors commonly remained on postoperative opioids, even if not receiving opioids before surgery. Opioid reduction strategies need to be implemented at the surgical, primary physician, long-term care, and patient levels. These findings form a basis for future investigations following implementation of opioid reduction approaches.

RéSUMé: OBJECTIF: Les aînés canadiens subissant une arthroplastie de la hanche ou du genou éprouvent souvent une douleur postopératoire importante, ce qui pourrait entraîner la consommation persistante d'opioïdes. Nous avons cherché à documenter l'impact d'une utilisation préopératoire d'opioïdes et d'autres caractéristiques sur les prescriptions postopératoires d'opioïdes chez les patients âgés suivant un remplacement de hanche ou de genou avant l'utilisation répandue de stratégies de réduction d'opioïdes. MéTHODE: Nous avons réalisé une étude de cohorte historique pour évaluer la consommation postopératoire d'opioïdes chez les patients de plus de 65 ans subissant une arthroplastie totale primaire de la hanche ou du genou sur une période de dix ans du 1er avril 2006 au 31 mars 2016, à l'aide de données administratives dépersonnalisées et codées de l'Ontario. Nous avons déterminé la durée des ordonnances préopératoires et postopératoires d'opioïdes (à court terme [1-90 jours], prolongées [91-180 jours], chroniques [181-365 jours] ou non documentées). RéSULTATS: L'étude a porté sur 49 638 patients ayant subi une arthroplastie de la hanche et 85 558 patients une arthroplastie du genou. Dix-huit pour cent des patients ayant subi une arthroplastie de la hanche et 21 % des patients ayant subi une arthroplastie du genou ont reçu une ordonnance d'opioïdes dans les 90 jours précédant leur chirurgie. En période postopératoire, 51 % des patients ont utilisé leurs ordonnances d'opioïdes pendant 1 à 90 jours, tandis que 24 % des patients d'arthroplastie de la hanche et 29 % des patients d'arthroplastie du genou ont utilisé leurs ordonnances entre six et 12 mois. Le fait d'habiter dans un établissement de soins de longue durée était un prédicteur important de consommation chronique d'opioïdes (hanche : rapport de cotes [RC], 2,64; intervalle de confiance [IC] à 95 %, 1,93 à 3,59; genou : RC, 2,46; IC 95 %, 1,75 à 3,45); le sexe féminin et l'augmentation des comorbidités constituaient d'autres facteurs de risque. CONCLUSION: Bien que l'un des principaux objectifs de l'arthroplastie articulaire soit le soulagement de la douleur, les personnes âgées continuent généralement à consommer des opioïdes en période postopératoire, même si elles ne prenaient pas d'opioïdes avant leur chirurgie. Il est nécessaire de mettre en œuvre des stratégies de réduction des opioïdes qui s'adressent aux chirurgiens, aux médecins traitants, aux soins de longue durée et aux patients. Ces constatations constituent la base d'études futures réalisées à la suite de la mise en œuvre d'approches de réduction des opioïdes.

Use of instrumented lumbar spinal surgery for degenerative conditions: trends and costs over time in Ontario, Canada

Background: Instrumented lumbar surgeries, such as lumbar fusion and lumbar disc replacement, are increasingly being used in the United States for low back pain, with utilization rates approaching those of total joint arthroplasty. It is unknown whether there is a similar pattern in Canada. We sought to determine utilization rates and total medical costs of instrumented lumbar surgeries in a single-payer system and to compare these with the rates and costs of total hip and knee replacements. Methods: We included Ontarians aged 20 years and older who underwent instrumented lumbar surgery or total knee or total hip replacement between April 1993 and March 2012. Utilization and medical cost of the procedures were evaluated and compared using linear regression in a time-series analysis. Instrumented lumbar surgical procedures were stratified by age and main indication for surgery. Results: Utilization of instrumented lumbar surgeries rose from 6.2 to 14.2 procedures per 100 000 population between 1993 and 2012 (p < 0.001), well below the utilization of knee and hip arthroplasties. Patients were younger than 50 years for 29.2% of all instrumented lumbar surgery cases; annual procedure rates among those older than 80 years rose 7.6-fold. Direct medical costs of instrumented lumbar surgeries from 2002 to 2012 totaled $176 million. Spinal stenosis and spondylolisthesis were the most common indications for instrumented lumbar surgeries. Conclusion: Use of instrumented lumbar surgeries in Ontario's single-payer system has increased rapidly, especially among patients older than 80 years. In contrast to the situation in the United States, these rates were well below those of total joint arthroplasties. These data provide useful insights about resource allocation for surgical treatment of lumbar degenerative disorders.

Contexte: Les chirurgies lombaires instrumentées, telles que l'arthrodèse ou la prothèse discale lombaires, sont de plus en plus utilisées aux États-Unis pour le traitement de la lombalgie, leurs taux d'utilisation s'approchant de ceux de l'arthroplastie totale. On ignore si la tendance est la même au Canada. Nous avons voulu mesurer les taux d'utilisation et les coûts médicaux totaux des chirurgies lombaires instrumentées et les comparer aux taux et aux coûts de l'arthroplastie totale de la hanche et du genou. Méthodes: Nous avons inclus les Ontariens de 20 ans et plus ayant subi une chirurgie lombaire instrumentée ou une arthroplastie totale du genou ou de la hanche entre avril 1993 et mars 2012. L'utilisation et les coûts médicaux des interventions ont été évalués et comparés par analyse de régression linéaire des séries chronologiques. Les chirurgies lombaires ont été stratifiées selon l'âge et la principale indication. Résultats: Le recours aux chirurgies lombaires instrumentées a augmenté de 6,2 à 14,2 interventions par 100 000 de population entre 1993 et 2012 (p < 0,001), ce qui reste bien inférieur au recours à l'arthroplastie du genou et de la hanche. Les patients avaient moins de 50 ans pour 29,2 % de tous les cas de chirurgies lombaires instrumentées; le taux annuel d'interventions chez les patients de plus de 80 ans a augmenté selon un facteur de 7,6. Les coûts médicaux directs des chirurgies lombaires instrumentées ont totalisé 176 millions de dollars entre 2002 et 2012. La sténose rachidienne et le spondylolisthésis étaient les plus fréquentes indications des chirurgies lombaires instrumentées. Conclusion: L'utilisation de la chirurgie lombaire instrumentée pour le régime d'assurance santé à payeur unique ontarien a augmenté rapidement, particulièrement chez les patients de plus de 80 ans. Comparativement à la situation qui prévaut aux États-Unis, ces taux sont bien inférieurs aux taux d'arthroplasties totales. Ces données sont intéressantes du point de vue de l'allocation des ressources pour le traitement chirurgical de la dégénérescence discale lombaire.

Pain Management Strategies and Health Care Use in Community-Dwelling Individuals Living with Chronic Pain.

OBJECTIVE: To describe factors associated with high clinic and emergency room (ER) use among individuals with chronic pain. DESIGN: This study is part of a larger cross-sectional survey on the epidemiology of chronic pain in Canada. The current analysis was guided by the Andersen-Newman Service Utilization Model. METHODS: Respondents (N = 702) were grouped into high (top 10%) and low (bottom 90%) users based on the number of visits made to clinics and ERs over the past year. The two groups were compared on predisposing (e.g., pain self-efficacy and sociodemographic characteristics), enabling (e.g., income and education), and need (e.g., pain characteristics and number of comorbidities) factors as well as personal health behaviors (e.g., use of medications). Binary logistic regression analysis was used to identify characteristics associated with high use in each setting. RESULTS: High users were defined as 30 or more clinic visits or one or more ER visits. The factors associated with high clinic use in the adjusted analysis were low pain self-efficacy (odds ratio [OR] = 2.60, 95% confidence interval [CI] = 1.50-4.51), two or more comorbidities (OR = 2.13, 95% CI = 1.23-3.69), five or more pain sites (OR = 2.30, 95% CI = 1.28-4.14), and having an "other" pain diagnosis (OR = 1.78, 95% CI = 1.01-3.20). Factors that increased ER use were low pain self-efficacy (OR = 2.01, 95% CI = 1.28-3.15) and two or more comorbidities (OR = 2.31, 95% CI = 1.48-3.59), while use of alternative pain management strategies reduced ER use (OR = 0.42, 95% CI = 0.21-0.84). CONCLUSIONS: Longitudinal studies are needed to confirm if modifiable factors such as pain self-efficacy and use of alternative therapies reduce health care use.

Infants Born to Opioid-Dependent Women in Ontario, 2002-2014.

BACKGROUND: There is a paucity of data characterizing mother-infant pairs with prenatal opioid dependence in Canada. We therefore conducted a study of relevant births in Ontario from 2002 to 2014. METHODS: We used data from the Institute for Clinical Evaluative Sciences, the linked databases of coded population-based Ontario health services records. Differences in characteristics of opioid-dependent mother-neonate pairs and infant hospital costs by year were assessed using linear regression, and we calculated rates of preterm birth, low birth weight, birth defects, mortality, and neonatal abstinence syndrome. RESULTS: The number of infants born to opioid-dependent women in Ontario rose from 46 in 2002 to almost 800 in 2014. Methadone was most frequently used for prenatal opioid dependence; there was little buprenorphine or buprenorphine + naloxone use. Rates of preterm birth and low birth weight were high. The proportion of neonates with neonatal abstinence syndrome (58%) was stable over the study period. The mean length of neonatal hospital stay was 13.96 days. Infant hospital costs increased from $724 774 in 2003 to $10 539 988 in 2013, and the mean cost per infant grew from $9928 to $12 917. Birth defect prevalence was 75.84/1000 live births (95% CI 68.12/1000 to 84.10/1000). The stillbirth rate was 11.39/1000 births (95% CI 8.47/1000 to 14.99/1000), and the infant mortality rate was 12.21/1000 live births (95% CI 9.16/1000 to 15.95/1000). CONCLUSION: We observed a 16-fold increase in the number of mother-infant pairs affected by opioid dependence in Ontario over the past decade. Adverse birth outcome rates were high. Expanded services for opioid-dependent women and their children are needed.

Frequency and characteristics of healthcare visits associated with chronic pain: results from a population-based Canadian study.

PURPOSE: This study was designed to investigate the role of chronic pain in healthcare visits. The specific objectives were to document the frequency of healthcare visits and to identify characteristics associated with frequent visits. METHODS: This is a secondary analysis of data from a Canadian cross-sectional study on chronic pain. One thousand two hundred and ninety-four participants were screened for chronic pain, and 741 reported having "pain or discomfort that had been experienced either all the time or intermittently for at least three months". Data regarding sociodemographics, general health, and healthcare visits were also collected. The frequency of healthcare visits was defined as at or above the 90th percentile for the group. Frequency was calculated for each setting, i.e., physicians' offices (≥ 9), emergency departments (≥ 1), and other (≥ 15). Binary logistic regression analyses were conducted to identify factors associated with frequent visits. RESULTS: Chronic pain increased the frequency of visits to physicians (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.8 to 7.9), emergency departments (OR, 1.4; 95% CI, 1.0 to 2.0), and "other" healthcare professionals (OR, 8.3; 95% CI, 4.5 to 15.5). Having ≥3 chronic conditions significantly increased the odds of frequent healthcare visits. CONCLUSION: Interventions aimed at reducing healthcare costs for chronic pain should target individuals living with multiple chronic conditions. Research is needed to develop and test interventions that focus on the needs of these groups. Identifying the risk factors for high healthcare use and improving self-management may reduce healthcare visits.

Predictors of hospital stay and home care services use: a population-based, retrospective cohort study in stage IV gastric cancer.

BACKGROUND: Home care services use has been proposed as a means of reducing costs in palliative care by decreasing hospital stay without impacting quality of clinical care; however, little is known about utilization of these services in the time following a terminal cancer diagnosis. AIM: To examine disease, patient and healthcare system predictors of hospital stay, and home care services use in metastatic gastric cancer patients. DESIGN: This is a population-based, retrospective cohort study. Chart review and administrative data were linked, using a 26-month time horizon to collect health services data. PARTICIPANTS: All patients diagnosed with metastatic gastric cancer in the province of Ontario between 2005 and 2008 were included in the study (n = 1433). RESULTS: Age, comorbidity, tumor location, and burden of metastatic disease were identified as predictors of hospital stay and receipt of home care services. Individuals who received home care services spent fewer days in hospital than individuals who did not (relative risk: 0.44; 95% confidence interval: 0.38-0.51). Patients who interacted with a high-volume oncology specialist had shorter cumulative hospital stay (relative risk: 0.62; 95% confidence interval: 0.54-0.71) and were less likely to receive home care services (relative risk: 0.80; 95% confidence interval: 0.72-0.88) than those who did not. CONCLUSION: Examining how differences in hospital stay and home care services use impact clinical outcomes and how policies may reduce costs to the healthcare system is necessary.

Sex/Gender-Based Pharmacology and Statin Utilization Amongst Elderly Patients with Diabetes.

PURPOSE: The purpose of this study was to explore the ten-year trends in utilization of bioequivalent doses of statin amongst elderly patients with diabetes according to sex/gender in Ontario, Canada. METHODS: A cohort of patients with diabetes (>65 years) was constructed using the Ontario Diabetes Database Statin utilization data (2003-2012) was obtained from the Ontario Drug Benefit Program for both women and men. Bioequivalent doses for statins were calculated according to the dosing conversion factor in therapeutic interchange programs in clinical practice. Utilization pattern of high potency (Atorvastatin and Rosuvastatin) vs. low potency statins (Simvastatin, Lovastatin, Fluvastatin, Pravastatin) were also analyzed. RESULTS: The average bioequivalent Simvastatin utilization in 2003 was 29.22 mg/day for women and 30.35 mg/day for men. By 2008, this gap in dosing was higher for both women and men and by 2013 it had increased to 47.75 mg/day for women and 52.98 mg/day for men. For average number of day supply per year, there was no significant trend of changes over the 10-year period, although the use of high potency statins increased significantly (P<0.001) for both women and men. No differences were seen for sex/gender; either for the 10-year period or for each year. CONCLUSIONS: There has been significant increase in bioequivalent statin utilization amongst elderly patients with diabetes in Ontario; for both men and women. In a publicly-funded healthcare system such as Ontario, there were no sex/gender differences in the utilization of high potency statin (Atorvastatin and Rosuvastatin) amongst elderly patient with diabetes.

A Frailty Index to Predict Mortality, Resource Utilization and Costs in Patients Undergoing Coronary Artery Bypass Graft Surgery in Ontario.

Background: People living with frailty are vulnerable to poor outcomes and incur higher health care costs after coronary artery bypass graft (CABG) surgery. Frailty-defining instruments for population-level research in the CABG setting have not been established. The objectives of the study were to develop a preoperative frailty index for CABG (pFI-C) surgery using Ontario administrative data; assess pFI-C suitability in predicting clinical and economic outcomes; and compare pFI-C predictive capabilities with other indices. Methods: A retrospective cohort study was conducted using health administrative data of 50,682 CABG patients. The pFI-C comprised 27 frailty-related health deficits. Associations between index scores and mortality, resource use and health care costs (2022 Canadian dollars [CAD]) were assessed using multivariable regression models. Capabilities of the pFI-C in predicting mortality were evaluated using concordance statistics; goodness of fit of the models was assessed using Akakie Information Criterion. Results: As assessed by the pFI-C, 22% of the cohort lived with frailty. The pFI-C score was strongly associated with mortality per 10% increase (odds ratio [OR], 3.04; 95% confidence interval [CI], [2.83,3.27]), and was significantly associated with resource utilization and costs. The predictive performances of the pFI-C, Charlson, and Elixhauser indices and Johns Hopkins Aggregated Diagnostic Groups were similar, and mortality models containing the pFI-C had a concordance (C)-statistic of 0.784. Cost models containing the pFI-C showed the best fit. Conclusions: The pFI-C is predictive of mortality and associated with resource utilization and costs during the year following CABG. This index could aid in identifying a subgroup of high-risk CABG patients who could benefit from targeted perioperative health care interventions.

Contexte: Les personnes dont l'état de santé est fragilisé sont susceptibles de connaître des issues défavorables et de générer des coûts plus élevés pour le système de santé après un pontage aortocoronarien. Aucun instrument n'a été établi pour définir la fragilité dans la recherche populationnelle en contexte de pontage aortocoronarien. Les objectifs de l'étude étaient les suivants : 1) concevoir un indice de fragilité préopératoire en vue d'un pontage aortocoronarien (preoperative frailty index for CABG surgery, pFI-C) en utilisant des données administratives de l'Ontario; 2) évaluer la capacité de cet indice à prédire les issues cliniques et économiques; et 3) comparer la valeur prédictive de cet indice avec celle d'autres indices. Méthodologie: Une étude de cohorte rétrospective a été menée à partir de données médico-administratives portant sur 50 682 patients ayant subi un pontage aortocoronarien. Le pFI-C comprenait 27 déficits de santé liés à la fragilité. Des liens entre les scores de l'indice et la mortalité, l'utilisation des ressources et les coûts de soins de santé (en $ CA de 2022) ont été évalués à l'aide de modèles de régression multivariable. La capacité du pFI-C à prédire la mortalité a été évaluée à l'aide de la statistique de concordance; la qualité de l'ajustement des modèles a été évaluée en fonction du critère d'information d'Akaike. Résultats: Selon l'évaluation par le pFI-C, 22 % de la cohorte vivait avec une fragilité. Le score de l'indice était fortement corrélé à la mortalité par tranche d'augmentation de 10 % (rapport de cotes de 3,04; intervalle de confiance à 95 % de 2,83 à 3,27) et était corrélé de manière significative à l'utilisation des ressources et aux coûts. La valeur prédictive du pFI-C, des indices de Charlson et Elixhauser, et de Johns Hopkins Aggregated Diagnostic Groups était similaire, et les modèles de mortalité contenant le pFI-C affichaient une valeur statistique C de 0,784. Les modèles de coûts contenant le pFI-C affichaient le meilleur ajustement. Conclusions: Le pFI-C est un facteur prédictif de mortalité et est corrélé à l'utilisation des ressources et aux coûts engagés durant l'année qui suit un pontage aortocoronarien. Cet indice pourrait faciliter la détection d'un sous-groupe de patients subissant un pontage aortocoronarien et présentant un risque élevé qui pourraient bénéficier de soins périopératoires ciblés.

Carotid Plaque Score is Associated with 10-year Major Adverse Cardiovascular Events in Low-Intermediate Risk Patients Referred to a General Cardiology Community Clinic.

AIMS: Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE). METHODS AND RESULTS: Patients ≥40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery (ICA) were given 1 point per segment if plaque present (plaque score 0 to 6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8,472 patients, 60% were females (n = 5,121). Plaque was more prevalent in males (64% vs 53.9%; P <0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9 % vs females 6.0%; P = 0.004). Having both maximal CCA IMT <1.00 mm and plaque score = 0, was associated with less events. A plaque score <2 was associated with a low 10-year event rate (4.1%) compared to 2-4 (8.7%) and 5-6 (20%). CONCLUSION: A plaque score ≥2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

Development of advance care planning research priorities: a call to action.

The objective of this study was to develop a national, prioritized research agenda for advance care planning (ACP). We first identified a list of comprehensive ACP research topics and determined priority criteria through focus groups. We next conducted a survey wherein importance weights were assigned to priority criteria and each ACP topic was rated. We combined weights and ratings into overall scores. A total of 17 ACP topics were developed and placed into four categories: patients and family members, the general public, professionals, and the healthcare system. Four main priority criteria were created: feasibility, consistency with ethical and societal values, economic considerations, and impact. Of the 100 individuals we invited to participate in the survey, 62 accepted. Prioritized topics centred largely on the impact of ACP on health resource utilization, communicating advance care planning across settings, and the preferred manner of engaging patients in ACP.

Evaluation of definitions for oral anticoagulant-associated major bleeding: A population-based cohort study.

INTRODUCTION: Major bleeding is the most serious complication of oral anticoagulants (OACs). While consensus criteria to define major bleeding have been established by the International Society for Thrombosis and Haemostasis (ISTH), Bleeding Academic Research Consortium (BARC) and Thrombolysis in Myocardial Infarction (TIMI), significant variability exists across these definitions. We sought to evaluate the agreement of cases identified by the three definitions and to assess their effect on mortality and OAC resumption. METHODS: We used a dataset of individuals ≥66 years in Ontario, Canada presenting with OAC-related bleeding from 2010 to 2015. For case agreement, we calculated Cohen's κ between the three major bleeding definitions. We used multivariate regression to determine differences in mortality and OAC resumption among ISTH, BARC and TIMI-defined major bleeds. RESULTS: Among 2002 cases of OAC-related bleeding, agreement in case identification between ISTH and BARC was substantial (Cohen's κ = 0.69); however, agreement between TIMI and other definitions were poor. Using 30-day mortality of clinically relevant non-major bleeds as comparator, ISTH-, BARC- and TIMI-defined major bleeds conferred 3.3-, 3.2- and 5.9-fold increased risk. Among survivors, 50% with ISTH- and BARC-defined major bleeds resumed OACs at 180 days, compared to 31% of TIMI-associated cases. CONCLUSION: Major bleeds identified by ISTH and BARC criteria showed good agreement and similar prognostic utility, whereas TIMI criteria identified patients at greater clinical risk. Our results highlight the need to revise major bleeding definitions based on criteria that are independently predictive of clinically relevant morbidity and mortality to more effectively reflect the risk associated with major bleeding and appropriately influence anticoagulant therapy decisions.

A Rapid Literature Review of Multi-Criteria Decision Support Methods in the Context of One Health for All-Hazards Threat Prioritization.

Background: Multi-Criteria Decision Analysis (MCDA) is a decision support tool that can be used in public health emergency management. The use of a One Health lens in MCDA can support the prioritization of threats and interventions which cut across the human, animal, and environmental domains. Previous literature reviews have focused on creating a snapshot of MCDA methodological trends. Our study provides an update to the MCDA methods literature with key considerations from a One Health perspective and addresses the application of MCDA in an all-hazards decision-making context. Methods: We conducted a literature search on MEDLINE, EMBASE, SCOPUS, the CAB database, and a limited online gray literature search in partnership with a librarian from Health Canada. Articles were limited to those published in the year 2010 or later in a high-income setting (OECD member countries). Results: Sixty-two articles were included for synthesis. Of these articles, most were Canadian studies (20%); and prioritized health risks, threats, and interventions in the human domain (69%). Six commonly used prioritization criteria were identified: threat, health, intervention, strategic, social, and economic impact. Stakeholders were engaged in 85% of studies and commonly consisted of government groups, non-governmental groups, subject matter experts, and the public. While most articles (65%) included elements of One Health based on our definition, only 5 studies (9%) explicitly acknowledged One Health as a guiding principle for the study. Forty seven percentage of studies noted that MCDA was beneficial in supporting the decision-making process. Conclusion: Current literature on health prioritization presents some variability in the depth of integration of the One Health framework and on the use of various MCDA methodologies given prioritization objectives. Studies which applied a comprehensive One Health approach, prioritized disparate threats, or conducted cyclical prioritizations for governing bodies were broad in scope, but sparse. The results of our review indicate the need for better guidance on the integration of a One Health approach and the use of various MCDA methods given the main prioritization objectives.

Beyond Wellness Monitoring: Continuous Multiparameter Remote Automated Monitoring of Patients.

The pursuit of more efficient patient-friendly health systems and reductions in tertiary health services use has seen enormous growth in the application and study of remote patient monitoring systems for cardiovascular patient care. While there are many consumer-grade products available to monitor patient wellness, the regulation of these technologies varies considerably, with most products having little to no evaluation data. As the science and practice of virtual care continues to evolve, clinicians and researchers can benefit from an understanding of more comprehensive solutions capable of monitoring multiple biophysical parameters (eg, oxygen saturation, heart rate) continuously and simultaneously. These devices, herein referred to as continuous multiparameter remote automated monitoring (CM-RAM) devices, have the potential to revolutionise virtual patient care. Through seamless integration of multiple biophysical signals, CM-RAM technologies can allow for the acquisition of high-volume big data for the development of algorithms to facilitate early detection of negative changes in patient health status and timely clinician response. In this article, we review key principles, architecture, and components of CM-RAM technologies. Work to date in this field and related implications are also presented, including strategic priorities for advancing the science and practice of CM-RAM.

Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation.

OBJECTIVE: Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes. INTERVENTIONS: The use of procalcitonin-guided antibiotic therapy. METHODS AND MAIN RESULTS: We searched computerized databases, reference lists of pertinent articles, and personal files. We included randomized controlled trials conducted in the intensive care unit that compared a procalcitonin-guided strategy to usual care and reported on antibiotic utilization and clinically important outcomes. Results were qualitatively and quantitatively summarized. On the basis of no effect in hospital mortality or hospital length of stay, a cost or cost-minimization analysis was conducted using the costs of procalcitonin testing and antibiotic acquisition and administration. Costs were determined from the literature and are reported in 2009 Canadian dollars. Five articles met the inclusion criteria. Procalcitonin-guided strategies were associated with a significant reduction in antibiotic use (weighted mean difference -2.14 days, 95% confidence interval -2.51 to -1.78, p < .00001). No effect was seen of a procalcitonin-guided strategy on hospital mortality (risk ratio 1.06, 95% confidence interval 0.86-1.30, p = .59; risk difference 0.01, 95% confidence interval -0.04 to +0.07, p = .61) and intensive care unit and hospital lengths of stay. The cost model revealed that, for the base case scenario (daily price of procalcitonin Can$49.42, 6 days of procalcitonin measurement, and 2-day difference in antibiotic treatment between procalcitonin-guided therapy and usual care), the point at which the cost of testing equals the cost of antibiotics saved is when daily antibiotics cost Can$148.26 (ranging between Can$59.30 and Can$296.52 on the basis of different assumptions in sensitivity analyses). CONCLUSIONS: Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality.

A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies.

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.