Innovation in resident education - Description of the Neurology International Residents Videoconference and Exchange (NIRVE) program.

There is considerable heterogeneity in residency education around the world. The Neurology International Residents Videoconference and Exchange (NIRVE) program aims to deliver neurology educational content to residents across different resource settings and countries through a monthly videoconferencing platform. Its purpose is to fill gaps in didactic teaching, increase exposure to a variety of cases including various practices and delivery of neurology in multiple countries, as well as integrate global health content into neurology education. NIRVE also facilitates resident exchanges among participating sites. In this descriptive article, we report NIRVE's structure and its cumulative productivity. Since its creation, NIRVE has held more than 90 videoconference rounds and has connected 16 sites in North America, South America, Europe, Asia and Africa. We describe challenges encountered since the inception of the program eleven years ago. NIRVE also fosters a culture of long-term international connection and collaboration. During global disease outbreaks, such as the current COVID-19 pandemic, videoconference rounds serve as a sustainable alternative means to deliver education. Future goals include increasing the number of sites involved, including a focus on Africa and Asia, and fostering resident-led advocacy projects.

Risk of Mortality in Immigrants with Multiple Sclerosis in Ontario, Canada.

INTRODUCTION: Little is known about how mortality in multiple sclerosis (MS) may differ based on sociodemographic factors, such as immigrant status. We compared mortality in immigrants versus long-term residents with MS in Ontario, Canada. METHODS: In this retrospective cohort study, we applied a validated algorithm to linked, population-based immigration and health administrative data to identify incident MS cases in Ontario between 1994 and 2014. We identified date of death, if it occurred. We used a Cox model adjusting for age, sex, income, and comorbidity, to compare survival in immigrants versus long-term residents. RESULTS: There were 23,603 incident MS cases of whom 1,410 (6.0%) were immigrants. After adjusting for covariates, risk of death was higher in immigrants in the first year after diagnosis (hazard ratio [HR] 1.66; 95% CI 1.05-2.63, p = 0.031). However, in years 1-5 (HR 0.63; 95% CI 0.40-0.98, p = 0.041) and 5-10 (HR 0.42; 95% CI 0.24-0.75, p = 0.003) after diagnosis, risk of death was lower in immigrants. Older age at onset and comorbidity were associated with higher mortality; female sex and higher socioeconomic status were associated with lower mortality. CONCLUSIONS: In this large population with universal access to health care, immigrants with MS had higher mortality compared to long-term residents in the first year after onset and lower mortality thereafter. Lower mortality in immigrants to Canada is well described and thought to be due to the healthy immigrant effect. Higher mortality in the first year after MS onset warrants further investigation as some early deaths may be preventable.

Patterns of care and outcomes after computed tomography scans for headache.

BACKGROUND: concerns exist about potential overuse of computed tomography (CT) scans for headache in ambulatory care. METHODS: we sought to examine health services use, brain tumor diagnosis, and death during the year after CT scanning for headache by linking records of an audit of 3930 outpatient CT brain scans performed in 2005 in Ontario, Canada, to administrative databases. RESULTS: of 623 patients receiving CT scans for a sole indication of headache, few (2.1%) scans contained findings potentially causing their headache. For most patients, the index CT scan was the only one received over an 11-year period. However, 28.4% of patients received 1 or more CT brain scans during the preceding decade and 6.7% received 1 or more CT brain scans during the subsequent year. Of the 473 patients (75.9%) whose index scan was ordered by a primary care physician, most (80.3%) did not see a specialist during follow-up. One patient with an indeterminate finding on the index scan was diagnosed with a malignant brain tumor (0.2%), and 6 patients (1.0%) died during follow-up. Among the 4 deaths in which the cause could be determined, none were due to central nervous system causes. CONCLUSION: because of the potential risk of cancer from exposure to ionizing radiation, efforts should be made to avoid CT scanning for headache when the likelihood of serious illness is low. Evidence-based decision rules that identify which patients with headache do not require neuroimaging may decrease the use of CT scans in situations of little benefit.

Increasing use of disease modifying drugs for MS in Canada.

BACKGROUND/OBJECTIVES: The course of multiple sclerosis may be slowed by use of the disease modifying drugs (DMDs): subcutaneous or intramuscular interferon beta-1a, interferon beta-1b, glatiramer acetate, and natalizumab. We set out to compare utilization of these drugs in the Canadian provinces from 2002-2007. METHODS: Using a retrospective cohort analysis, we reviewed population data from International Medical Statistics (IMS) Health between November 2001 and October 2007. RESULTS: The total annual number of DMD prescriptions increased from 3.9, in 2002, to 5.1, in 2007, per 1,000 Canadians. The total annual cost of prescriptions rose from $187 million to $287 million. Of the four provinces responsible for the majority of prescriptions--Alberta, BC, Ontario, and Quebec--Quebec had the highest average annual prescription rate (7 per 1,000 population) and BC had the lowest rate (3.3 per 1,000 population). Subcutaneous interferon beta-1a was the most commonly used drug whereas glatiramer acetate showed the greatest growth in use from 2002 to 2007. CONCLUSIONS: Disease modifying drugs prescription rates and costs increased by more than 30% between 2002 and 2007. There was wide variation in DMD prescription rates and relative drug preferences across the provinces.

Where does the waiting list begin? A short review of the dynamics and organization of modern waiting lists.

Waiting for medical care is the by-product of system rationing, where demand exceeds supply. In this short report we expand on the conventional concept of the queue, by focusing on the regulation of demand and by incorporating a funnel and spout analogy. Real-world examples are used to illustrate the infancy of funnel or demand-side reform initiatives targeting the queue, and the suggestion is made that policy needs to address the concept of 'waiting' much earlier in the treatment cycle.

Differences between systematic reviews and health technology assessments: a trade-off between the ideals of scientific rigor and the realities of policy making.

OBJECTIVES: To elucidate important differences between a health technology assessment (HTA) and a systematic review, using an HTA of positron emission tomography (PET) as an example. METHODS: Interviews with seventeen individuals who were authors or users of the PET HTA. RESULTS: Those interviewed identified seven areas in which HTAs often differ from traditional systematic reviews: (i) methodological standards (HTAs may include literature of relatively poor methodological quality if a topic is of importance to decision-makers), (ii) replication of previous studies (relatively common for HTAs but not systematic reviews), (iii) choice of topics (more policy oriented for HTAs, while systematic reviews tend to be driven by researcher interest), (iv) inclusion of content experts and policy-makers as authors (policy-makers more likely to be included in HTAs, although there are potential conflicts of interest), (v) inclusion of economic evaluations (more often with HTAs, although economic evaluations based upon poor clinical data may not be useful), (vi) making policy recommendations (more likely with HTAs, although this must be done with caution), and (vii) dissemination of the report (more often actively done for HTAs). CONCLUSIONS: This case study of an HTA of PET scanning confirms that HTAs are a bridge between science and policy and require a balance between the ideals of scientific rigor and the realities of policy making.