Identifying barriers to care for complex airway disease and multidisciplinary solutions to optimize therapy in Canada.

BACKGROUND: Complex airway disease such as Chronic Rhinosinusitis with Asthma or Aspirin Exacerbated Respiratory Disease requires a multidisciplinary approach to management and treatment. Many centers in the USA have created collaborative multidisciplinary clinics to support the management of these patients; however, similar structures do not appear to exist in Canada. METHODS: This mixed methods study used a combination of structured interviews and a cross-sectional national survey. Interviewees included members of the Canadian Rhinology Working Group and survey participants were a combination of academic and community Rhinologists, Respirologists and Allergists. All participation was voluntary and selection criteria was based on their involvement in treating complex airway disease. Our objective was to identify the current state of diagnosis and treatment of complex airway patients in Canada between Rhinology, Respirology and Allergy and understand the barriers, challenges and propose solutions to establishing a multidisciplinary airway clinic in Canada. RESULTS: Four Rhinologists participated in qualitative interviews and a convenience sample of 42 specialists through our known network responded to our quantitative survey. From our survey, 54.8% believed multidisciplinary clinics were necessary in the management of complex airway disease, providing better outcomes and cost-savings (69%, 45.2%). Most specialties agreed that history, physical, pulmonary function and skin prick testing was important for diagnosis (92.9%, 92.9%, 88.1%). If clinicians were to participate in a multidisciplinary clinic, they would be willing to forego an average of 14.2% of their mean daily income for that clinic. The ideal clinic location was split between a neutral shared location vs. a Rhinology clinic space (38.1%, 45.2%). CONCLUSIONS: Complex airway diseases are currently managed in subspecialty silos resulting in fragmented care. Our study highlights gaps in management, areas for improvement and support for establishing multidisciplinary complex airway disease clinics in Canada to better treat this population.

Selective laser trabeculoplasty vs. topical medications for step-up treatment in primary open angle glaucoma: comparing clinical effectiveness, quality of life and cost-effectiveness.

INTRODUCTION: The aim of this study was to investigate the clinical effectiveness, health related quality of life (HRQoL) and cost effectiveness of selective laser trabeculoplasty (SLT) compared to topical anti-glaucoma medications in step-up treatment of patients with primary open angle glaucoma (POAG). METHODS: Seventeen POAG patients with suboptimal IOP control despite pre-existing topical medications were subjected to adjunct SLT (50 applications 180 degrees) or second line medical therapy. Current medications were continued, and patients were followed up for 6 months for degree of intraocular pressure (IOP) lowering. HRQoL was assessed using Glaucoma Quality of Life 36-item (GlauQoL-36), Assessment of Quality of Life-7D (AQoL-7D) and Vision related Quality of Life (VisQoL). Costs involved were calculated and compared to the effect (IOP reduction) achieved in each arm. RESULTS: Ten patients were in the SLT group and 7 in the topical medication (MED) group. Mean baseline intraocular pressure (IOP) was 18.90±3.48mmHg in SLT group and 15.57±2.23mmHg in MED group. Mean reduction of IOP was 4.30±1.64mmHg in SLT group and 2.71±2.56 mmHg in MED group at 6 months which was not statistically significant (p=0.14) between two groups. All the HRQoL questionnaires did not show significant changes in the groups or between groups when compared baseline with 6-month post treatment (p-values ranging from 0.247 to 0.987). For every 1mmHg reduction in IOP, cost involved in MED group (RM53.61) was 165% of the cost involved in SLT group (RM32.56). DISCUSSION AND CONCLUSION: This study has shown that SLT was as effective clinically and tolerable as topical anti glaucoma medications and was possibly more cost effective in the step-up treatment of patients with POAG at 6 months follow- up.

Mortality following bone metastasis and skeletal-related events among men with prostate cancer: a population-based analysis of US Medicare beneficiaries, 1999-2006.

Information on the impact of bone metastasis and skeletal-related events (SREs) on mortality among prostate cancer patients is limited. Using the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified men aged 65 years or older diagnosed with prostate cancer between July 1 1999 and December 31 2005 and followed to determine deaths through December 31 2006. We classified subjects as having bone metastasis and SREs as indicated by Medicare claims. Using Cox regression, we estimated mortality hazards ratios (HR) among men with bone metastasis with or without SRE, compared with men without bone metastasis. Among 126,978 men with prostate cancer (median follow-up, 3.3 years), 9746 (7.7%) had bone metastasis at prostate cancer diagnosis (1.7%) or during follow-up (5.9%). SREs occurred in 4296 (44%) men with bone metastasis. HRs for risk of death were 6.6 (95% CI=6.4-6.9) and 10.2 (95% CI=9.8-10.7), respectively, for men with bone metastasis but no SRE and for men with bone metastasis plus SRE, compared with men without bone metastasis. Bone metastasis was associated with mortality among prostate cancer patients. This association appeared to be stronger for bone metastasis plus SRE than for bone metastasis without SRE.