Spine surgeons' requirements for imaging at the time of referral: a survey of Canadian spine surgeons.

BACKGROUND: Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals. METHODS: We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints. RESULTS: Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints. CONCLUSION: Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.

CONTEXTE: Le recours systématique aux épreuves d'imagerie chez les patients qui se plaignent de maux de dos et qui sont référés pour consultation en chirurgie pourrait constituer une utilisation inefficace des ressources technologiques. Notre objectif était d'analyser les épreuves d'imagerie demandées par les chirurgiens canadiens spécialistes de la colonne vertébrale, suite aux demandes de consultation qui leur sont adressées pour des patients qui ont des problèmes de colonne vertébrale. MÉTHODES: Nous avons administré un sondage en 8 questions aux 100 chirurgiens en pratique active qui forment la Canadian Spine Society; le questionnaire portait sur des variables démographiques et sur les demandes d'épreuves d'imagerie pour les patients qui leur sont référés pour des maux de dos. RÉSULTATS: Cinquante-cinq chirurgiens de la colonne ont répondu à notre sondage, pour un taux de réponse de 55 %. La plupart des répondants (43; 78 %) ont dit demander des épreuves d'imagerie pour toutes les références qui leur sont adressées pour des problèmes de colonne vertébrale. Les types d'épreuves d'imagerie demandés variaient considérablement et les répondants ont mentionné 7 combinaisons d'épreuves différentes. La moitié d'entre eux (47 %) demandaient une imagerie par résonnance magnétique et 38 % demandaient des radiographies ordinaires, seules ou combinées à d'autres modalités d'imagerie. La moitié des répondants ont dit refuser de voir 20 % ou plus de tous les patients qui leur étaient référés pour des maux de dos. CONCLUSION: La plupart des chirurgiens spécialistes de la colonne vertébrale au Canada demandent des épreuves d'imagerie pour tous les patients qui leur sont référés pour des problèmes de colonne vertébrale; toutefois, les types d'épreuves et leurs combinaisons sont très variables et de nombreux patients qui sont référés en consultation ne réussissent jamais à voir les spécialistes. La standardisation et l'optimisation des pratiques au chapitre de l'imagerie pour les patients qui souffrent de maux de dos et qui sont référés à un chirurgien représentent un poste budgétaire important où des économies pourraient être réalisées.

Temporal Trends in Spinal Imaging in Ontario (2002-2019) and Manitoba (2001-2011), Canada.

Background Several studies have reported the overuse of spinal imaging, which, in Canada, led to several provincial pathways aimed at optimizing the use of imaging. We assessed temporal trends in spine imaging in two Canadian provinces. Methods We explored the use of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) examinations of the cervical, thoracic, and lumbar spine regions among adults in Ontario (April 1, 2002, to March 31, 2019) and in Manitoba, Canada (April 1, 2001, to March 31, 2011) using linked Ontario Health Insurance Plan administrative databases and data from Manitoba Health. We calculated the age- and sex-adjusted rates of spinal X-ray, CT, and MRI examinations by dividing the number of imaging studies by the population of each province for each year and estimated the use of each imaging modality per 100,000 persons. Results The total cost of spine imaging in Ontario increased from $45.8 million in 2002/03 to $70.3 million in 2018/19 (a 54% increase), and in Manitoba from $2.2 million in 2001/02 to $5 million in 2010/11 (a 127% increase). In Ontario, rates of spine X-rays decreased by 12% and spine CT scans decreased by 28% over this time period, while in Manitoba, rates of spine X-rays and CT scans remained constant. Age- and sex-adjusted utilization of spinal MRI scans per 100,000 persons markedly increased over time in both Ontario (277%) and Manitoba (350%). Conclusion Despite efforts to reduce the use of inappropriate spinal imaging, both Ontario and Manitoba have greatly increased utilization of spine MRI in the past two decades.

An International Perspective on Preceding Infections in Guillain-Barré Syndrome: The IGOS-1000 Cohort.

BACKGROUND AND OBJECTIVES: Infections play a key role in the development of Guillain-Barré syndrome (GBS) and have been associated with specific clinical features and disease severity. The clinical variation of GBS across geographical regions has been suggested to be related to differences in the distribution of preceding infections, but this has not been studied on a large scale. METHODS: We analyzed the first 1,000 patients included in the International GBS Outcome Study with available biosamples (n = 768) for the presence of a recent infection with Campylobacter jejuni, hepatitis E virus, Mycoplasma pneumoniae, cytomegalovirus, and Epstein-Barr virus. RESULTS: Serologic evidence of a recent infection with C. jejuni was found in 228 (30%), M. pneumoniae in 77 (10%), hepatitis E virus in 23 (3%), cytomegalovirus in 30 (4%), and Epstein-Barr virus in 7 (1%) patients. Evidence of more than 1 recent infection was found in 49 (6%) of these patients. Symptoms of antecedent infections were reported in 556 patients (72%), and this proportion did not significantly differ between those testing positive or negative for a recent infection. The proportions of infections were similar across continents. The sensorimotor variant and the demyelinating electrophysiologic subtype were most frequent across all infection groups, although proportions were significantly higher in patients with a cytomegalovirus and significantly lower in those with a C. jejuni infection. C. jejuni-positive patients were more severely affected, indicated by a lower Medical Research Council sum score at nadir (p = 0.004) and a longer time to regain the ability to walk independently (p = 0.005). The pure motor variant and axonal electrophysiologic subtype were more frequent in Asian compared with American or European C. jejuni-positive patients (p < 0.001, resp. p = 0.001). Time to nadir was longer in the cytomegalovirus-positive patients (p = 0.004). DISCUSSION: Across geographical regions, the distribution of infections was similar, but the association between infection and clinical phenotype differed. A mismatch between symptom reporting and serologic results and the high frequency of coinfections demonstrate the importance of broad serologic testing in identifying the most likely infectious trigger. The association between infections and outcome indicates their value for future prognostic models.

Building a safety and quality culture in healthcare: where it starts.

Healthcare in Canada underachieves stakeholders' expectations for safe, high-quality care. The authors maintain that a common understanding of, and vision for, what is required to achieve improved outcomes for patients is missing. Educating tomorrow's healthcare professionals is paramount to address this critical shortfall. However, healthcare educational institutions must themselves break out of a 20th-century paradigm of viewing healthcare safety and quality as functions of individual healthcare providers rather than as properties of the clinical micro- and meso-systems within which they function and are a part. Canadian healthcare systems are ailing; like treating a sick patient, interventions should be grounded on a solid understanding of anatomy (structure) and physiology (function). The Healthcare Encounter Safety and Quality Model (HESQM) highlights the structures underlying healthcare delivery and the key system functions required to achieve safe, high-quality care. The model has been used to frame the University of Calgary Faculty of Medicine's educational strategy for achieving safer, higher-quality care. The HESQM is based on leadership - leaders whose decisions and actions are guided by core safety and quality principles. Today's and especially tomorrow's healthcare leaders require a common understanding of how to achieve higher-performing healthcare systems; it is the responsibility of Canada's post-secondary institutions to deliver it.

Identifying patients with post-discharge care problems using an interactive voice response system.

INTRODUCTION: Adverse events (AEs) are poor outcomes caused by medical care. They occur in 20% of medical patients following hospital discharge. We designed an interactive voice response system (IVRS) with the intent of identifying patients who might be experiencing an AE following discharge or were at risk of developing one. OBJECTIVES: We determined the proportion of post-discharge patients requiring an intervention after identifying potential problems using the IVRS, the relationship between IVRS responses and AE occurrence, and patients' opinions of the IVRS call. METHODS: We studied patients discharged from the general medical service of an academic hospital. The IVRS called patients 2 days post-discharge and asked three questions to determine the need for nurse follow-up. We contacted patients 30 days later to elicit AE status and perceptions of the IVRS. RESULTS: Our cohort consisted of 270 elderly patients [median 64 years (IQR 50-76)] with multiple co-morbidities. Responses to the IVRS identified 57 patients (21%, 95% CI 17%-27%) for follow-up. When contacted by a nurse, 25 patients (9%, 95% CI 6%-13%) actually required an intervention. At 30-day follow-up, AEs occurred in 33 patients (12%, 95% CI 8%-17%). Only three AEs (9%) were identified by the IVRS; the remainder occurred before or after the IVRS call. Patients remembering the IVRS call found it easy to use (97%), and a minority would prefer a person to call (8%). CONCLUSION: An IVRS-based method of monitoring was acceptable to patients and identified a significant proportion requiring changes in management. However, the method identified only a minority of AEs. To have a significant improvement in care, this method will need to be combined with other interventions.

Real-world replication of randomized controlled trial results for carotid endarterectomy.

BACKGROUND: The efficacy of carotid endarterectomy (CE) has been shown in randomized clinical trials (RCTs), but doubts remain about whether the results can be replicated in routine clinical practice, especially in asymptomatic patients for whom the absolute risk reduction shown in the trials is small. In particular, a low rate of short-term adverse events is required for the long-term benefits of CE to accrue over time. OBJECTIVE: To determine whether the incidence of short-term adverse events after CE met the standards established by the major RCTs and those recommended by major clinical practice guidelines. Design, Setting, and Patients We used clinically detailed data derived from a comprehensive medical record review to measure the short-term adverse outcomes of CE, focusing on in-hospital death and stroke, in 3283 cases in western Canada in 2000 and 2001, and compared the results with those from the RCTs. RESULTS: For symptomatic patients, the in-hospital ischemic stroke or death rate was 3.9%; for asymptomatic patients, the rate was 2.6%. Extrapolating our in-hospital results to the 30-day post-CE results of the RCTs gave stroke or death rates of 4.9% for cases involving symptomatic patients and 4.1% for cases involving asymptomatic patients. These results are comparable to or better than those of the major RCTs for symptomatic patients but slightly worse for asymptomatic patients. About 45% of hospitals had adverse event rates higher than those recommended by authoritative clinical practice guidelines. CONCLUSIONS: This large population-based study shows that the RCT results for CE can be achieved in the real world. However, the finding that some hospitals exceeded the maximum suggested rates of adverse events highlights the need for continuous outcome monitoring and associated quality improvement efforts to ensure that all providers and institutions involved achieve desired outcomes.

Evidence-based guidelines on the use of intravenous immune globulin for hematologic and neurologic conditions.

In Canada, intravenous immune globulin (IVIG) use has increased by 115% over the past 7 to 8 years. Given this increased usage, Canadian Blood Services and the National Advisory Committee on Blood and Blood Products for Canada identified the need to develop and disseminate evidence-based guidelines to facilitate appropriate IVIG use. As a result, guidelines for IVIG use in hematologic and neurologic conditions have been developed and are published in this supplement of Transfusion Medicine Reviews. This commentary provides a brief description of the process used to develop these guidelines and includes a summary of the recommendations for IVIG use in the various conditions evaluated.

Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Due to uncertain evidence, lumbar fusion for degenerative indications is associated with the greatest measured practice variation of any surgical procedure. OBJECTIVE: To summarize the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications. METHODS: A systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models. RESULTS: The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality. CONCLUSION: Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153).

Evidence for small fiber neuropathy in early Parkinson's disease.

INTRODUCTION: Parkinson's disease (PD) is neurodegenerative movement disorder affecting primarily the central nervous system with several recognized non-motor symptoms that can occur at various stages of the disease. Recently it has been shown that patients with PD may be prone to peripheral nervous system pathology in the form of a peripheral neuropathy (PN). It is unclear if PN is an inherent feature of PD or if it is an iatrogenic effect of the mainstay PD treatment Levodopa. METHODS: To determine if peripheral neuropathy occurs in early untreated PD we employed a case-control study design using gold standard tests for PN, including neurological examination according to the Utah Early Neuropathy Scale (UENS) and nerve conduction studies, as well as new, more sensitive and informative tests for PN including the skin biopsy and corneal confocal microscopy (CCM). RESULTS: We studied 26 patients with PD and 22 controls using the neurological examination and nerve conduction studies (NCS) and found no significant difference between groups except for some reduced vibration sense in the PD group. Epidermal nerve densities in the skin biopsies were similar between our cohorts. However, using CCM - a more sensitive test and a surrogate marker of small fiber damage in PN, we found that patients with PD had significantly reduced corneal nerve fiber densities and lengths as compared to controls. CONCLUSIONS: We conclude that our positive CCM results provide evidence of preclinical PN in newly diagnosed PD patients.

Statins are associated with better outcomes after carotid endarterectomy in symptomatic patients.

BACKGROUND AND PURPOSE: Statins have been associated with a reduction in mortality from noncardiac surgery. This study aimed to determine whether statin use on admission to hospital for carotid endarterectomy was associated with a reduction of in-hospital adverse outcomes. METHODS: Data describing patient characteristics, surgical indication, statin treatment, and in-hospital outcomes of death, ischemic stroke or death and cardiac outcomes were collected from a chart review of all patients (3360) undergoing carotid endarterectomy in Western Canada from January 2000 to December 2001. Outcomes of patients on statins versus those not on statins were compared using logistic regression to account for differences in patient characteristics, and propensity score methods to account for factors influencing patient allocation to statins. RESULTS: Eight hundred and fifteen of 2031 symptomatic patients and 665 of 1252 asymptomatic patients were on a statin at the time of hospital admission. Statin use by symptomatic patients was associated with reduced in-hospital mortality and in-hospital ischemic stroke or death, but not in-hospital cardiac outcomes (adjusted odds ratio 0.25 [CI, 0.07 to 0.90], 0.55 [CI, 0.32 to 0.95], 0.87 [CI, 0.49 to 1.54], respectively). The improvement in outcomes was robust when tested using propensity score matching. This association was not seen in asymptomatic patients on statins (adjusted odds ratio, in-hospital mortality 0.54 [CI, 0.13 to 2.24]; in-hospital ischemic stroke or death 1.34 [CI, 0.61 to 2.93]; in-hospital cardiac outcomes 1.37 [CI, 0.73 to 2.58]). CONCLUSIONS: These findings are suggestive of a protective effect of statin therapy in symptomatic patients pre-treated at the time of carotid endarterectomy, though this needs confirmation in a randomized controlled trial.

Hospital and surgeon determinants of carotid endarterectomy outcomes.

BACKGROUND: Prior studies have found associations between surgeon and hospital case volumes and outcomes after carotid endarterectomy (CEA), but they have not simultaneously assessed the importance of a number of surgeon and hospital characteristics. OBJECTIVE: To simultaneously assess associations between hospital case volume, teaching status, clinical trial participation, and surgeon specialty and case volume and the outcome after CEA. DESIGN: Analysis of a large administrative data-base using logistic regression to correlate adverse outcomes after CEA with surgeon and hospital characteristics. SETTING AND PATIENTS: A Canadian administrative hospital discharge database of all patients undergoing CEA in fiscal years 1994 through 1997. MAIN OUTCOME MEASURES: In-hospital stroke and/or death. RESULTS: We found an inverse relationship between both hospital and surgeon case volumes and adverse outcomes. Teaching status had no association with outcome, but previous clinical trial participation predicted a better outcome. General surgeons fared worse than other specialists. Low-volume surgeons in low-volume hospitals had a relative risk of 3.5 for adverse outcomes compared with high-volume surgeons in high-volume hospitals. CONCLUSIONS: Several physician and hospital characteristics are determinants of outcome after CEA, but the negative effects of low hospital and surgeon case volumes, in particular, suggest that regionalization should be considered for CEA and that surgeons with low case volumes should not be performing CEA.

Provincial carotid endarterectomy outcomes.

BACKGROUND: Outcomes must be measured as a first step toward improving performance. We sought to measure the national and provincial outcomes from carotid endarterectomy (CE) and explain provincial differences. METHODS: We analyzed a large Canada-wide administrative hospital discharge database of all patients, except those in Quebec, receiving CE in 1994-1997 and used logistic regression for risk adjustment to measure adverse outcomes nationally and by province. Our main outcome measures were in-hospital stroke and/or death. RESULTS: A total of 14,268 patients underwent CE in the years 1994-1997. The overall death rate was 1.3% and the combined stroke and/or death rate was 4.1%. There was a trend towards improvement over the four years. The provinces of Saskatchewan and Newfoundland had significantly higher adverse event rates for the risk-adjusted combined outcome measure. CONCLUSIONS: The outcome of CE in Canada is good and showed improvement over four years. However, significant differences in provincial outcomes were found. This suggests that regionalization across provincial boundaries may be needed to promote higher surgeon and hospital case volumes and thus improve outcomes.

Carotid endarterectomy: a review.

BACKGROUND: Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEA results. INVESTIGATION: Brain imaging with CT or MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRA or CT angiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment. INDICATIONS: Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50-69% symptomatic stenosis, and those with asymptomatic stenosis > or = 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions. TECHNIQUES: Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. "Eversion" endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis. CAROTID ANGIOPLASTY AND STENTING: Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA. AUDITING: It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.

An audit tool for assessing the appropriateness of carotid endarterectomy.

BACKGROUND: To update appropriateness ratings for carotid endarterectomy using the best clinical evidence and to develop a tool to audit the procedure's use. METHODS: A nine-member expert panel drawn from all the Canadian Specialist societies that are involved in the care of patients with carotid artery disease, used the RAND Appropriateness Methodology to rate scenarios where carotid endarterectomy may be performed. A 9-point rating scale was used that permits the categorization of the use of carotid endarterectomy as appropriate, uncertain, or inappropriate. A descriptive analysis was undertaken of the final results of the panel meeting. A database and code were then developed to rate all carotid endarterectomies performed in a Western Canadian Health region from 1997 to 2001. RESULTS: All scenarios for severe symptomatic stenosis (70-99%) were determined to be appropriate. The ratings for moderate symptomatic stenosis (50-69%) ranged from appropriate to inappropriate. It was never considered appropriate to perform endarterectomy for mild stenosis (0-49%) or for chronic occlusions. Endarterectomy for asymptomatic carotid disease was thought to be of uncertain benefit at best. The majority of indications for the combination of endarterectomy either prior to, or at time of coronary artery bypass grafting were inappropriate. The audit tool classified 98.0% of all cases. CONCLUSIONS: These expert panel ratings, based on the best evidence currently available, provide a comprehensive and updated guide to appropriate use of carotid endarterectomy. The resulting audit tool can be downloaded by readers from the Internet and immediately used for hospital audits of carotid endarterectomy appropriateness.

Appropriateness of the use of intravenous immune globulin before and after the introduction of a utilization control program.

BACKGROUND: Intravenous immune globulin (IVIG) is an expensive and sometimes scarce blood product that carries some risk. It may often be used inappropriately. We evaluated the appropriateness of IVIG use before and after the introduction of an utilization control program to reduce inappropriate use. METHODS: We used the RAND/UCLA Appropriateness Method to measure the appropriateness of IVIG use in the province of British Columbia (BC) in 2001 and 2003, before and after the introduction of a utilization control program designed to reduce inappropriate use. For comparison, we measured the appropriateness of use during the same periods in the province of Alberta, which had no control program. RESULTS: Of 2256 instances of IVIG use, 54.1% were deemed to be appropriate, 17.4% were of uncertain benefit, and 28.5% were deemed inappropriate. The frequency of inappropriate use in BC after the introduction of the utilization control program did not differ significantly from the frequency before the program or the frequency in Alberta. INTERPRETATION: Almost half of IVIG use in BC and Alberta was judged to be inappropriate or of uncertain benefit, and the frequency of inappropriate use did not decrease after implementation of a utilization control program in BC. More effective utilization controls are necessary to prevent wasted resources and unnecessary risk to patients.

Chart documentation quality and its relationship to the validity of administrative data discharge records.

The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.