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.

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.

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.

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.

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.

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.

Complication rates after left- versus right-sided carotid endarterectomy.

BACKGROUND: Studies suggest that the side of carotid endarterectomy (CE) may influence the rate of postoperative complications. We sought to clarify this by (1) analysis of individual-level data from 3 large studies and (2) systematic review and meta-analysis of additional published descriptions of outcomes by side. METHODS AND RESULTS: The Western Canada Carotid Endarterectomy (WCCE) study (n=3164) was analyzed for outcomes by side along with data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET; n=1415), and the ASA [Acetylsalicylic Acid] in Carotid Endarterectomy Trial (ACE; n=2469). Pooled analysis of individual-level data from these three studies allowed calculation of rate ratios for stroke or death by side. Medline and EMBASE were searched to identify additional studies reporting CE outcomes by side, and an overall risk ratio for outcomes by side was determined with fixed-effects meta-analysis. The WCCE in-hospital stroke or death rates for left and right-sided CE were 3.72% and 3.07%, respectively (P=0.27). A pooled analysis of the NASCET and ACE trials also revealed higher stroke or death rates for left-sided CE (5.39% versus 2.96%; P<0.001). The corresponding risk-adjusted rate ratios for stroke or death for left- versus right-sided surgery were 1.22 (95% CI, 0.83 to 1.77) for WCCE and 1.82 (1.32 to 2.50) for the pooled NASCET and ACE trials. Systematic review of the literature identified 2 additional studies. Meta-analysis of all 5 available studies yielded a corresponding pooled rate ratio for stroke or death of 1.36 (1.18 to 1.56). CONCLUSIONS: Left-sided CE is consistently associated with higher postoperative adverse event rates. Research into potential mechanisms is required to explain and address this finding.

Management of MRI wait lists in Canada.

Excessive wait times for magnetic resonance imaging (MRI) studies are a major problem in the Canadian healthcare system. To determine how requests for MRI studies are managed, the authors performed a survey of public MRI facilities in Canada. Ninety-six per cent had some method to triage MRI requests. However, only 42% had documented guidelines for prioritization, and none employed quality assurance methods to ensure that guidelines were followed. Target timelines for each prioritization category varied widely. Sixteen per cent of centres were not able to meet their target timelines for any prioritization category, and 45% of centres met target times only for some prioritization categories. Strategies for dealing with wait lists primarily involved attempts to increase capacity. No centres attempted to reduce wait times by decreasing inappropriate requests. There appears to be a need to standardize MRI wait list management given the variation in management practices and wait times observed.

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.

Automated patient assessments after outpatient surgery using an interactive voice response system.

OBJECTIVE: To test the feasibility and utility of an interactive voice response system (IVRS) for monitoring patients after outpatient surgery. METHODS: We studied consecutive patients undergoing gynecologic day surgery. The IVRS called patients on the first postoperative day and asked them if they were experiencing new problems. Feasibility was assessed in terms of call responses and acceptance by patients. Utility was measured in terms of the ability of the IVRS to identify adverse events (AEs), defined as procedure-related symptoms requiring a physician or hospital visit. We contacted patients 30 days later to elicit their perceptions of the IVRS and determine AE status. RESULTS: Follow-up was complete for 249 of 270 enrolled patients (92%). The IVRS successfully contacted 130 patients (52%). Of the 22 patients (17%) who required a follow-up phone call, 9 had a new problem related to surgery, 7 had new or worsening symptoms, 6 wanted to speak with a nurse, and 1 had a medication-related problem. Patients remembering the automated call (n = 96) reported the system easy to use (82%) and comprehend (86%). Most patients (68%) preferred the IVRS to a personal follow-up call (probability greater than 50%, P <.001). AEs occurred in 40 patients (16%; 95% confidence interval = 12%, 21%). The IVRS did not identify any AEs because 90% of these occurred after the automated call. CONCLUSION: An IVRS-based method of monitoring outpatient surgery patients is feasible. To improve utility, calls must occur later than first postoperative day.

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.