Cost-Utility Analysis of the Ontario Fracture Screening and Prevention Program.

BACKGROUND: The Fracture Screening and Prevention Program (FSPP), a fracture liaison service (FLS), was implemented in the province of Ontario, Canada, in 2007 to prevent recurrent fragility fractures and to improve post-fracture care. The objective of this analysis was to determine the cost-effectiveness of the current model of the FSPP compared with usual care (no program) from the perspective of the universal public health-care payer (Ontario Ministry of Health and Long-Term Care [MOHLTC]), over the lifetime of older adults who presented with a fragility fracture of the proximal part of the femur, the proximal part of the humerus, or the distal part of the radius and were not taking medications to prevent or slow bone loss and reduce the risk of fracture (bone active medications). METHODS: We developed a state-transition (Markov) model to conduct a cost-effectiveness analysis of the FSPP in comparison with usual care. The model simulated a cohort of patients with a fragility fracture starting at 71 years of age. Model parameters were obtained from published literature and from the FSPP. Quality-adjusted life-years (QALYs) and costs in 2018 Canadian dollars were predicted over a lifetime horizon using a 1.5% annual discount rate. Health outcomes included subsequent proximal femoral, vertebral, proximal humeral, and distal radial fractures. Scenario and subgroup analyses were reported. RESULTS: The FSPP had lower expected costs ($277 less) and higher expected effectiveness (by 0.018 QALY) than usual care over the lifetime horizon. Ninety-four percent of the 10,000 Monte Carlo simulated incremental cost-effectiveness ratios (ICERs) demonstrated lower costs and higher effectiveness of the FSPP. CONCLUSIONS: The FSPP appears to be cost-effective compared with usual care over a lifetime for patients with fragility fracture. This information may help to quantify the value of the FSPP and to assist policy-makers in deciding whether to expand the FSPP to additional hospitals or to initiate similar programs where none exist. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Beliefs related to Pap smear intention among Jamaicans: A qualitative research study.

ABSTRACT: Globally, most women who are diagnosed with cervical cancer do not obtain regular screening with the Pap smear/test. Women in developing countries have high cervical cancer incidence and mortality. Therefore, a qualitative research study was conducted to determine the referents, and salient and control beliefs related to Pap smear/test intention among Jamaicans.

Factors associated with screening positive for high falls risk in fragility fracture patients: a cross-sectional study.

BACKGROUND: We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk. METHODS: The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression. RESULTS: Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50-64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk. CONCLUSIONS: Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted.

PROM-ED: Development and Testing of a Patient-Reported Outcome Measure for Emergency Department Patients Who Are Discharged Home.

STUDY OBJECTIVE: Common outcomes of care valued by emergency department (ED) patients who are not hospitalized have been characterized, but no measurement instrument has been developed to date. We developed and validated a patient-reported outcome measure for use with adult ED patients who are discharged home (PROM-ED). METHODS: In previous research, 4 main outcomes of importance to ED patients were defined: symptom relief, understanding, reassurance, and having a plan. We developed a bank of potential questions (phase 1) that were first tested for suitability through cognitive debriefing with patients (phase 2). Revised questions were then tested quantitatively with a large panel of participants who had recently received ED care (phase 3). Informed by these results, a panel of experts used a modified Delphi process to make decisions on item reduction. The resulting instrument (PROM-ED 1.0) was then evaluated for its measurement properties (structural validity, hypothesis testing, and reliability). RESULTS: Sixty-seven questions divided among 4 scales (1 for each outcome domain) were assembled. In accordance with cognitive debriefing with 8 patients (phase 2), 15 questions were modified and 13 removed. Testing of these questions with 444 participants (phase 3) identified problematic floor or ceiling effects (n=10), excessive correlations between items (n=11), and low item-total correlations (n=7). The expert panel (22 participants, phase 4) made decisions using this information on the exclusion of items, resulting in 22 questions across 4 scales that together constitute the PROM-ED 1.0. Testing provided good evidence of validity and test-retest reliability (n=200). CONCLUSION: The PROM-ED enables the measurement of patient-centered outcomes of importance to patients receiving care in the ED who are not hospitalized. These data could have important applications in research and care improvement.

Telemedicine delivery of patient education in remote Ontario communities: feasibility of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-led inflammatory arthritis education program.

OBJECTIVE: Telemedicine-based approaches to health care service delivery improve access to care. It was recognized that adults with inflammatory arthritis (IA) living in remote areas had limited access to patient education and could benefit from the 1-day Prescription for Education (RxEd) program. The program was delivered by extended role practitioners with advanced training in arthritis care. Normally offered at one urban center, RxEd was adapted for videoconference delivery through two educator development workshops that addressed telemedicine and adult education best practices. This study explores the feasibility of and participant satisfaction with telemedicine delivery of the RxEd program in remote communities. MATERIALS AND METHODS: Participants included adults with IA attending the RxEd program at one of six rural sites. They completed post-course program evaluations and follow-up interviews. Educators provided post-course feedback to identify program improvements that were later implemented. RESULTS: In total, 123 people (36 in-person and 87 remote, across 6 sites) participated, attending one of three RxEd sessions. Remote participants were satisfied with the quality of the video-conference (% agree/strongly agree): could hear the presenter (92.9%) and discussion between sites (82.4%); could see who was speaking at other remote sites (85.7%); could see the slides (95.3%); and interaction between sites adequately facilitated (94.0%). Educator and participant feedback were consistent. Suggested improvements included: use of two screens (speaker and slides); frontal camera angles; equal interaction with remote sites; and slide modifications to improve the readability on screen. Interview data included similar constructive feedback but highlighted the educational and social benefits of the program, which participants noted would have been inaccessible if not offered via telemedicine. CONCLUSION: Study findings confirm the feasibility of delivering the RxEd program to remote communities by using telemedicine. Future research with a focus on the sustainability of this and other models of technology-supported patient education for adults with IA across Ontario is warranted.

A prospective comparison of telemedicine versus in-person delivery of an interprofessional education program for adults with inflammatory arthritis.

Introduction We evaluated two modes of delivery of an inflammatory arthritis education program ("Prescription for Education" (RxEd)) in improving arthritis self-efficacy and other secondary outcomes. Methods We used a non-randomized, pre-post design to compare videoconferencing (R, remote using telemedicine) versus local (I, in-person) delivery of the program. Data were collected at baseline (T1), immediately following RxEd (T2), and at six months (T3). Self-report questionnaires served as the data collection tool. Measures included demographics, disorder-related, Arthritis Self-Efficacy Scale (SE), previous knowledge (Arthritis Community Research and Evaluation Unit (ACREU) rheumatoid arthritis knowledge questionnaire), coping efficacy, Illness Intrusiveness, and Effective Consumer Scale. Analysis included: baseline comparisons and longitudinal trends (R vs I groups); direct between-group comparisons; and Generalized Estimating Equations (GEE) analysis. Results A total of 123 persons attended the program (I: n = 36; R: n = 87) and 111 completed the baseline questionnaire (T1), with follow-up completed by 95% ( n = 117) at T2 and 62% ( n = 76) at T3. No significant baseline differences were found across patient characteristics and outcome measures. Both groups (R and I) showed immediate effect (improved arthritis SE, mean change (95% confidence interval (CI)): R 1.07 (0.67, 1.48); I 1.48 (0.74, 2.23)) after the program that diminished over six months (mean change (95% CI): R 0.45 (-0.1, 0.1); I 0.73 (-0.25, 1.7)). For each of the secondary outcomes, both groups showed similar trends for improvement (mean change scores (95% CI)) over time. GEE analysis did not show any meaningful differences between groups (R vs I) over time. Discussion Improvements in arthritis self-efficacy and secondary outcomes displayed similar trends for I and R participant groups.

Content validity of global measures for at-work productivity in patients with rheumatic diseases: an international qualitative study.

OBJECTIVES: To identify from a patient's perspective, difficulties and differences in the comprehension of five global presenteeism measures in patients with inflammatory arthritis and OA across seven countries. METHODS: Seventy patients with a diagnosis of inflammatory arthritis or OA in paid employment were recruited from seven countries across Europe and Canada. Patients were randomly allocated to be cognitively debriefed on 3/5 global measures [Work Productivity Scale - Rheumatoid Arthritis, Work Productivity and Activity Impairment Questionnaire (WPAI), Work Ability Index, Quality and Quantity questionnaire, and WHO Health and Work Performance Questionnaire (HPQ)], with the WPAI debriefed in all patients as a standard measure of comparison between countries and patients. NVivo was used to code the data into four themes: construct and anchor, time recall, reference frame, and attribution. RESULTS: Discrepancies were found in the interpretation of the word performance (HPQ) between countries, with Romania and Sweden relating performance to sports rather than work. Seventy percent of patients considered that a 7-day recall (WPAI) can accurately represent how their disease affects work productivity. The compared to normal reference (Quality and Quantity questionnaire) was reportedly too ambiguous, and the comparison with colleagues (HPQ), made many feel uncomfortable. Overall, 29% of patients said the WPAI was the most relevant to them, making it the most favoured measure. CONCLUSION: Overall, patients across countries agree that the construct of work productivity in the last 7 days can accurately reflect the impact of disease while at work. Some current constructs to assess at-work productivity are not interchangeable between languages.

Test-retest Reliability and Correlations of 5 Global Measures Addressing At-work Productivity Loss in Patients with Rheumatic Diseases.

OBJECTIVE: Several global measures to assess at-work productivity loss or presenteeism in patients with rheumatic diseases have been proposed, but the comparative validity is hampered by the lack of data on test-retest reliability and comparative concurrent and construct validity. Our objective was to test-retest 5 global measures of presenteeism and to compare the association between these scales and health-related well-being. METHODS: Sixty-five participants with inflammatory arthritis or osteoarthritis in paid employment were recruited from 7 countries (UK, Canada, Netherlands, France, Sweden, Romania, and Italy). At baseline and 2 weeks later, 5 global measures of presenteeism were evaluated: the Work Productivity Scale-Rheumatoid Arthritis (WPS-RA), Work Productivity and Activity Impairment Questionnaire (WPAI), Work Ability Index (WAI), Quality and Quantity questionnaire (QQ), and the WHO Health and Performance Questionnaire (HPQ). Agreement between the 2 timepoints was assessed using single-measure intraclass correlations (ICC) and correlated between each other and with visual analog scale general well-being scores at followup by Spearman correlation. RESULTS: ICC between measures ranged from fair (HPQ 0.59) to excellent (WPS-RA 0.78). Spearman correlations between measures were moderate (Qquality vs WAI, r = 0.51) to strong (WPS-RA vs WPAI, r = 0.88). Correlations between measures and general well-being were low to moderate, ranging from -0.44 ≤ r ≤ 0.66. CONCLUSION: Test-retest results of 4 out of 5 global measures were good, and the correlations between these were moderate. The latter probably reflect differences in the concepts, recall periods, and references used in the measures, which implies that some measures are probably not interchangeable.

Measurement properties of the QuickDASH (disabilities of the arm, shoulder and hand) outcome measure and cross-cultural adaptations of the QuickDASH: a systematic review.

PURPOSE: To identify and synthesize evidence for the measurement properties of the QuickDASH, a shortened version of the 30-item DASH (Disabilities of the Arm, Shoulder and Hand) instrument. METHODS: This systematic review used a best evidence synthesis approach to critically appraise the measurement properties [using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of the QuickDASH and cross-cultural adaptations. A standard search strategy was conducted between 2005 (year of first publication of QuickDASH) and March 2011 in MEDLINE, EMBASE and CINAHL. RESULTS: The search identified 14 studies to include in the best evidence synthesis of the QuickDASH. A further 11 studies were identified on eight cross-cultural adaptation versions. CONCLUSIONS: Many measurement properties of the QuickDASH have been evaluated in multiple studies and across most of the measurement properties. The best evidence synthesis of the QuickDASH English version suggests that this tool is performing well with strong positive evidence for reliability and validity (hypothesis testing), and moderate positive evidence for structural validity testing. Strong negative evidence was found for responsiveness due to lower correlations with global estimates of change. Information about the measurement properties of the cross-cultural adaptation versions is still lacking, or the available information is of poor overall methodological quality.