The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study.

OBJECTIVES: Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times. METHODS: Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED. RESULTS: Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates. CONCLUSIONS: A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.

ABSTRAIT: OBJECTIF: Les longs temps d'attente dans les services d'urgence (SU) à cause de blocage de l'accès à l'hôpital sont une préoccupation croissante pour le système de santé canadien. Notre objectif était de quantifier l'impact d'un autre niveau de soins sur le bloc d'accès à l'hôpital et d'évaluer les effets probables d'interventions multiples sur les temps d'attente aux départements d'urgences. MéTHODES: Des modèles de simulation aux événements discrets ont été développés pour simuler les flux de patients dans les urgences et les soins aigus de six hôpitaux canadiens. Le mod èle a été rempli de données administratives ayant plusieurs sources (avril 2017 à mars 2018). Nous avons simulé et évalué l'impact de six scénarios d'intervention différents sur trois mesures de résultats : 1) le temps d'attente pour l'évaluation initiale du médecin, 2) le temps d'attente pour un lit pour des patients hospitalisés et 3) les patients qui partent sans être vus. Nous avons comparé chaque mesure de résultats de ce scénario au scénario de référence pour chaque département d'urgences. RéSULTATS: L'élimination de 30 % des jours d'hospitalisation à un autre niveau de soins des patients médicaux a réduit le temps moyen d'attente pour un patient hospitalisé de 0,25 à 4,22 heures. L'augmentation du nombre des médecins des urgences a réduit le temps moyen d'attente pour l'évaluation initiale du médecin (∆ 0,16 à 0,46 heures). Les transitions de soins de haute qualité ciblant les patients médicaux ont réduit la période moyen d'attente des patients hospitalisés pour tous les services d'urgence (∆ 0,34 à 6,85 heures). La réduction des visites à l'urgence pour des conditions sensibles à la médecine familiale ou l'augmentation de la continuité des soins ont entraîné des réductions cliniquement insignifiantes des temps d'attente et des taux de patients qui quittent sans être vus. CONCLUSIONS: Une réduction modérée du nombre d'un autre niveau de soins pour les patients médicaux pourrait non seulement soulager le blocage de l'accès mais aussi réduire les temps d'attente aux urgences, afin de l'ampleur de la réduction varie selon le site. L'augmentation du nombre de médecins des urgences et l'harmonisation de la capacité des médecins avec la demande d'afflux pourraient également réduire le temps d'attente. Les stratégies opérationnelles destinées à réduire les temps d'attente aux urgences devraient accorder la priorité à la résolution des facteurs de sortie et de débit plutôt qu'aux facteurs d'entrée.

Aquatic exercise training for fibromyalgia.

BACKGROUND: Exercise training is commonly recommended for individuals with fibromyalgia. This review examined the effects of supervised group aquatic training programs (led by an instructor). We defined aquatic training as exercising in a pool while standing at waist, chest, or shoulder depth. This review is part of the update of the 'Exercise for treating fibromyalgia syndrome' review first published in 2002, and previously updated in 2007. OBJECTIVES: The objective of this systematic review was to evaluate the benefits and harms of aquatic exercise training in adults with fibromyalgia. SEARCH METHODS: We searched The Cochrane Library 2013, Issue 2 (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, NHS Economic Evaluation Database), MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, WHO international Clinical Trials Registry Platform, and AMED, as well as other sources (i.e., reference lists from key journals, identified articles, meta-analyses, and reviews of all types of treatment for fibromyalgia) from inception to October 2013. Using Cochrane methods, we screened citations, abstracts, and full-text articles. Subsequently, we identified aquatic exercise training studies. SELECTION CRITERIA: Selection criteria were: a) full-text publication of a randomized controlled trial (RCT) in adults diagnosed with fibromyalgia based on published criteria, and b) between-group data for an aquatic intervention and a control or other intervention. We excluded studies if exercise in water was less than 50% of the full intervention. DATA COLLECTION AND ANALYSIS: We independently assessed risk of bias and extracted data (24 outcomes), of which we designated seven as major outcomes: multidimensional function, self reported physical function, pain, stiffness, muscle strength, submaximal cardiorespiratory function, withdrawal rates and adverse effects. We resolved discordance through discussion. We evaluated interventions using mean differences (MD) or standardized mean differences (SMD) and 95% confidence intervals (95% CI). Where two or more studies provided data for an outcome, we carried out meta-analysis. In addition, we set and used a 15% threshold for calculation of clinically relevant differences. MAIN RESULTS: We included 16 aquatic exercise training studies (N = 881; 866 women and 15 men). Nine studies compared aquatic exercise to control, five studies compared aquatic to land-based exercise, and two compared aquatic exercise to a different aquatic exercise program.We rated the risk of bias related to random sequence generation (selection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), blinding of outcome assessors (detection bias), and other bias as low. We rated blinding of participants and personnel (selection and performance bias) and allocation concealment (selection bias) as low risk and unclear. The assessment of the evidence showed limitations related to imprecision, high statistical heterogeneity, and wide confidence intervals. Aquatic versus controlWe found statistically significant improvements (P value < 0.05) in all of the major outcomes. Based on a 100-point scale, multidimensional function improved by six units (MD -5.97, 95% CI -9.06 to -2.88; number needed to treat (NNT) 5, 95% CI 3 to 9), self reported physical function by four units (MD -4.35, 95% CI -7.77 to -0.94; NNT 6, 95% CI 3 to 22), pain by seven units (MD -6.59, 95% CI -10.71 to -2.48; NNT 5, 95% CI 3 to 8), and stiffness by 18 units (MD -18.34, 95% CI -35.75 to -0.93; NNT 3, 95% CI 2 to 24) more in the aquatic than the control groups. The SMD for muscle strength as measured by knee extension and hand grip was 0.63 standard deviations higher compared to the control group (SMD 0.63, 95% CI 0.20 to 1.05; NNT 4, 95% CI 3 to 12) and cardiovascular submaximal function improved by 37 meters on six-minute walk test (95% CI 4.14 to 69.92). Only two major outcomes, stiffness and muscle strength, met the 15% threshold for clinical relevance (improved by 27% and 37% respectively). Withdrawals were similar in the aquatic and control groups and adverse effects were poorly reported, with no serious adverse effects reported. Aquatic versus land-basedThere were no statistically significant differences between interventions for multidimensional function, self reported physical function, pain or stiffness: 0.91 units (95% CI -4.01 to 5.83), -5.85 units (95% CI -12.33 to 0.63), -0.75 units (95% CI -10.72 to 9.23), and two units (95% CI -8.88 to 1.28) respectively (all based on a 100-point scale), or in submaximal cardiorespiratory function (three seconds on a 100-meter walk test, 95% CI -1.77 to 7.77). We found a statistically significant difference between interventions for strength, favoring land-based training (2.40 kilo pascals grip strength, 95% CI 4.52 to 0.28). None of the outcomes in the aquatic versus land comparison reached clinically relevant differences of 15%. Withdrawals were similar in the aquatic and land groups and adverse effects were poorly reported, with no serious adverse effects in either group. Aquatic versus aquatic (Ai Chi versus stretching in the water, exercise in pool water versus exercise in sea water)Among the major outcomes the only statistically significant difference between interventions was for stiffness, favoring Ai Chi (1.00 on a 100-point scale, 95% CI 0.31 to 1.69). AUTHORS' CONCLUSIONS: Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. Very low to low quality evidence suggests that there are benefits of aquatic and land-based exercise, except in muscle strength (very low quality evidence favoring land). No serious adverse effects were reported.

Resistance exercise training for fibromyalgia.

BACKGROUND: Fibromyalgia is characterized by chronic widespread pain that leads to reduced physical function. Exercise training is commonly recommended as a treatment for management of symptoms. We examined the literature on resistance training for individuals with fibromyalgia. Resistance training is exercise performed against a progressive resistance with the intention of improving muscle strength, muscle endurance, muscle power, or a combination of these. OBJECTIVES: To evaluate the benefits and harms of resistance exercise training in adults with fibromyalgia. We compared resistance training versus control and versus other types of exercise training. SEARCH METHODS: We searched nine electronic databases (The Cochrane Library, MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, Current Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform, AMED) and other sources for published full-text articles. The date of the last search was 5 March 2013. Two review authors independently screened 1856 citations, 766 abstracts and 156 full-text articles. We included five studies that met our inclusion criteria. SELECTION CRITERIA: Selection criteria included: a) randomized clinical trial, b) diagnosis of fibromyalgia based on published criteria, c) adult sample, d) full-text publication, and e) inclusion of between-group data comparing resistance training versus a control or other physical activity intervention. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently assessed risk of bias and extracted intervention and outcome data. We resolved disagreements between the two review authors and questions regarding interpretation of study methods by discussion within the pairs or when necessary the issue was taken to the full team of 11 members. We extracted 21 outcomes of which seven were designated as major outcomes: multidimensional function, self reported physical function, pain, tenderness, muscle strength, attrition rates, and adverse effects. We evaluated benefits and harms of the interventions using standardized mean differences (SMD) or mean differences (MD) or risk ratios or Peto odds ratios and 95% confidence intervals (CI). Where two or more studies provided data for an outcome, we carried out a meta-analysis. MAIN RESULTS: The literature search yielded 1865 citations with five studies meeting the selection criteria. One of the studies that had three arms contributed data for two comparisons. In the included studies, there were 219 women participants with fibromyalgia, 95 of whom were assigned to resistance training programs. Three randomized trials compared 16 to 21 weeks of moderate- to high-intensity resistance training versus a control group. Two studies compared eight weeks of progressive resistance training (intensity as tolerated) using free weights or body weight resistance exercise versus aerobic training (ie, progressive treadmill walking, indoor and outdoor walking), and one study compared 12 weeks of low-intensity resistance training using hand weights (1 to 3 lbs (0.45 to 1.36 kg)) and elastic tubing versus flexibility exercise (static stretches to major muscle groups).Statistically significant differences (MD; 95% CI) favoring the resistance training interventions over control group(s) were found in multidimensional function (Fibromyalgia Impact Questionnaire (FIQ) total decreased 16.75 units on a 100-point scale; 95% CI -23.31 to -10.19), self reported physical function (-6.29 units on a 100-point scale; 95% CI -10.45 to -2.13), pain (-3.3 cm on a 10-cm scale; 95% CI -6.35 to -0.26), tenderness (-1.84 out of 18 tender points; 95% CI -2.6 to -1.08), and muscle strength (27.32 kg force on bilateral concentric leg extension; 95% CI 18.28 to 36.36).Differences between the resistance training group(s) and the aerobic training groups were not statistically significant for multidimensional function (5.48 on a 100-point scale; 95% CI -0.92 to 11.88), self reported physical function (-1.48 units on a 100-point scale; 95% CI -6.69 to 3.74) or tenderness (SMD -0.13; 95% CI -0.55 to 0.30). There was a statistically significant reduction in pain (0.99 cm on a 10-cm scale; 95% CI 0.31 to 1.67) favoring the aerobic groups.Statistically significant differences were found between a resistance training group and a flexibility group favoring the resistance training group for multidimensional function (-6.49 FIQ units on a 100-point scale; 95% CI -12.57 to -0.41) and pain (-0.88 cm on a 10-cm scale; 95% CI -1.57 to -0.19), but not for tenderness (-0.46 out of 18 tender points; 95% CI -1.56 to 0.64) or strength (4.77 foot pounds torque on concentric knee extension; 95% CI -2.40 to 11.94). This evidence was classified low quality due to the low number of studies and risk of bias assessment. There were no statistically significant differences in attrition rates between the interventions. In general, adverse effects were poorly recorded, but no serious adverse effects were reported. Assessment of risk of bias was hampered by poor written descriptions (eg, allocation concealment, blinding of outcome assessors). The lack of a priori protocols and lack of care provider blinding were also identified as methodologic concerns. AUTHORS' CONCLUSIONS: The evidence (rated as low quality) suggested that moderate- and moderate- to high-intensity resistance training improves multidimensional function, pain, tenderness, and muscle strength in women with fibromyalgia. The evidence (rated as low quality) also suggested that eight weeks of aerobic exercise was superior to moderate-intensity resistance training for improving pain in women with fibromyalgia. There was low-quality evidence that 12 weeks of low-intensity resistance training was superior to flexibility exercise training in women with fibromyalgia for improvements in pain and multidimensional function. There was low-quality evidence that women with fibromyalgia can safely perform moderate- to high-resistance training.

Beverage consumption patterns of Canadian adults aged 19 to 65 years.

OBJECTIVE: To investigate the beverage intake patterns of Canadian adults and explore characteristics of participants in different beverage clusters. DESIGN: Analyses of nationally representative data with cross-sectional complex stratified design. SETTING: Canadian Community Health Survey, Cycle 2.2 (2004). SUBJECTS: A total of 14 277 participants aged 19-65 years, in whom dietary intake was assessed using a single 24 h recall, were included in the study. After determining total intake and the contribution of beverages to total energy intake among age/sex groups, cluster analysis (K-means method) was used to classify males and females into distinct clusters based on the dominant pattern of beverage intakes. To test differences across clusters, χ2 tests and 95 % confidence intervals of the mean intakes were used. RESULTS: Six beverage clusters in women and seven beverage clusters in men were identified. 'Sugar-sweetened' beverage clusters - regular soft drinks and fruit drinks - as well as a 'beer' cluster, appeared for both men and women. No 'milk' cluster appeared among women. The mean consumption of the dominant beverage in each cluster was higher among men than women. The 'soft drink' cluster in men had the lowest proportion of the higher levels of education, and in women the highest proportion of inactivity, compared with other beverage clusters. CONCLUSIONS: Patterns of beverage intake in Canadian women indicate high consumption of sugar-sweetened beverages particularly fruit drinks, low intake of milk and high intake of beer. These patterns in women have implications for poor bone health, risk of obesity and other morbidities.

Fruit drink consumption is associated with overweight and obesity in Canadian women.

OBJECTIVE: Overweight and obesity in Canada have significantly increased during the last three decades, paralleled by increased intake of fat and sugar, particularly sugary beverages. The Canadian Community Health Survey, Cycle 2.2, conducted in 2004 (CCHS 2.2), provides the opportunity to evaluate beverage intakes in relation to overweight and obesity using body mass index (BMI). Our objective was to examine the association between sugar-sweetened beverages and BMI in Canadian adults. METHODS: CCHS 2.2 data were used (n=14,304, aged >18 years and < or =65 years) and dietary intake was assessed on the basis of single 24-hour recall. Using cluster analysis (K-means method), males and females were classified into distinct clusters based on the dominant pattern of beverage intakes. Logistic regression models were used to determine associations between dominant beverage consumption patterns and BMI, controlling for age and other confounding factors. RESULTS: BMI in women with predominant "fruit drink" pattern (28.3 +/- 1.0 kg/m2) was higher than in those with no dominant pattern (26.8 +/- 0.3 kg/m2), p < 0.001. Adjusting for energy intake and other potential confounders, high intake of fruit drinks was a significant predictor of overweight (OR=1.84, 95% CI: 1.06-3.20), obesity (OR = 2.55, 95% CI: 1.46-4.47) and overweight/obesity (OR = 2.05, 95% CI: 1.29-3.25) in women. In men, mean BMI was not different among beverage consumption clusters and none of the beverage intake patterns was a predictor for overweight and obesity. CONCLUSION: Using a nationally representative dataset, there was an association between sugar-sweetened beverages and overweight and obesity in Canadian women.

Beverage patterns among Canadian children and relationship to overweight and obesity.

Sweetened beverage intake has risen in past decades, along with a rise in prevalence of overweight and obesity among children. Our objective was to examine the relationship between beverage intake patterns and overweight and obesity among Canadian children. Beverage intake patterns were identified by cluster analysis of data from the cross-sectional Canadian Community Health Survey 2.2. Intake data were obtained from a single 24-hour recall, height and weight were measured, and sociodemographic data were obtained via interview. Data on children and adolescents aged 2-18 years who met inclusion criteria (n = 10 038) were grouped into the following categories: 2-5 years (male and female), 6-11 years (female), 6-11 years (male), 12-18 years (female), and 12-18 years (male). χ² test was used to compare rates of overweight and obesity across clusters. Logistic regression was used to determine the association between overweight and obesity and beverage intake patterns, adjusting for potential confounders. Clustering resulted in distinct groups of who drank mostly fruit drinks, soft drinks, 100% juice, milk, high-fat milk, or low-volume and varied beverages (termed "moderate"). Boys aged 6-11 years whose beverage pattern was characterized by soft drink intake (553 ± 29 g) had increased odds of overweight-obesity (odds ratio 2.3, 95% confidence interval 1.2-4.1) compared with a "moderate" beverage pattern (23 ± 4 g soft drink). No significant relationship emerged between beverage pattern and overweight and obesity among other age-sex groups. Using national cross-sectional dietary intake data, Canadian children do not show a beverage-weight association except among young boys who drink mostly soft drinks, and thus may be at increased risk for overweight or obesity.

Beverage intake patterns of Canadian children and adolescents.

OBJECTIVE: Little is known of the beverage intake patterns of Canadian children or of characteristics within these patterns. The objective was to determine beverage intake patterns among Canadian children and compare intakes of fourteen types of beverages, along with intakes of vitamin C and Ca, and sociodemographic factors across clusters. DESIGN: Dietary information was collected using one 24 h recall. Sociodemographic data were collected by interview. Cluster analysis was used to determine beverage intake patterns. Pearson's χ2 and 95 % CI were used to test differences across clusters. SETTING: Data from the Canadian Community Health Survey Cycle 2·2. SUBJECTS: Children aged 2-18 years with plausible energy intake and complete sociodemographic data (n 10 038) were grouped into the following categories: 2-5-year-old boys and girls, 6-11-year-old girls, 6-11-year-old boys, 12-18-year-old girls and 12-18-year-old boys. RESULTS: Five beverage clusters emerged for children aged 2-5 years, six clusters for children aged 6-11 years (both sexes) and four clusters for those aged 12-18 years (both sexes). Sweetened beverage clusters appeared in all age-sex groups. Intakes of sweetened beverages ranged from 553 to 1059 g/d and contributed between 2 % and 18 % of total energy intake. Girls 6-11 years of age in the 'soft drink' cluster had lower Ca intake compared with other clusters in that age-sex group. Age and ethnicity differed across clusters for most age-sex groups. Differences for household food security status and income were found; however, no pattern emerged. CONCLUSIONS: Patterns in beverage intake among Canadian children include beverages that are predominantly sugar sweetened. Public health nutrition professionals can use knowledge about beverage patterns among children, as well as the characteristics of these groups, in the development of nutritional programmes and policies.

Exercise therapy for fibromyalgia.

Fibromyalgia syndrome, a chronic condition typically characterized by widespread pain, nonrestorative sleep, fatigue, cognitive dysfunction, and other somatic symptoms, negatively impacts physical and emotional function and reduces quality of life. Exercise is commonly recommended in the management of people with fibromyalgia, and interest in examining exercise benefits for those with the syndrome has grown substantially over the past 25 years. Research supports aerobic and strength training to improve physical fitness and function, reduce fibromyalgia symptoms, and improve quality of life. However, other forms of exercise (e.g., tai chi, yoga, Nordic walking, vibration techniques) and lifestyle physical activity also have been investigated to determine their effects. This paper highlights findings from recent randomized controlled trials and reviews of exercise for people with fibromyalgia, and includes information regarding factors that influence response and adherence to exercise to assist clinicians with exercise and physical activity prescription decision-making to optimize health and well-being.