Predicting changes in cataract surgery health outcomes using a cataract surgery appropriateness and prioritization instrument.

OBJECTIVE: Determine whether items in a cataract surgery appropriateness and prioritization questionnaire can predict change in best corrected visual acuity (BCVA) and health related quality of life (HRQOL) following cataract surgery. METHODS: 313 patients with a cataract in Ontario, Canada were recruited to participate. BCVA was measured using the Snellen chart. HRQOL was measured using a generic instrument (EQ5D), a visual functioning instrument (Catquest-9SF), and an appropriateness and prioritization instrument (17 items). Outcomes were measured preoperatively and 3-6 months postoperatively. Descriptive statistics were used to describe demographics and outcomes. For each appropriateness and prioritization questionnaire item, a one-way ANOVA was used to compare group means of the change in BCVA, EQ5D, and Catquest-9SF. RESULTS: Participants had a mean age of 69 years and were 56% female. BCVA improved in 81%, EQ5D in 49.6%, and Catquest-9SF score in 84% of patients. Improvement in both BCVA and Catquest-9SF scores were found in 68.5% of patients. The ANOVA showed a statistically significant association between a change in BCVA and the ability to participate in social life, and a statistically significant association between a change in Catquest-9SF and glare, extent of impairment in visual function, safety and injury concerns, ability to work and care for dependents, ability to take care of local errands, ability to assist others and ability to participate in social life. CONCLUSIONS: Almost all patients had improved BCVA and/or visual functioning after surgery. Seven variables from the cataract appropriateness and prioritization instrument were found to be predictors of improvement in Catquest-9SF measuring visual functioning.

Using an electronic tool to improve teamwork and interprofessional communication to meet the needs of complex hospitalized patients: A mixed methods study.

BACKGROUND: Teamwork and interprofessional communication are important in addressing the comprehensive care needs of complex hospitalized patients. The objective of this study is to evaluate the impact of an electronic interprofessional communication and collaboration platform on teamwork, communication, and adverse events in the hospital setting. MATERIALS AND METHODS: In this mixed methods study, we used a quasi-experimental design in the quantitative component and deployed the electronic tool in a staged fashion to 2 hospital wards 3 months apart. We measured teamwork, communication, and adverse events with Relational Coordination survey, video recordings of team rounds, and retrospective chart review. We conducted qualitative semi-structured interviews with clinicians to understand the perceived impacts of the electronic tool and other contextual factors. RESULTS: Teamwork sustainably improved (overall Relational Coordination score improved from 3.68 at baseline to 3.84 at three and six months after intervention, p = 0.03) on ward 1. A small change in face-to-face communication pattern during team rounds was observed (making plans increased from 22% to 24%, p = 0.004) at 3 months on ward 1 but was not sustained at 6 months. Teamwork and communication did not change after the intervention on ward 2. There was no meaningful change to adverse event rates on either ward. Clinicians reported generally positive views about the electronic tool's impact but described non-technology factors on each ward that affected teamwork and communication. CONCLUSION: The impact of using an electronic tool to improve teamwork and communication in the hospital setting appears mixed, but can be positive in some settings. Improving teamwork and communication likely require both appropriate technology and addressing non-technology factors.

Clinician user involvement in the real world: Designing an electronic tool to improve interprofessional communication and collaboration in a hospital setting.

OBJECTIVES: User involvement is vital to the success of health information technology implementation. However, involving clinician users effectively and meaningfully in complex healthcare organizations remains challenging. The objective of this paper is to share our real-world experience of applying a variety of user involvement methods in the design and implementation of a clinical communication and collaboration platform aimed at facilitating care of complex hospitalized patients by an interprofessional team of clinicians. METHODS: We designed and implemented an electronic clinical communication and collaboration platform in a large community teaching hospital. The design team consisted of both technical and healthcare professionals. Agile software development methodology was used to facilitate rapid iterative design and user input. We involved clinician users at all stages of the development lifecycle using a variety of user-centered, user co-design, and participatory design methods. RESULTS: Thirty-six software releases were delivered over 24 months. User involvement has resulted in improvement in user interface design, identification of software defects, creation of new modules that facilitated workflow, and identification of necessary changes to the scope of the project early on. CONCLUSION: A variety of user involvement methods were complementary and benefited the design and implementation of a complex health IT solution. Combining these methods with agile software development methodology can turn designs into functioning clinical system to support iterative improvement.

Access to surgery for paediatric patients with medically refractory epilepsy: a systems analysis.

PURPOSE: A systems analysis perspective was undertaken to evaluate access to surgery for children with medically refractory epilepsy (MRE) in Ontario, the largest province in Canada. The analysis focused on the assessment of referral patterns, healthcare utilization, time intervals and patient flow to determine surgical candidacy in children with MRE. The purpose of this systems analysis study was to identify rate limiting steps that may lead to delayed surgical candidacy decision and surgery. METHODS: Prolonged video electroencephalography (vEEG) is the common entry point into the process for all potential epilepsy surgery candidates. Therefore, a single centre retrospective chart review of children and adolescents referred to the epilepsy monitoring unit (EMU) for vEEG monitoring at the primary referral centre for paediatric epilepsy surgery in the province. Basic demographic and referral data were abstracted for all screened cases. Included cases were: (1) age <19 years old at time of first EMU admission, (2) date of EMU admission between April 1, 2004 and March 31, 2006 and (3) referral for elective vEEG and/or overnight with vEEG greater than 8h duration. Data were collected on number of seizure conferences, surgical candidacy, surgical outcomes (seizure free and seizure reduction), resource utilization, and recorded time stamps for each event to estimate system delays. RESULTS: During the two-year period, 463 patients were referred to the EMU of whom 349 received prolonged vEEG (>8h). Forty five percent (n=160) of patients came to seizure conference for discussion of their data, of whom 40% (64/160) were considered surgical candidates. Time from first seizure to EMU referral was approximately 4.6 years. Time from referral to admission and admission to first seizure conference were approximately 103 days and 71 days, respectively. From initial EMU referral to surgery ranged from 1.6 to 1.1 years depending on whether the patient required invasive monitoring with intracranial EEG. Overall, 95% of surgical patients had a reduction in seizure frequency, 74% were seizure free after one year post-surgery. SIGNIFICANCE: Referral rates for surgical assessment are low relative to the estimated number of children living with MRE in Ontario, less than 2%. Hence, only a limited number of children with this disorder in the province of Ontario who could benefit from epilepsy surgery are being assessed for surgical candidacy. The majority of Ontario children with MRE are not being provided the potential opportunity to be seizure free and live without functional limitations following surgical intervention. These data document the critical need for health system redesign in Ontario, the goal of which should be to provide more consistent and just access to evidence-based medical and surgical care for those citizens of the province who suffer from epilepsy.

Simulating an emergency department: the importance of modeling the interactions between physicians and delegates in a discrete event simulation.

BACKGROUND: Computer simulation studies of the emergency department (ED) are often patient driven and consider the physician as a human resource whose primary activity is interacting directly with the patient. In many EDs, physicians supervise delegates such as residents, physician assistants and nurse practitioners each with different skill sets and levels of independence. The purpose of this study is to present an alternative approach where physicians and their delegates in the ED are modeled as interacting pseudo-agents in a discrete event simulation (DES) and to compare it with the traditional approach ignoring such interactions. METHODS: The new approach models a hierarchy of heterogeneous interacting pseudo-agents in a DES, where pseudo-agents are entities with embedded decision logic. The pseudo-agents represent a physician and delegate, where the physician plays a senior role to the delegate (i.e. treats high acuity patients and acts as a consult for the delegate). A simple model without the complexity of the ED is first created in order to validate the building blocks (programming) used to create the pseudo-agents and their interaction (i.e. consultation). Following validation, the new approach is implemented in an ED model using data from an Ontario hospital. Outputs from this model are compared with outputs from the ED model without the interacting pseudo-agents. They are compared based on physician and delegate utilization, patient waiting time for treatment, and average length of stay. Additionally, we conduct sensitivity analyses on key parameters in the model. RESULTS: In the hospital ED model, comparisons between the approach with interaction and without showed physician utilization increase from 23% to 41% and delegate utilization increase from 56% to 71%. Results show statistically significant mean time differences for low acuity patients between models. Interaction time between physician and delegate results in increased ED length of stay and longer waits for beds. CONCLUSION: This example shows the importance of accurately modeling physician relationships and the roles in which they treat patients. Neglecting these relationships could lead to inefficient resource allocation due to inaccurate estimates of physician and delegate time spent on patient related activities and length of stay.

Impact of the 1997 Canadian guidelines on the conduct of Canadian-based economic evaluations in the published literature.

OBJECTIVE: To assess the impact of the 1997 Canadian guidelines on the methods and presentation of economic evaluations conducted from a Canadian perspective in the published literature. METHODS: A systematic literature review was conducted to identify health technology economic evaluations conducted from a Canadian perspective published in peer-reviewed journals between 2001 and 2006. To investigate the impact of the 1997 Canadian Coordinating Office of Health Technology Assessment guidelines, each included study was assessed against 17 of the 25 recommendations. RESULTS: Of the 153 included studies, a base set of 9 methodological standards, as outlined by the 1997 guidelines, were followed by over 50% of the studies including: indications, outcomes for cost utility analysis, outcomes for cost benefit analysis, discounting future cost and outcomes, cost identification and valuation, evaluating uncertainty and disclosing funding relationships. Main divergences from the guidelines were found for analytic technique (38%), study perspective (23%), source of preferences (8%), equity (7%), and cost measurement (24%). CONCLUSION: The current assessment has shown that the 1997 Canadian guidelines have set a minimum methodological standard within the community of "doers" conducting economic analyses from a Canadian perspective. Although there was divergence from some of the recommendations, the majority were reflected as changes in the 2006 Canadian guidelines.

Health technology assessment for radiologists: basic principles and evaluation framework.

Decision makers are faced with the task of allocating health resources to maximize patients' health under budget constraints. To offer structure to the complexity of the decision-making process, the field of health technology assessment (HTA) was developed. This paper offers an introduction to the fundamental aspects of HTA and acts as a guide to the conduct of HTA for radiologists. First, the authors define HTA and describe how it is linked to the field of diagnostics. Second, a basic 11-step framework for the conduct of an HTA is outlined. The framework begins with the identification of the problem and proceeds through to the dissemination and impact of an HTA. Third, the authors provide a real-world example of an HTA in the field of diagnostics. Last, they describe the challenges and barriers faced in HTA.

Health technology assessment from a Canadian device industry perspective.

Health technology assessment has significantly improved the decision-making process via the thorough and systematic evaluation of the clinical utility and cost-effectiveness of new drugs and health technologies. However, the device industry faces a significant challenge in meeting the evidentiary demands of the health technology assessment process, particularly given the small size of the Canadian market and device manufacturers. This is further compounded by the somewhat short-sighted nature of health care budgets, which see medical devices as a cost-driver given the sometimes significant upfront investment required to implement a technology producing downstream benefits in the long-term. Industry is the research and development of the health care system, but innovative development could be stifled unless the health technology assessment process recognizes the risk of manufacturers. The authors propose that health technology assessment can be improved by recognizing the challenges that device manufacturers face and by sharing the risk associated with evaluations of effectiveness. Health technology assessment is a powerful tool that can be used to evaluate new and potentially obsolete technologies alike, with the goal of meeting the needs of patients as customers of both the device industry and the health care system.

In search of the evidentiary foundation of published Canadian economic evaluations (2001-06).

OBJECTIVES: The aim of this study was to present a review of economic evaluations conducted from a Canadian perspective and to characterize sources of evidence and statistical methods to analyze effectiveness measures, resource utilization, and uncertainty. METHODS: A search strategy was developed to identify Canadian economic evaluations published between January 2001 and June 2006. A standardized abstraction form was used to extract key data (e.g., study design, data sources, statistical methods). RESULTS: A total of 153 unique studies were included for review, of which 75 were evaluations of drug therapies and less than half were funded by industry. Cost-effectiveness analysis was the most common type of economic evaluation and 80 percent of the studies used modeling techniques. A single source of evidence for effectiveness measures was used in half of the studies. Statistical methods were commonly reported to compare effectiveness measures when the economic evaluation was conducted alongside a clinical trial but less commonly when determining effectiveness input parameters in model-based economic evaluations, or to analyze resource utilization data. Authors relied mostly on univariate sensitivity analyses to explore uncertainty. CONCLUSIONS: This review identifies the need to improve the conduct and reporting of statistical methods for economic evaluations to improve confidence in the results.