Evaluation of a single-dose HPV vaccine strategy for promoting vaccine, health, and gender equity.

Although several countries have adopted a single-dose human papillomavirus (HPV) vaccination strategy, many other countries continue to include multiple doses in their vaccination programmes. There are ethical reasons to transition to a single-dose strategy. We discuss how a single-dose HPV vaccination strategy advances equity in three dimensions: vaccine equity, health equity, and gender equity. Adopting a single-dose strategy eases pressure on vaccine supply, lowers programme costs, and is easier to distribute. This change facilitates vaccine procurement and implementation programmes (contributing to vaccine equity) and reaching hard to reach people or populations (contributing to health equity). A lower number of cases of HPV-related diseases that stem from greater vaccine distribution reduces the burden on women, who are at a higher risk of HPV-related disease or who act as caregivers, which prevents them from accessing opportunities that contribute to their empowerment (contributing to gender equity). Thus, pursuing the single-dose HPV vaccination programme strategy is ethically desirable.

Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

A Longitudinal Survey on Canadian Emergency Physician Burnout.

STUDY OBJECTIVE: Since Canada eased pandemic restrictions, emergency departments have experienced record levels of patient attendance, wait times, bed blocking, and crowding. The aim of this study was to report Canadian emergency physician burnout rates compared with the same physicians in 2020 and to describe how emergency medicine work has affected emergency physician well-being. METHODS: This longitudinal study on Canadian emergency physician wellness enrolled participants in April 2020. In September 2022, participants were invited to a follow-up survey consisting of the Maslach Burnout Inventory and an optional free-text explanation of their experience. The primary outcomes were emotional exhaustion and depersonalization levels, which were compared with the Maslach Burnout Inventory survey conducted at the end of 2020. A thematic analysis identified common stressors, challenges, emotions, and responses among participants. RESULTS: The response rate to the 2022 survey was 381 (62%) of 615 between September 28 and October 28, 2022, representing all provinces or territories in Canada (except Yukon). The median participant age was 42 years. In total, 49% were men, and 93% were staff physicians with a median of 12 years of work experience. 59% of respondents reported high emotional exhaustion, and 64% reported high depersonalization. Burnout levels in 2022 were significantly higher compared with 2020. Prevalent themes included a broken health care system, a lack of societal support, and systemic workplace challenges leading to physician distress and loss of physicians from the emergency workforce. CONCLUSION: We found very high burnout levels in emergency physician respondents that have increased since 2020.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Expediting approval for medical countermeasures to address high burden disease: an ethical justification to move beyond emergency use authorisation.

Addressing global health crises requires a receptive and expedient policy environment to minimise delays in making available potentially life-saving technologies. Over time, the policy environment has adapted to ensure that communities have expedited access to promising technologies, such as vaccines, that can mitigate morbidity and mortality. Emergency authorisations are one such policy mechanism. While these have been employed successfully for several diseases, such as influenza, Ebola and COVID-19, the policy mechanism is tied to contexts where key bodies have designated the disease an 'emergency', whereas no equivalent mechanism exists for those failing to acquire the designation (eg, malaria and tuberculosis). In this paper, we examine ethical issues associated with emergency authorisations. We argue that there is no moral difference between those diseases considered emergencies and many that fail to be designated as such with respect to impact on affected communities. Thus, tying access to an expedient policy mechanism for approval to an emergency designation is ethically unjustified-it should be based on considerations of risks and benefits, the disease burden and the values of the communities that carry those risks and not contingent on if the disease is designated an emergency. We suggest the need to further enhance the policy environment to ensure access to similar expedited approval programmes irrespective of if a disease is an emergency. Levelling the field for access to expedited approval programmes across diseases can help in moving towards achieving global health equity but is not a panacea.

Associations between education policies and the geographic disposition of family physicians: a retrospective observational study of McMaster University education data.

The maldistribution of family physicians challenges equitable primary care access in Canada. The Theory of Social Attachment suggests that preferential selection and distributed training interventions have potential in influencing physician disposition. However, evaluations of these approaches have focused predominantly on rural underservedness, with little research considering physician disposition in other underserved communities. Accordingly, this study investigated the association between the locations from which medical graduates apply to medical school, their undergraduate preclerkship, clerkship, residency experiences, and practice as indexed across an array of markers of underservedness. We built association models concerning the practice location of 347 family physicians who graduated from McMaster University's MD Program between 2010 and 2015. Postal code data of medical graduates' residence during secondary school, pre-clerkship, clerkship, residency and eventual practice locations were coded according to five Statistics Canada indices related to primary care underservedness: relative rurality, employment rate, proportion of visible minorities, proportion of Indigenous peoples, and neighbourhood socioeconomic status. Univariate and multivariable logistic regression models were then developed for each dependent variable (i.e., practice location expressed in terms of each index). Residency training locations were significantly associated with practice locations across all indices. The place of secondary school education also yielded significant relationships to practice location when indexed by employment rate and relative rurality. Education interventions that leverage residency training locations may be particularly influential in promoting family physician practice location. The findings are interpreted with respect to how investment in education policies can promote physician practice in underserved communities.

Humans not heroes: Canadian emergency physician experiences during the early COVID-19 pandemic.

BACKGROUND: The pandemic has upended much clinical care, irrevocably changing our health systems and thrusting emergency physicians into a time of great uncertainty and change. This study is a follow-up to a survey that examined the early pandemic experience among Canadian emergency physicians and aimed to qualitatively describe the experiences of these physicians during the global pandemic. The study was conducted at a time when Canadian COVID-19 case numbers were low. METHODS: The investigators engaged in an interview-based study that used an interpretive description analytic technique, sensitised by the principles of phenomenology. One-to-one interviews were conducted, transcribed and then analysed to establish a codebook, which was subsequently grouped into key themes. Results underwent source triangulation (with survey data from a similar period) and investigator-driven audit trail analysis. RESULTS: A total of 16 interviews (11 female, 5 male) were conducted between May and September 2020. The isolated themes on emergency physicians' experiences during the early pandemic included: (1) disruption and loss of emergency department shift work; (2) stress of COVID-19 uncertainty and information bombardment; (3) increased team bonding; (4) greater personal life stress; (5) concern for patients' isolation, miscommunication and disconnection from care; (6) emotional distress. CONCLUSIONS: Canadian emergency physicians experienced emotional and psychological distress during the early COVID-19 pandemic, at a time when COVID-19 prevalence was low. This study's findings could guide future interventions to protect emergency physicians against pandemic-related distress.

Heterogeneity in multicentre trial participating centers: lessons from the TOPCAT trial on interpreting trial data for clinical practice.

OBJECTIVES: Randomized controlled trials (RCTs) are considered a "gold standard" of evidence, provided they meet rigorous standards in design and execution. Recently, some investigators of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial advocate reanalysis of results, deviating from the statistical analysis plan. We briefly review the rationale by the TOPCAT investigators and implications for interpreting trial data. STUDY DESIGN AND SETTING: Critical examination of existing literature. RESULTS: The TOPCAT trial showed variation in patient characteristics and outcomes among different geographic regions. The investigators suggest that the observed variation indicated unreliable data, warranting deviation from protocol. That lead to claims of therapeutic effectiveness for populations in select regions. We suggest that some variation is expected in multicentre RCTs and argue that discriminating between natural variation and unreliable data can be challenging. Thus, the warrant for deviation from protocol is not clear. CONCLUSION: The TOPCAT investigators highlight important concerns about heterogeneity in RCT samples and how that may impact our interpretation of the results. If we are to maintain rigor in the RCT methodology and preserve its status as a reliable form of evidence for clinical practice, we must carefully consider when it is appropriate to deviate from a protocol when analyzing and interpreting trial data.

The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA).

PURPOSE: The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians. METHODS: We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate. RESULTS: There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5). CONCLUSION: Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.

Clinical recommendations: The role of mechanisms in the GRADE framework.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework has become one of the most influential frameworks for assessing quality of research and developing clinical recommendations. The GRADE framework has been presented as an evolution in the Evidence-Based Medicine (EBM) movement. Both GRADE and EBM emphasize effect estimates derived from population-level clinical trials and, as a consequence, devalue the role of mechanisms as the basis for clinical decisions. Although mechanisms do not hold the epistemic privilege of rigorous clinical trials in EBM reasoning, this paper will argue that mechanisms appear to be important in the use and application of GRADE, as described in the literature. The seemingly necessary role of mechanisms in the development of clinical recommendations has, so far, received little attention and is not explicitly featured in the literature describing GRADE. The analysis of the GRADE framework presented in this paper reveals an apparent tension between EBM's willingness to downplay mechanisms and what seems their inevitable use in GRADE. In this paper, we take the position that if mechanistic reasoning is inevitable in the use of GRADE, then the instructional literature on the framework would benefit from more explicit discussion of how to consider and integrate mechanisms.

Canadian emergency medicine physician burnout: a survey of Canadian emergency physicians during the second wave of the COVID-19 pandemic.

OBJECTIVES: A previous survey of Canadian emergency medicine (EM) physicians during the first wave of the COVID-19 pandemic documented less than 20% experienced high levels of burnout. This study examined the experience of a similar group of physicians during the second pandemic wave. We reported the associations between burnout and physician age, gender, having children at home and training route. METHODS: This study utilized a national survey of Canadian emergency physicians. We collected data on demographics and measured burnout using the Maslach Burnout Inventory (MBI). Multiple logistic regression models identified associations between the emotional exhaustion and depersonalization domains of the MBI and EM physician demographics (age, gender, children living at home, and training route). RESULTS: Between November 25, 2020, and February 4, 2021, 416 emergency physicians completed the survey, representing all Provinces or Territories in Canada (except Nunavut). The mean participant age was 44, 53% were male, 64% had children living at home and 41% were FRCPC and 41% CCFP-EM trained. Sixty percent reported high burnout (either high emotional exhaustion and/or high depersonalization). Increasing age was associated with lower emotional exhaustion and depersonalization; female or nonbinary gender was associated with an increase in emotional exhaustion; and having children living at home was associated with lower depersonalization. CONCLUSIONS: Most Canadian emergency physicians participating in our study during the COVID-19 pandemic reported high burnout levels. Younger physicians and female physicians were more likely than their coworkers to report high burnout levels. Hospitals should address emergency physician burnout during the pandemic because it is a threat to quality of patient care and retention of the workforce for the future.

RéSUMé: OBJECTIFS: Une enquête précédente sur les médecins d'urgence canadiens pendant la première vague de la pandémie de COVID-19 a montré que moins de 20 % d'entre eux souffraient de niveaux élevés d'épuisement professionnel. Cette étude a examiné l'expérience d'un groupe similaire de médecins au cours de la deuxième vague et a rapporté les associations entre l'épuisement professionnel et l'âge du médecin, son sexe, le fait d'avoir des enfants à la maison et le parcours de formation. MéTHODES: Cette étude s'est appuyée sur une enquête nationale auprès des médecins d'urgence canadiens. Nous avons recueilli des données démographiques et mesuré le burnout à l'aide du Maslach Burnout Inventory (MBI). De multiples modèles de régression logistique ont identifié des associations entre les domaines de l'épuisement émotionnel et de la dépersonnalisation du MBI et les données démographiques des médecins de la médecine d'urgence (âge, sexe, enfants vivant à la maison et parcours de formation). RéSULTATS: Entre le 25 novembre 2020 et le 4 février 2021, 416 médecins urgentistes ont répondu au sondage, représentant toutes les provinces ou territoires du Canada (sauf le Nunavut). L'âge moyen des participants était de 44 ans, 53% étaient des hommes, 64% avaient des enfants vivant à la maison et 41% étaient formés FRCPC et 41% CMFC-MU. Soixante pour cent ont signalé un épuisement professionnel élevé (soit un épuisement émotionnel élevé et/ou une dépersonnalisation élevée). L'augmentation de l'âge était associée à une diminution de l'épuisement émotionnel et de la dépersonnalisation ; le sexe féminin ou non binaire était associé à une augmentation de l'épuisement émotionnel ; et le fait d'avoir des enfants vivant à la maison était associé à une diminution de la dépersonnalisation. CONCLUSIONS: La plupart des médecins urgentistes canadiens ayant participé à notre étude pendant la pandémie de COVID-19 ont signalé des niveaux élevés d'épuisement professionnel. Les médecins plus jeunes et les femmes médecins étaient plus susceptibles que leurs collègues de déclarer des niveaux élevés d'épuisement professionnel. Les hôpitaux doivent s'attaquer au problème de l'épuisement professionnel des médecins urgentistes pendant la pandémie, car il constitue une menace pour la qualité des soins aux patients et la rétention de la main-d'œuvre pour l'avenir.

Utilization of CT angiography of the head and neck in the era of endovascular therapy for acute ischemic stroke: a retrospective study.

PURPOSE: To describe the impact of a new institutional Code Stroke protocol on ordering volume of head and neck CT angiographies (CTA), and to determine the number and proportion of these studies that resulted in an endovascular or surgical intervention. METHODS: Clinical and administrative data was collected on all head and neck CTAs ordered within the ED at two high-volume community hospitals and an affiliated urgent care centre during the 6-year period between January 1, 2014, and December 31, 2019. Of those patients who underwent CTA, we identified those who were then transferred to a regional stroke centre for consideration of EVT and those who underwent carotid endarterectomy or stenting within 14 days. RESULTS: A total of 4719 CTAs were ordered during the 6-year period. There was nearly a tenfold rise in the yearly number of CTAs ordered per 10,000 ED visits, from 5.3 (in 2014) to 53.1 (in 2019). A total of 164 patients who underwent CTAs (3.5%) were ultimately transferred to a regional tertiary care centre, of whom 43 (0.9%) were transferred to a regional stroke centre for consideration of EVT. A total of 61 (1.3%) patients underwent a carotid intervention within 14 days. CONCLUSION: Little is known of the impacts on healthcare resources that have resulted from the system-wide changes made necessary by the widespread adoption of EVT. Our study shows that at our site, these system changes have resulted in large increases in CTA utilization with very small numbers of patients ultimately undergoing EVT or carotid intervention.

Thirty years of teaching evidence-based medicine: have we been getting it all wrong?

Evidence based medicine (EBM) has been synonymous to delivery of quality care for almost thirty years. Since the movement's inception, the assumption has been that decisions based on high quality evidence would translate to better care for patients. Despite EBM's many attractive features and the substantive attention it has received in the contemporary clinical and medical education literature, how it is defined and operationalized as a component of training is often unclear and problematic. How to practice EBM is not well articulated in the literature; therefore, it becomes difficult to teach and equally challenging to assess. In this paper, we put forward a call for deeper consideration of how EBM is taught, and for clarification on how it is defined and operationalized in medical education. In preparing this paper, we considered questions such as what it means to practice EBM, the role that medical education plays in helping realize EBM, how the teaching of EBM can change to reflect recent developments in clinical practice and education, and whether transformations in the practice of medicine necessitate a change in how we teach EBM. We end with four avenues that may be pursued to advance the teaching of EBM in medical education: (1) consensus on what we mean by EBM; (2) clear articulation of EBM-associated competencies; (3) empirically and theoretically supported means of promoting EBM competencies; (4) ways to assess both skill acquisition and use of EBM. We discuss implications for educators of EBM.

Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department.

INTRODUCTION: Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding. METHODS AND ANALYSIS: This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule. ETHICS AND DISSEMINATION: The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media. TRIAL REGISTRATION NUMBER: NCT03745755.