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2.
Can J Surg ; 62(6): 017016, 2019 Sep 23.
Artigo em Inglês | MEDLINE | ID: mdl-31545563

RESUMO

Background: Instrumented lumbar surgeries, such as lumbar fusion and lumbar disc replacement, are increasingly being used in the United States for low back pain, with utilization rates approaching those of total joint arthroplasty. It is unknown whether there is a similar pattern in Canada. We sought to determine utilization rates and total medical costs of instrumented lumbar surgeries in a single-payer system and to compare these with the rates and costs of total hip and knee replacements. Methods: We included Ontarians aged 20 years and older who underwent instrumented lumbar surgery or total knee or total hip replacement between April 1993 and March 2012. Utilization and medical cost of the procedures were evaluated and compared using linear regression in a time-series analysis. Instrumented lumbar surgical procedures were stratified by age and main indication for surgery. Results: Utilization of instrumented lumbar surgeries rose from 6.2 to 14.2 procedures per 100 000 population between 1993 and 2012 (p < 0.001), well below the utilization of knee and hip arthroplasties. Patients were younger than 50 years of age for 29.2% of all instrumented lumbar surgery cases; annual procedure rates among those older than 80 years of age rose 7.6-fold. Direct medical costs of instrumented lumbar surgeries from 2002 to 2012 totaled $176 million. Spinal stenosis and spondylolisthesis were the most common indications for instrumented lumbar surgeries. Conclusion: Use of instrumented lumbar surgeries in Ontario's single-payer system has increased rapidly, especially among patients older than 80 years of age. In contrast to the situation in the United States, these rates were well below those of total joint arthroplasties. These data provide useful insights about resource allocation for surgical treatment of lumbar degenerative disorders.

3.
Thromb Res ; 182: 12-19, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31434018

RESUMO

INTRODUCTION: Direct oral anticoagulants (DOACs) have expanded the options for antithrombotic therapy. DOAC-related major bleeds are associated with favorable outcomes compared to warfarin in clinical trials and routine practice. However, it is unclear whether management of DOAC-associated major bleeding incurs higher resource utilization and costs. MATERIALS AND METHODS: We screened medical records of patients ≥ 66 years with atrial fibrillation admitted to one of five tertiary care hospitals in Ontario, Canada with a hemorrhage. We abstracted bleeds involving DOACs or warfarin and linked them to administrative databases to capture length of hospital stay, blood product use, procedural interventions, intensive care unit (ICU) utilization and related direct medical costs. To control for confounders, multivariate logistic and linear regressions were used for binary and linear outcomes respectively. RESULTS: Among 19,061 records screened, 1978 (10.4%) cases involving 1632 patients met criteria of oral anticoagulant-associated bleeding. Baseline characteristics between DOAC and warfarin groups were similar. Blood product costs were higher for DOACs (all comparisons DOACs vs. warfarin, $1456 vs. $1109, mean difference $347, 95% CI $185 to $509), but length of stay and ICU use were similar. Mean direct medical costs did not differ ($9217 vs. $10,790, adjusted relative ratio 0.94, 95% CI 0.84-1.05). CONCLUSIONS: Prior to introduction of DOAC-specific reversal agents, resource utilization and medical costs were comparable between DOAC- and warfarin-associated major bleeds, despite marginally higher blood product costs incurred by the former. Resource intensity associated with anticoagulant-related bleeding remains high, and our data provide measures for cost-effectiveness evaluation of emerging DOAC antidotes.

4.
Can J Aging ; : 1-8, 2018 Nov 22.
Artigo em Inglês | MEDLINE | ID: mdl-30463636

RESUMO

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

5.
Can J Cardiol ; 34(7): 850-862, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29960614

RESUMO

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.

6.
J Thorac Cardiovasc Surg ; 155(6): 2254-2264.e4, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29499864

RESUMO

OBJECTIVES: To determine hospital incidence, mortality, and management for thoracic aortic dissections and aneurysms. METHODS: A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of thoracic aortic dissections and aneurysms were identified between 2002 and 2014. Treatment and mortality trends were assessed. RESULTS: There were 5966 aortic dissections (Type A n = 2289 [38%] and Type B n = 3632 [61%]). Overall incidence proportion for aortic dissections was 4.6 per 100,000. There were 9392 thoracic aortic aneurysms with an overall incidence proportion of 7.6 per 100,000. The incidence for both dissections and aneurysms significantly increased over the 12-year study. Only 53% (1204 out of 2289) of Type A dissections underwent surgery. Type B dissection treatment was 83% (3000 out of 3632) medical, 10% (370 out of 3632) surgery, and 7% (262 out of 3632) endovascular. Thoracic aortic aneurysm treatment was 53% (4940 out of 9392) surgery, 44% (4129 out of 9392) medical, and 3% (323 out of 9392) endovascular. Thirty-five percent of known descending thoracic aortic aneurysms (323 out of 924) received a stent graft. Cardiac surgeons performed 87% of the open surgical repairs. Vascular surgeons performed 91% of the endovascular procedures. All-cause 3-year mortality significantly decreased for both aortic dissections (44% to 40%) and aneurysms (30% to 22%). All-cause hospital mortality also decreased. Women had worse outcomes than men. CONCLUSIONS: The incidence of thoracic aortic dissections and aneurysms increased over time but all-cause hospital and late outcomes improved. Gender differences exist. Men incur more disease but women have higher hospital mortality. Surgery was primarily referred to cardiac surgeons. Endovascular therapy was primarily referred to vascular surgeons.

7.
Foot (Edinb) ; 2017 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-29108669

RESUMO

BACKGROUND: Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment. METHODS: A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data. RESULTS: The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data. CONCLUSION: This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.

8.
Foot (Edinb) ; 2017 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-29174064

RESUMO

BACKGROUND: Ankle and foot sprains and fractures are prevalent injuries, which may result in substantial physical and economic consequences for the patient and place a financial burden on the health care system. Therefore, the objectives of this paper are to examine the direct and indirect costs of treating ankle and foot injuries (sprains, dislocations, fractures), as well as to provide an overview of the outcomes of full economic analyses of different treatment strategies. METHODS: A systematic review was carried out among seven databases to identify English language publications on the health economics of ankle and foot injury treatment published between 1980 and 2014. The direct and indirect costs were abstracted by two independent reviewers. All costs were adjusted for inflation and reported in 2016 US dollars (USD). RESULTS: Among 2047 identified studies, 32 were selected for analysis. The direct costs of ankle sprain management ranged from $292 to $2268 per patient (2016 USD), depending on the injury severity and treatment strategy. The direct costs of managing ankle fractures were higher ($1908-$19,555). Foot fracture treatment had similar direct costs ranging from $998 to $21,801. The economic evaluations were conducted from the societal or payer's perspectives. CONCLUSION: The costs of treating ankle and foot sprains and fractures varied among the studies, mostly due to differences in injury type and study characteristics, which impacted the ability of directly comparing the financial burden of treatment. Nonetheless, the review showed that the costs experienced by the patient and the health care system increased with injury complexity.

9.
Chest ; 152(1): 81-91, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28219635

RESUMO

BACKGROUND: Direct oral anticoagulants (DOACs) have expanded the armamentarium for antithrombotic therapy. Although DOAC-related major bleeding was associated with favorable outcomes compared with warfarin in clinical trials, warfarin effects were reversed in < 40% of cases, raising concerns about the generalizability of this finding. METHODS: Consecutive patients ≥ 66 years presented to five tertiary care hospitals across three cities in Ontario, Canada from October 2010 to March 2015 with diagnoses that included hemorrhage. Charts were screened for association with DOAC or warfarin use; eligible cases were abstracted and linked to administrative databases. RESULTS: Among 19,061 records screened, 2,002 (460 receiving DOAC, 1,542 receiving warfarin) were eligible. Reversal agents (72.9% vitamin K, 40.7% prothrombin complex concentrates) were frequently used in warfarin bleeding events. Red blood cell transfusions occurred more often in DOAC bleeding events than in warfarin events (52.0% vs 39.5%; adjusted relative risk [aRR], 1.32; 95% CI, 1.19-2.47). However, units of blood products transfused were not different between the two groups. Thirty-four DOAC cases (7.4%) received activated prothrombin complex concentrates or recombinant factor VIIa. In-hospital mortality was lower following DOAC bleeding events (9.8% vs 15.2%; aRR, 0.66; 95% CI, 0.49-0.89), although differences in 30-day mortality did not reach statistical significance (12.6% vs 16.3%; aRR, 0.79; 95% CI, 0.61-1.03). CONCLUSIONS: In this unselected cohort of patients with oral anticoagulant-related hemorrhage with high rates of warfarin reversal, in-hospital mortality was lower among DOAC-associated bleeding events. These findings support the safety of DOACs in routine care and present useful baseline measures for evaluations of DOAC-specific reversal agents.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Dabigatrana , Transfusão de Eritrócitos , Fator VIIa/uso terapêutico , Hemorragia , Acidente Vascular Cerebral/prevenção & controle , Varfarina , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Antitrombinas/administração & dosagem , Antitrombinas/efeitos adversos , Fibrilação Atrial/complicações , Dabigatrana/administração & dosagem , Dabigatrana/efeitos adversos , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/diagnóstico , Hemorragia/mortalidade , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Masculino , Conduta do Tratamento Medicamentoso/estatística & dados numéricos , Ontário/epidemiologia , Proteínas Recombinantes/uso terapêutico , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Varfarina/administração & dosagem , Varfarina/efeitos adversos
10.
Eur J Health Econ ; 18(4): 471-479, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-27167229

RESUMO

An obesity paradox has been described, whereby obese patients have better health outcomes than normal weight patients in certain clinical situations, including cardiac surgery. However, the relationship between body mass index (BMI) and resource utilization and costs in patients undergoing coronary artery bypass graft (CABG) surgery is largely unknown. We examined resource utilization and cost data for 53,224 patients undergoing CABG in Ontario, Canada over a 10-year period between 2002 and 2011. Data for costs during hospital admission and for a 1-year follow-up period were derived from the Institute for Clinical Evaluative Sciences, and analyzed according to pre-defined BMI categories using analysis of variance and multivariate models. BMI independently influenced healthcare costs. Underweight patients had the highest per patient costs ($50,124 ± $36,495), with the next highest costs incurred by morbidly obese ($43,770 ± $31,747) and normal weight patients ($42,564 ± $30,630). Obese and overweight patients had the lowest per patient costs ($40,760 ± $30,664 and $39,960 ± $25,422, respectively). Conversely, at the population level, overweight and obese patients were responsible for the highest total yearly population costs to the healthcare system ($92 million and $50 million, respectively, compared to $4.2 million for underweight patients). This is most likely due to the high proportion of CABG patients falling into the overweight and obese BMI groups. In the future, preoperative risk stratification and preparation based on BMI may assist in reducing surgical costs, and may inform health policy measures aimed at the management of weight extremes in the population.


Assuntos
Ponte de Artéria Coronária/economia , Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Obesidade/economia , Magreza/economia , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Bases de Dados Factuais , Feminino , Recursos em Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ontário , Cirurgia Torácica/economia
11.
BMJ ; 355: i5650, 2016 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-27852621

RESUMO

OBJECTIVE:  To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains. DESIGN:  A randomised controlled trial of 503 participants followed for six months. SETTING:  Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada. PARTICIPANTS:  The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol. INTERVENTION:  Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy. MAIN OUTCOME MEASURES:  The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months. RESULTS:  The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score. CONCLUSIONS:  In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).


Assuntos
Traumatismos do Tornozelo/reabilitação , Modalidades de Fisioterapia , Entorses e Distensões/reabilitação , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Recuperação de Função Fisiológica , Inquéritos e Questionários , Resultado do Tratamento
12.
Pain Res Manag ; 20(5): 255-60, 2015 Sep-Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26448971

RESUMO

BACKGROUND: Access to postoperative acute pain treatment is an important component of perioperative care and is frequently managed by a multidisciplinary team of anesthesiologists, surgeons, pharmacists, technicians and nurses. In some developing countries, treatment modalities are often not performed due to scarce health care resources, knowledge deficiencies and cultural attitudes. OBJECTIVES: In advance of a comprehensive knowledge translation initiative, the present study aimed to determine the perspectives, perceptions and experiences of anesthesia residents regarding postoperative pain management strategies. METHODS: The present study was conducted using a qualitative assessment strategy in a large teaching hospital in Rwanda. During two sessions separated by seven days, a 10-participant semistructured focus group needs analysis was conducted with anesthesia residents at the Centre Hospitalier Universitaire de Kigali (Kigali, Rwanda). Field notes were analyzed using interpretative and descriptive phenomenological approaches. Participants were questioned regarding their perspectives, perceptions and experiences in pain management. RESULTS: The responses from the focus groups were related to five general areas: general patient and medical practice management; knowledge base regarding postoperative pain management; pain evaluation; institutional/system issues related to protocol implementation; and perceptions about resource allocation. Within these areas, challenges (eg, communication among stakeholders and with patients) and opportunities (eg, on-the-job training, use of protocols, routine pain assessment, participation in resource allocation decisions) were identified. CONCLUSIONS: The present study revealed the prevalent challenges residents perceive in implementing postoperative pain management strategies, and offers practical suggestions to overcoming them, primarily through training and the implementation of practice recommendations.


Assuntos
Manejo da Dor/métodos , Manejo da Dor/psicologia , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/terapia , Percepção , Feminino , Hospitais de Ensino/estatística & dados numéricos , Humanos , Masculino , Ruanda/epidemiologia
13.
J Am Heart Assoc ; 4(7)2015 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-26159363

RESUMO

BACKGROUND: The "obesity paradox" reflects an observed relationship between obesity and decreased morbidity and mortality, suggesting improved health outcomes for obese individuals. Studies examining the relationship between high body mass index (BMI) and adverse outcomes after cardiac surgery have reported conflicting results. METHODS AND RESULTS: The study population (N=78 762) was comprised of adult patients who had undergone first-time coronary artery bypass (CABG) or combined CABG/aortic valve replacement (AVR) surgery from April 1, 1998 to October 31, 2011 in Ontario (data from the Institute for Clinical Evaluative Sciences). Perioperative outcomes and 5-year mortality among pre-defined BMI (kg/m(2)) categories (underweight <20, normal weight 20 to 24.9, overweight 25 to 29.9, obese 30 to 34.9, morbidly obese >34.9) were compared using Bivariate analyses and Cox multivariate regression analysis to investigate multiple confounders on the relationship between BMI and adverse outcomes. A reverse J-shaped curve was found between BMI and mortality with their respective hazard ratios. Independent of confounding variables, 30-day, 1-year, and 5-year survival rates were highest for the obese group of patients (99.1% [95% Confidence Interval {CI}, 98.9 to 99.2], 97.6% [95% CI, 97.3 to 97.8], and 90.0% [95% CI, 89.5 to 90.5], respectively), and perioperative complications lowest. Underweight and morbidly obese patients had higher mortality and incidence of adverse outcomes. CONCLUSIONS: Overweight and obese patients had lower mortality and adverse perioperative outcomes after cardiac surgery compared with normal weight, underweight, and morbidly obese patients. The "obesity paradox" was confirmed for overweight and moderately obese patients. This may impact health resource planning, shifting the focus to morbidly obese and underweight patients prior to, during, and after cardiac surgery.


Assuntos
Valva Aórtica/cirurgia , Índice de Massa Corporal , Ponte de Artéria Coronária/mortalidade , Implante de Prótese de Valva Cardíaca/mortalidade , Obesidade Mórbida/mortalidade , Magreza/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Obesidade Mórbida/complicações , Obesidade Mórbida/diagnóstico , Ontário/epidemiologia , Seleção de Pacientes , Modelos de Riscos Proporcionais , Fatores de Proteção , Medição de Risco , Fatores de Risco , Magreza/complicações , Magreza/diagnóstico , Fatores de Tempo , Resultado do Tratamento
14.
Palliat Med ; 29(2): 147-56, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25344156

RESUMO

BACKGROUND: Home care services use has been proposed as a means of reducing costs in palliative care by decreasing hospital stay without impacting quality of clinical care; however, little is known about utilization of these services in the time following a terminal cancer diagnosis. AIM: To examine disease, patient and healthcare system predictors of hospital stay, and home care services use in metastatic gastric cancer patients. DESIGN: This is a population-based, retrospective cohort study. Chart review and administrative data were linked, using a 26-month time horizon to collect health services data. PARTICIPANTS: All patients diagnosed with metastatic gastric cancer in the province of Ontario between 2005 and 2008 were included in the study (n = 1433). RESULTS: Age, comorbidity, tumor location, and burden of metastatic disease were identified as predictors of hospital stay and receipt of home care services. Individuals who received home care services spent fewer days in hospital than individuals who did not (relative risk: 0.44; 95% confidence interval: 0.38-0.51). Patients who interacted with a high-volume oncology specialist had shorter cumulative hospital stay (relative risk: 0.62; 95% confidence interval: 0.54-0.71) and were less likely to receive home care services (relative risk: 0.80; 95% confidence interval: 0.72-0.88) than those who did not. CONCLUSION: Examining how differences in hospital stay and home care services use impact clinical outcomes and how policies may reduce costs to the healthcare system is necessary.


Assuntos
Serviços de Assistência Domiciliar/estatística & dados numéricos , Hospitalização/economia , Tempo de Internação/economia , Cuidados Paliativos/economia , Neoplasias Gástricas/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Pesquisa sobre Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ontário , Cuidados Paliativos/métodos , Cuidados Paliativos/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
15.
Lung Cancer ; 86(2): 281-7, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25267166

RESUMO

OBJECTIVES: Surgical resection and adjuvant chemotherapy have become standard of care for treating resectable early stage non-small cell lung cancer (NSCLC). The purpose was to describe and compare the overall and regional resource utilization and costs of resected NSCLC treated with and without adjuvant chemotherapy. MATERIALS & METHODS: A population-based retrospective cohort study of resected NSCLC patients, diagnosed between 2004 and 2006 (representing the cohort immediately affected by the change in clinical practice) was performed using administrative data. Patients were followed for four years from the date of surgery. The healthcare system perspective was used, and cost estimates (2012 US$) were derived from administrative data and the literature. RESULTS: 3354 patients were included. The average cost per patient treated with surgery and adjuvant chemotherapy was $37,860.88 and was significantly higher than the average cost per patient treated with surgery alone $32,221.45 (p<0.0001). Among regions, the costs of patients treated with surgery and chemotherapy ($32,672-$45,453) and the costs of those treated with surgery alone ($28,679-$36,845) varied significantly (p<0.0001). Rates of chemotherapy, the proportion of patients who received any imaging scans, hospitalizations, specialist visits, emergency room visits, mean number of imaging scans, general physician visits, and blood transfusions all varied significantly among geographic regions. CONCLUSIONS: This population-based study demonstrates an average cost per patient similar to that shown in randomized controlled trials; however, costs for either treatment approach varied by geographic region. Understanding the regional variation in costs and resource utilization is important with respect to delivering optimal treatment in a cost-effective strategy.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Custos de Cuidados de Saúde , Recursos em Saúde , Neoplasias Pulmonares/epidemiologia , Idoso , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/terapia , Gerenciamento Clínico , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/terapia , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Vigilância da População , Sistema de Registros , Estudos Retrospectivos
16.
J Palliat Care ; 29(2): 99-106, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23923473

RESUMO

The objective of this study was to develop a national, prioritized research agenda for advance care planning (ACP). We first identified a list of comprehensive ACP research topics and determined priority criteria through focus groups. We next conducted a survey wherein importance weights were assigned to priority criteria and each ACP topic was rated. We combined weights and ratings into overall scores. A total of 17 ACP topics were developed and placed into four categories: patients and family members, the general public, professionals, and the healthcare system. Four main priority criteria were created: feasibility, consistency with ethical and societal values, economic considerations, and impact. Of the 100 individuals we invited to participate in the survey, 62 accepted. Prioritized topics centred largely on the impact of ACP on health resource utilization, communicating advance care planning across settings, and the preferred manner of engaging patients in ACP.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Prioridades em Saúde , Pesquisa/classificação , Pesquisa/organização & administração , Canadá , Humanos , Ontário , Desenvolvimento de Programas/métodos
17.
CMAJ Open ; 1(3): E115-9, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25077110

RESUMO

BACKGROUND: The clinical armamentarium for anticoagulation has expanded substantially since the recent approval of dabigatran, rivaroxaban and apixaban for the prevention of stroke in atrial fibrillation. However, patients in the general population often differ from participants in clinical trials. In this study, we assessed the uptake of these novel oral anticoagulants in Ontario, Canada, within the first 2 years after dabigatran's approval for this indication. METHODS: Using data on province-wide prescription volumes, we conducted a time-series analysis of prescription trends between October 2010 and September 2012 for all orally administered anticoagulants (warfarin, dabigatran and rivaroxaban) that were available in this period. We stratified dabigatran prescription rates by age group (20-39, 40-59, 60-64, 65-84 and ≥ 85 yr). We compared the proportion of dabigatran prescriptions to patients aged 65 or older with similar data from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) study. RESULTS: Over the 24-month study period, we found that prescriptions for the novel anticoagulants rose more than 20-fold, to represent 21.1% of all prescriptions of oral anticoagulants by September 2012. The rise in prescriptions was due primarily to an increase in dabigatran use. Prescription rates of dabigatran were highest among people aged 85 years or more, a group at increased risk of bleeding who are markedly older than the average participant in the clinical trial in which the drug was tested (71 yr). In September 2012, most of the dabigatran prescriptions were for the lower-dose formulation (110 mg) in the older groups (58.8% of dabigatran prescriptions in the 65-84 age group and 93.6% in the oldest group). INTERPRETATION: We observed rapid growth in the uptake of the novel oral anticoagulants since their approval for use in patients with atrial fibrillation, especially among those aged 85 years or more. This increase in use in the oldest group, a population at high risk of bleeding, signals the need to evaluate outcomes of use of novel oral anticoagulants in the clinical setting.

18.
Sex Transm Dis ; 38(10): 889-91, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21934557

RESUMO

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.


Assuntos
Efeitos Psicossociais da Doença , Doenças Sexualmente Transmissíveis/economia , Humanos , Inflação , Estados Unidos
19.
Crit Care Med ; 39(7): 1792-9, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21358400

RESUMO

OBJECTIVE: Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes. INTERVENTIONS: The use of procalcitonin-guided antibiotic therapy. METHODS AND MAIN RESULTS: We searched computerized databases, reference lists of pertinent articles, and personal files. We included randomized controlled trials conducted in the intensive care unit that compared a procalcitonin-guided strategy to usual care and reported on antibiotic utilization and clinically important outcomes. Results were qualitatively and quantitatively summarized. On the basis of no effect in hospital mortality or hospital length of stay, a cost or cost-minimization analysis was conducted using the costs of procalcitonin testing and antibiotic acquisition and administration. Costs were determined from the literature and are reported in 2009 Canadian dollars. Five articles met the inclusion criteria. Procalcitonin-guided strategies were associated with a significant reduction in antibiotic use (weighted mean difference -2.14 days, 95% confidence interval -2.51 to -1.78, p < .00001). No effect was seen of a procalcitonin-guided strategy on hospital mortality (risk ratio 1.06, 95% confidence interval 0.86-1.30, p = .59; risk difference 0.01, 95% confidence interval -0.04 to +0.07, p = .61) and intensive care unit and hospital lengths of stay. The cost model revealed that, for the base case scenario (daily price of procalcitonin Can$49.42, 6 days of procalcitonin measurement, and 2-day difference in antibiotic treatment between procalcitonin-guided therapy and usual care), the point at which the cost of testing equals the cost of antibiotics saved is when daily antibiotics cost Can$148.26 (ranging between Can$59.30 and Can$296.52 on the basis of different assumptions in sensitivity analyses). CONCLUSIONS: Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality.


Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Calcitonina/sangue , Precursores de Proteínas/sangue , Choque Séptico/tratamento farmacológico , Infecções Bacterianas/sangue , Infecções Bacterianas/economia , Biomarcadores/sangue , Peptídeo Relacionado com Gene de Calcitonina , Cuidados Críticos , Humanos , Choque Séptico/sangue , Choque Séptico/economia , Fatores de Tempo , Resultado do Tratamento
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