Development, implementation and impact of an immunoglobulin stewardship programme in Saskatchewan, Canada.

BACKGROUND AND OBJECTIVES: Intravenous immunoglobulin (IVIG) is one of the most costly and limited-supply blood products. Judicious use of this therapy is important to ensure a continued supply is available for patients in need. The Saskatchewan IG Stewardship Program was initiated to monitor and reduce inappropriate IG use. MATERIALS AND METHODS: The Program was developed and implemented through the collaborative efforts of a multidisciplinary, inter-organizational team. Funding was provided from provincial organizations to create new positions within the Program and to support stakeholder engagement throughout the process of implementation. Data were collected from local and national databases regarding the amount of IVIG used and appropriateness of orders based on published criteria. RESULTS: Over 20 months, the Program helped to reduce unnecessary IVIG use from pre-intervention levels by more than 20%. Interventions from nurse navigators alone reduced inappropriate IVIG use by 2.6%. During the 20-month period following Program initiation, more than 4 million CAD less was spent on IVIG compared with the previous 20 months. CONCLUSION: The Saskatchewan IG Stewardship Program has led to more appropriate IVIG use across the province, more effective preservation of this limited healthcare resource, and cost savings that more than cover the cost of administering the Program.

Development and implementation of a clinician report to reduce unnecessary urine drug screen testing in the ED: a quality improvement initiative.

BACKGROUND: Unnecessary testing is a problem-facing healthcare systems around the world striving to achieve sustainable care. Despite knowing this problem exists, clinicians continue to order tests that do not contribute to patient care. Using behavioural and implementation science can help address this problem. Locally, audit and feedback are used to provide information to clinicians about their performance on relevant metrics. However, this is often done without evidence-based methods to optimise uptake. Our objective was to improve the appropriate use of laboratory tests in the ED using evidence-based audit and feedback and behaviour change techniques. METHODS: Using the behaviour change wheel, we implemented an audit and feedback tool that provided information to ED physicians about their use of laboratory tests; specifically, we focused on education and review of the appropriate use of urine drug screen tests. The report was designed in collaboration with end users to help maximise engagement. Following development of the report, audit and feedback sessions were delivered over an 18-month period. RESULTS: Data on urine drug screen testing were collected continually throughout the intervention period and showed a sustained decrease among ED physicians. Test use dropped from a monthly departmental average of 26 urine drug screen tests per 1000 patient visits to only eight tests per 1000 patient visits following the initiation of the audit and feedback intervention. CONCLUSION: Audit and feedback reduced unnecessary urine drug screen testing in the ED. Regular feedback sessions continuously engaged physicians in the audit and feedback intervention and allowed the implementation team to react to changing priorities and feedback from the clinical group. It was important to include the end users in the design of audit and feedback tools to maximise physician engagement. Inclusion in this process can help ensure physicians adopt a sense of ownership regarding which metrics to review and provides a key component for the motivation aspect of behaviour change. Departmental leadership is also critical to the process of implementing a successful audit and feedback initiative and achieving sustained behaviour change.

Identification of Staphylococci by Polymerase Chain Reaction Directly from a Positive Blood Culture and Effect on Patient Care.

BACKGROUND: As one of the most common bloodstream infections worldwide, Staphylococcus aureus bacteremia places a major burden on health care. Implementation of a rapid, genetic-based diagnostic test may have important implications in the clinical management of patients with S. aureus bacteremia. OBJECTIVES: The primary objective was to assess concordance between testing based on polymerase chain reaction (PCR) and the current gold standard, culture and sensitivity testing; the secondary objective was to assess the impact of this technology on patient care. METHODS: A pre-post intervention retrospective chart review was used to document the hospital course of patients with a diagnosis of S. aureus bacteremia before and after implementation of the PCR-based diagnostic system. Laboratory results from all patient samples subjected to PCR-based analysis following implementation of this system were compared with culture and sensitivity data for the same samples to determine accuracy of the new system. In addition, time to optimal therapy for each patient was calculated as the interval between the initiation of empiric and terminal therapies. The appropriateness of antimicrobial treatment was characterized as guideline-concordant, nonconcordant with the guidelines, or nonconcordant yet still clinically appropriate. RESULTS: In total, 98 and 99 patients met the inclusion criteria before and after implementation of the PCR-based diagnostic system, respectively. PCR-based results displayed 99.8% concordance (440/441 total samples) with results from culture and sensitivity testing. The time to optimal therapy was significantly shorter after implementation, by a mean of 22.8 h (p < 0.001). Overall, 97% of empiric and 99% of terminal antimicrobial regimens were either guideline-concordant or clinically appropriate for treatment of S. aureus bacteremia; 3% of empiric and 1% of terminal antimicrobial regimens were nonconcordant with clinical guidelines without any explanation based on other clinical considerations. CONCLUSIONS: The study findings support the utility of using a direct-from-positive-blood-culture PCR-based diagnostic tool as the primary method of identifying S. aureus bacteremia in patients, as well as the acceptance of and acting upon the new assay's results by our local clinicians. PCR-based assays can help reduce the time to optimal terminal therapy for patients with bacteremia.

CONTEXTE: La bactériémie à Staphylococcus aureus (BAC-SA), qui est l'une des infections du sang les plus répandues dans le monde, fait peser une lourde charge sur les soins de santé. La mise en place d'un test diagnostique génétique rapide pourrait avoir des retombées importantes sur la gestion clinique des patients présentant une BAC-SA. OBJECTIFS: L'objectif principal consistait à évaluer la concordance entre les tests basés sur la réaction en chaîne par polymérase (PCR) et le test de sensibilité et de culture, qui est la référence absolue actuelle; l'objectif secondaire consistait à évaluer l'impact de cette technologie sur les soins des patients. MÉTHODES: Un examen rétrospectif des dossiers pré-et post-intervention a servi à décrire le séjour à l'hôpital des patients ayant reçu un diagnostic de BAC-SA avant et après la mise en place du système de diagnostic de la PCR. Les résultats de laboratoire de tous les échantillons des patients soumis à une analyse de la PCR à la suite de la mise en place de ce système ont été comparés avec les données relatives à la culture et à la sensibilité de ces mêmes échantillons afin de déterminer la précision du nouveau système. De plus, l'évaluation du délai d'atteinte du traitement optimal de chaque patient repose sur le calcul de l'intervalle entre le début des thérapies empiriques et terminales. La pertinence du traitement antimicrobien était caractérisée comme suit : concordance avec les lignes directrices, non-concordance avec les lignes directrices ou non-concordance mais encore approprié d'un point de vue clinique. RÉSULTATS: Au total, 98 et 99 patients ont satisfait au critère d'inclusion respectivement avant et après la mise en place du système de diagnostic de la PCR. Les résultats basés sur la PCR affichaient une concordance de 99,8 % (440/441 échantillons au total) avec les résultats des tests de sensibilité et de culture. La diminution du délai d'atteinte du traitement optimal était importante après la mise en place du système, puisqu'elle atteignait en moyenne 22,8 h (p < 0,001). De manière générale, 97 % des régimes antimicrobiens empiriques et 99 % des régimes antimicrobiens terminaux concordaient avec les lignes directrices ou étaient cliniquement appropriés pour le traitement de la BAC-SA; 3 % des régimes antimicrobiens empiriques et 1 % des régimes antimicrobiens terminaux n'étaient pas conformes aux lignes directrices cliniques sans qu'aucune explication basée sur d'autres considérations cliniques n'ait été donnée. CONCLUSIONS: Les résultats de l'étude confirment la nécessité d'utiliser un outil diagnostique basé sur la PCR directement de l'hémoculture positive en guise de méthode principale pour déterminer la présence de BAC-SA chez les patients ainsi que l'acceptation et l'utilisation des nouveaux résultats du test par nos cliniciens locaux. Les tests basés sur la PCR peuvent aider à réduire le délai d'attente du traitement optimal pour les patients atteints de BAC-SA.

Smoking and multiple sclerosis: A systematic review and meta-analysis using the Bradford Hill criteria for causation.

BACKGROUND: Despite being one of the most common neurological disorders globally, the cause(s) of multiple sclerosis (MS) remain unknown. Cigarette smoking has been studied with regards to both the development and progression of MS. The Bradford Hill criteria for causation can contribute to a more comprehensive evaluation of a potentially causal risk factor-disease outcome relationship. The objective of this systematic review and meta-analysis was to assess the relationship between smoking and both MS risk and MS progression, subsequently applying Hill's criteria to further evaluate the likelihood of causal associations. METHODS: The Medline, EMBASE, CINAHL, PsycInfo, and Cochrane Library databases were searched for relevant studies up until July 28, 2015. A random-effects meta-analysis was conducted for three outcomes: MS risk, conversion from clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (CDMS), and progression from relapsing-remitting multiple sclerosis (RRMS) to secondary-progressive multiple sclerosis (SPMS). Dose-response relationships and risk factor interactions, and discussions of mechanisms and analogous associations were noted. Hill's criteria were applied to assess causality of the relationships between smoking and each outcome. The effect of second-hand smoke exposure was also briefly reviewed. RESULTS: Smoking had a statistically significant association with both MS risk (conservative: OR/RR 1.54, 95% CI [1.46-1.63]) and SPMS risk (HR 1.80, 95% CI [1.04-3.10]), but the association with progression from CIS to CDMS was non-significant (HR 1.13, 95% CI [0.73-1.76]). Using Hill's criteria, there was strong evidence of a causal role of smoking in MS risk, but only moderate evidence of a causal association between smoking and MS progression. Heterogeneity in study designs and target populations, inconsistent results, and an overall scarcity of studies point to the need for more research on second-hand smoke exposure in relation to MS prior to conducting a detailed meta-analysis. CONCLUSION: This first review to supplement systematic review and meta-analytic methods with Hill's criteria to analyze the smoking-MS association provides evidence supporting the causal involvement of smoking in the development and progression of MS. Smoking prevention and cessation programs and policies should consider MS as an additional health risk when aiming to reduce smoking prevalence in the population.

Immigrant status and having a regular medical doctor among Canadian adults.

OBJECTIVE: New immigrants generally arrive in Canada with a health advantage over their Canadian counterparts, but lose that advantage over time. Difficulties in acquiring a physician may contribute. Past studies relied on older data, and lacked control for many confounders and assessment of gender differences. We assessed the relationship between immigrant status and having a regular doctor among Canadian adults. METHODS: Cross-sectional data from the 2011-2012 Canadian Community Health Survey were self-reported by 73,958 respondents aged 18-64, representing >20 million Canadian adults. The relationship between immigrant status and having a doctor was analyzed using χ2 and logistic regression analyses stratified by gender. Age, body mass index, race, education, province of residence, physical activity, chronic conditions, self-perceived health, and number of children in household were controlled. RESULTS: Approximately 77% of males and 87% of females reported having a doctor. About 7% of respondents reported being new immigrants in Canada (0-9 years), while 16% were established immigrants (≥10 years). For males (M) and females (F) respectively, 78% and 88% of non-immigrants, 55% and 68% of new immigrants, and 84% and 91% of established immigrants reported having a doctor (p < 0.001). Compared to non-immigrants, new immigrants were significantly less likely to have a doctor (OR (95% CI) M: 0.43 (0.38-0.47); F: 0.36 (0.32-0.41)), while established immigrants were significantly more likely to have a doctor (M: 1.13 (1.03-1.24); F: 1.16 (1.03-1.30)). CONCLUSION: New Canadian immigrants are less likely to have a regular doctor compared to non-immigrants, and should be targeted by policies and programs facilitating finding a doctor.