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So J.P.P.,Hospital for Sick Children | Wright J.G.,Child Health Evaluative science | Wright J.G.,University of Toronto
Clinical Orthopaedics and Related Research

Background: Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial. Questions/purposes: The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries. Methods: We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size. Results: Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results. Conclusion: Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific. © 2011 The Association of Bone and Joint Surgeons®. Source

Ungar W.J.,Child Health Evaluative science | Ungar W.J.,University of Toronto
Journal of the Canadian Academy of Child and Adolescent Psychiatry

Next generation sequencing (NGS) is a new genome-based technology showing great promise in delineating the genetic basis of autism thus facilitating diagnosis and in the future, the selection of treatment. NGS can have a targeted use as well as provide clinically important findings from medically actionable variants regarding the risk of other disorders. As more is learned about the genomic basis of autism, the clinical utility of the risk information will increase. But at what cost? As the medical management that ensues from primary and secondary (incidental) findings grows, there will be increased pressure on sub-specialists with a longer and more circuitous pathway to care. This will result in higher costs to health care systems and to families. Health technology assessment is needed to measure the additional costs associated with NGS compared to standard care and to weigh these costs against additional health benefits. Well-designed data collection systems should be implemented early in clinical translation of this technology to enable assessment of clinical utility and cost-effectiveness and to generate high quality evidence to inform clinical and budget allocation decision-making. © 2015, Canadian Academy of Child and Adolescent Psychiatry. All rights reserved. Source

Pullenayegum E.M.,Child Health Evaluative science | Pullenayegum E.M.,University of Toronto
Statistics in Medicine

Observational cohort studies often feature longitudinal data subject to irregular observation. Moreover, the timings of observations may be associated with the underlying disease process and must thus be accounted for when analysing the data. This paper suggests that multiple outputation, which consists of repeatedly discarding excess observations, may be a helpful way of approaching the problem. Multiple outputation was designed for clustered data where observations within a cluster are exchangeable an adaptation for longitudinal data subject to irregular observation is proposed. We show how multiple outputation can be used to expand the range of models that can be fitted to irregular longitudinal data. © 2016 John Wiley & Sons, Ltd. Source

Karakochuk C.,University of Toronto | Van Den Briel T.,United Nations World Food Programme | Stephens D.,Child Health Evaluative science | Zlotkin S.,University of Toronto
American Journal of Clinical Nutrition

Background: Moderate and severe acute malnutrition affects 13% of children <5 y of age worldwide. Severe acute malnutrition affects fewer children but is associated with higher rates of mortality and morbidity. Supplementary feeding programs aim to treat moderate acute malnutrition and prevent the deterioration to severe acute malnutrition. Objective: The aim was to compare recovery rates of children with moderate acute malnutrition in supplementary feeding programs by using the newly recommended ration of ready-to-use supplementary food (RUSF) and the more conventional ration of corn-soya blend (CSB) in Ethiopia. Design: A total of 1125 children aged 6-60 mo with moderate acute malnutrition received 16 wk of CSB or RUSF. Children were randomly assigned to receive one or the other food. The daily rations were purposely based on the conventional treatment rations distributed at the time of the study in Ethiopia: 300 g CSB and 32 g vegetable oil in the control group (1413 kcal) and 92 g RUSF in the intervention group (500 kcal). The higher ration size of CSB was provided because of expected food sharing. Results: The HR for children in the CSB group was 0.85 (95% CI: 0.73, 0.99), which indicated that they had 15% lower recovery (P = 0.039). Recovery rates of children at the end of the 16-wk treatment period trended higher in the RUSF group (73%) than in the CSB group (67%) (P = 0.056). Conclusion: In comparison with CSB, the treatment of moderate acute malnutrition with RUSF resulted in higher recovery rates in children, despite the large ration size and higher energy content of the conventional CSB ration. This trial was registered at www.clinicaltrials.gov as NCT 01097889. © 2012 American Society for Nutrition. Source

Teuffel O.,University of Toronto | Amir E.,Princess Margaret Hospital | Alibhai S.M.H.,A+ Network | Alibhai S.M.H.,University of Toronto | And 3 more authors.

OBJECTIVE: Inpatient management remains the standard of care for treatment of febrile neutropenia (FN) in children with cancer. Clinical data suggest, however, that outpatient management might be a safe and efficacious alternative for patients with low-risk FN episodes. METHODS: A cost-utility model was created to compare 4 treatment strategies for low-risk FN. The base case considered pediatric cancer patients with low-risk FN. The model used a health care payer's perspective and a time horizon of 1 FN episode. Four treatment strategies were evaluated: (1) entire treatment in hospital with intravenous antibiotics (HospIV); (2) early discharge consisting of 48 hours of inpatient observation with intravenous antibiotics followed by oral outpatient treatment (EarlyDC); (3) entirely outpatient management with intravenous antibiotics (HomeIV); and (4) entirely outpatient management with oral antibiotics (HomePO). Outcome measures were quality-adjusted FN episodes (QAFNEs), costs (Canadian dollars), and incremental cost-effectiveness ratios. Parameter uncertainty was assessed with probabilistic sensitivity analyses. RESULTS: The most cost-effective strategy was HomeIV. It was cost-saving ($2732 vs $2757) and more effective (0.66 vs 0.55 QAFNE) as compared with HomePO. EarlyDC was slightly more effective (0.68 QAFNE) but significantly more expensive ($5579) than HomeIV, which resulted in an unacceptably high incremental cost-effectiveness ratio of more than $130 000 per QAFNE. HospIV was the least cost-effective strategy because it was more expensive ($14 493) and less effective (0.65 QAFNE) than EarlyDC. CONCLUSION: The findings of this decision-analytic model indicate that the substantially higher costs of inpatient management cannot be justified on the basis of safety and efficacy considerations or patient/parent preferences. Copyright © 2011 by the American Academy of Pediatrics. Source

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