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Van Hulst A.,University of Montréal | Barnett T.A.,University of Montréal | Dery V.,Institute National dExcellence en Sante et en Services Sociaux INESSS | Colin C.,University of Montréal
Canadian Journal of Dietetic Practice and Research | Year: 2013

Purpose: Taking advantage of a natural experiment made possible by the placement of health-promoting vending machines (HPVMs), we evaluated the impact of the intervention on consumers' attitudes toward and practices with vending machines in a pediatric hospital. Methods: Vending machines offering healthy snacks, meals, and beverages were developed to replace four vending machines offering the usual high-energy, low-nutrition fare. A pre- and post-intervention evaluation design was used; data were collected through exit surveys and six-week follow-up telephone surveys among potential vending machine users before (n=293) and after (n=226) placement of HPVMs. Chi-2 statistics were used to compare pre- and post-intervention participants' responses. Results: More than 90% of pre- and post-intervention participants were satisfied with their purchase. Post-intervention participants were more likely to state that nutritional content and appropriateness of portion size were elements that influenced their purchase. Overall, post-intervention participants were more likely than pre-intervention participants to perceive as healthy the options offered by the hospital vending machines. Thirty-three percent of post-intervention participants recalled two or more sources of information integrated in the HPVM concept. No differences were found between pre- and postintervention participants' readiness to adopt healthy diets. Conclusions: While the HPVM project had challenges as well as strengths, vending machines offering healthy snacks are feasible in hospital settings.

Lambert L.J.,Institute National Dexcellence en Sante et en Services Sociaux INESSS | Brown K.A.,Institute National Dexcellence en Sante et en Services Sociaux INESSS | Boothroyd L.J.,Institute National Dexcellence en Sante et en Services Sociaux INESSS | Segal E.,General Hospital | And 12 more authors.
Circulation | Year: 2014

Background-Interhospital transfer of patients with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PPCI) is associated with longer delays to reperfusion, related in part to turnaround ("door in" to "door out," or DIDO) time at the initial hospital. As part of a systematic, province-wide evaluation of STEMI care, we examined DIDO times and associations with patient, hospital, and process-of-care factors. Methods and Results-We performed medical chart review for STEMI patients transferred for PPCI during a 6-month period (October 1, 2008, through March 31, 2009) and linked these data to ambulance service databases. Two core laboratory cardiologists reviewed presenting ECGs to identify left bundle-branch block and, in the absence of left bundlebranch block, definite STEMI (according to both cardiologists) or an ambiguous reading. Median DIDO time was 51 minutes (25th to 75th percentile: 35-82 minutes); 14.1% of the 988 patients had a timely DIDO interval (?30 minutes as recommended by guidelines). The data-to-decision delay was the major contributor to DIDO time. Female sex, more comorbidities, longer symptom duration, arrival by means other than ambulance, arrival at a hospital not exclusively transferring for PPCI, arrival at a center with a low STEMI volume, and an ambiguous ECG were independently associated with longer DIDO time. When turnaround was timely, 70% of patients received timely PPCI (door-to-device time ?90 minutes) versus 14% if turnaround was not timely (P<0.0001). Conclusions-Benchmark DIDO times for STEMI patients transferred for PPCI were rarely achieved. Interventions aimed at facilitating the transfer decision, particularly in cases of ECGs that are difficult to interpret, are likely to have the best impact on reducing delay to reperfusion © 2014 American Heart Association, Inc..

PubMed | Center Hospitalier Regional Of Lanaudiere, McGill University, Lady Davis Institute for Medical Research, University of Quebec at Montréal and 6 more.
Type: Journal Article | Journal: The Canadian journal of cardiology | Year: 2016

Hospitals treating patients with ST-elevation myocardial infarction (STEMI) may show good results with reperfusion treatment (fibrinolysis or primary percutaneous coronary intervention [PPCI]), but a comprehensive evaluation should factor in outcomes of patients with STEMI who do not receive reperfusion. We compared outcomes of patients receiving and not receiving reperfusion within a complete system of STEMI care by hospital type: PPCI centres, fibrinolysis centres, centres that only transfer for PPCI, and centres providing a mix of fibrinolysis and PPCI transfer.All patients presenting to 82 Quebec hospitals with characteristic symptoms, a final diagnosis of acute myocardial infarction, and core-laboratory confirmed STEMI over two 6-month periods were studied.Of the total 3731 patients with STEMI, 2918 (78.2%) received reperfusion treatment (81% PPCI, 19% fibrinolysis); 813 (21.8%) did not. For reperfusion-treated patients, 30-day mortality was 5.4% in PPCI centres, 5.4% in fibrinolysis centres, 6.9% in transfer PPCI centres, and 6.0% in mixed centres (P= 0.55). For untreated patients, 30-day mortality was 15.7% (PPCI centres), 16.1% (fibrinolysis centres), 21.8% (transfer PPCI), and 24.6% (mixed) (P= 0.08). Adjusted mortality odds ratios for all patients were 1.00 (PPCI centres), 1.50 (95% CI: 0.97-2.32; fibrinolysis centres), 1.30 (0.95-1.78; transfer PPCI centres), and 1.58 (1.09-2.29; mixed centres). PPCI was within recommended delays in 35.4%, 11.9%, and 1.2% of PPCI, transfer, and mixed centres, respectively.Mixed centres had the highest crude and adjusted all-patient 30-day STEMI mortality. Relatively good outcomes of reperfusion-treated patients, despite long treatment delays, can misrepresent overall performance if untreated patients are not examined.

PubMed | Center Hospitalier Regional Of Lanaudiere, Lady Davis Institute for Medical Research, University of Quebec at Montréal, St Pauls Hospital and 6 more.
Type: Journal Article | Journal: The American journal of cardiology | Year: 2016

Patients with ST-elevation myocardial infarction (STEMI) who die in hospital before inpatient admission are generally not included in clinical studies and registries, and the clinical profiles of patients who die earlier versus later are not well defined. We aimed to characterize all patients with STEMI who arrived at emergency departments in the province of Quebec (Canada) based on inpatient admission status and when they died. All patients who presented with symptoms and core laboratory-confirmed STEMI or left bundle branch block during 6 months in 82 hospitals in Quebec were included. Death certificates were used to identify nonadmitted deaths. Of the 2017 patients with STEMI, 340 (16.9%) died within 1 year. Of the latter, 63 (18.5%) were nonadmitted deaths (group A), 179 (52.6%) were deaths after admission but within 30 days (group B), and 98 (28.8%) were deaths after 30 days to 1 year (group C). Group A was younger and most often hemodynamically unstable, followed for both features by B then C. Earliest presentation from symptom onset and most frequent ambulance use were found in group A, followed by B, then C. Presenting electrocardiogram (ECG) features were most severe in A, then B, then C (more arrhythmias, more anterior STEMI, more leads with ST elevation, and higher ST elevation). Patients who died earliest had the least frequency of previous myocardial infarction, coronary revascularization, vascular disease, and heart failure, and the least noncardiac co-morbidity. In conclusion, patients with STEMI dying in hospital before inpatient admission contributed substantially to overall STEMI mortality. Although dying patients who presented earlier had severer presenting clinical profiles, they were paradoxically younger and had less co-morbidity. Previous co-morbidities may favor adaptive protective mechanisms on initial presentation with STEMI.

Rossignol M.,Institute national dexcellence en sante et en services sociaux INESSS | Rossignol M.,McGill University | Chaillet N.,Université de Sherbrooke | Boughrassa F.,Institute national dexcellence en sante et en services sociaux INESSS | Moutquin J.-M.,McGill University
Birth | Year: 2014

Objectives: To critically appraise the literature on the relations between four intrapartum obstetric interventions-electronic fetal monitoring (EFM), epidural analgesia, labor induction, and labor acceleration; and two types of delivery-instrumental (forceps and vacuum) and cesarean section. Methods: This review included meta-analyses published between January 2000 and April 2012 including at least one randomized clinical trial published after 1995 and presenting results on low-risk pregnancies between 37 and 42 weeks of gestation, searched in the databases Medline, Cochrane Library, and EMBASE with no language restriction. Results: Of 306 documents identified, 8 fulfilled the inclusion criteria and presented results on women at low risk. EFM at admission (vs intermittent auscultation) was associated with cesarean delivery (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.00-1.44) and epidural analgesia (OR = 1.25, 95% CI 1.09-1.43). Epidural on request was associated with cesarean delivery (OR = 1.60, 95% CI 1.18-2.18), instrumental delivery (OR = 1.21, 95% CI 1.03-1.44), and oxytocin use (OR = 1.20, 95% CI 1.01-1.43) when compared with epidural on request plus nonpharmacological labor pain control methods such as one-to-one support, breathing techniques, and relaxation. Induction and acceleration of labor showed heterogeneous patterns of associations with cesarean delivery and instrumental delivery. Conclusions: Complex patterns of associations between obstetric interventions and modes of delivery were illustrated in an empirical model. Intermittent auscultation and nonpharmacological labor pain control interventions, such as one-to-one support during labor, have the potential for substantially reducing cesarean deliveries. © 2014, Wiley Periodicals, Inc.

PubMed | McGill University, Universte du Quebec en Outaouais, Université de Sherbrooke and Institute national dexcellence en sante et en services sociaux INESSS
Type: | Journal: International journal of public health | Year: 2016

In Quebec, various actors fund activities aimed at increasing physical activity, improving eating habits and reducing smoking. The objective was to evaluate how effective does the healthy lifestyle habits promotion (HLHP) strategy need to be to make to offset its costs.First, we built the logic model of the HLHP strategy. We then assessed the strategys total cost as well as the direct health care expenditures associated with lifestyle-related risk factors (smoking, physical inactivity, insufficient intake of fruits and vegetables, obesity and overweight). Finally, we estimated the break-even point beyond which the economic benefits of the HLHP strategy would outweigh its costs.The HLHP strategy cost for 2010-2011 was estimated at $110million. Direct healthcare expenditures associated with lifestyle-related risk factors were estimated at $4.161billion. We estimated that 47% of these expenditures were attributable to these risk factors.We concluded that the HLHP strategy cost corresponded to 5.6% of the annual healthcare expenditures attributable to these risk factors. This study compared the economic value of HLHP activities against healthcare expenditures associated with targeted risk factors.

PubMed | McGill University, Institute National Of Sante Publique Du Quebec Inspq, Institute national dexcellence en sante et en services sociaux INESSS and Laval University
Type: Journal Article | Journal: Journal of vascular surgery | Year: 2015

This study proposes the DEDE (Door-from-Emergency to Door-to-EVAR [endovascular aneurysm repair]) time as a new metric for ruptured abdominal aortic aneurysm (RAAA) delay time to surgery, permitting coherent centralization in large territories. It demonstrates how the DEDE time can be applied, using data from the province of Quebec, and looks at its potential effect on 30-day mortality.We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS), the linkage of five health administrative databases, to build a retrospective cohort of RAAA patients repaired operatively between April 1, 2006, and March 31, 2013. A validated algorithm was used to identify open surgical repair (OSR) and EVAR patients. Hospitals performing these operations were further characterized according to their location, volume of RAAA, types of surgeries (OSR vs EVAR), and surgeons volume. Logistic and log-binomial regression analyses identified the risk of 30-day mortality with age, sex, hospital volume, and surgical groups as variables. Using the DEDE 90 metric and the attributable fraction, we projected how centralization and increasing the number of EVAR would affect the 30-day mortality.Among patients aged 65 years, 895 RAAAs were identified. OSR was performed in 839 patients (93.7%) and EVAR in 56 (6.3%). The overall 30-day mortality was 34.4%, and more specifically, was 35.5% for OSR compared with 17.9% for EVAR (P = .0046). RAAAs were treated in 39 hospitals, including 16 centers averaging less than one RAAA repair per year. Low-volume (39.4%) vs high-volume centers (32.5%) had similar 30-day mortality (P = .2198). In the multivariate analysis, the relative risk for OSR was 1.95 (P = .0211) and was not significant for hospital volume. Applying the DEDE 90 metric and increasing access to EVAR to 50% of patients, the overall 30-day mortality would be 26.8%.DEDE 90 is a new metric for a coherent centralization model, particularly in large territories, where transport time is crucial. Increasing access to EVAR performed in high-volume centers, with consideration to transport time, could improve the 30-day mortality after a RAAA repair.

Lambert L.,Institute national dexcellence en sante et en services sociaux INESSS | Blais C.,Institute National Of Sante Publique Du Quebec Inspq | Blais C.,Laval University | Hamel D.,Institute National Of Sante Publique Du Quebec Inspq | And 7 more authors.
Canadian Journal of Cardiology | Year: 2012

Background: The evaluation of care and the surveillance of disease are important in respect to cardiovascular disease because it is prevalent and costly. In Canada, medico-administrative hospital data are readily available, continuously updated, and offer comprehensive coverage of the patient population. However, there is concern about the quality of the information. Methods: The reliability and predictive capability of comorbidity data contained within Québec's hospital discharge database were assessed in comparison with data collected by clinical medical record reabstraction in a sample of 1989 patients hospitalized from 2002 to 2006 in a mix of 13 hospitals. Patients either had a principal diagnosis of myocardial infarction or underwent angioplasty or bypass surgery. Twenty-one comorbidities included in the Charlson comorbidity index or known to be associated with mortality were validated via medical record reabstraction. Results: Of 14 comorbidities with > 2% prevalence, 8 had excellent agreement with medical record review (κ > 0.8) while 6 had substantial agreement (κ > 0.6). In general, positive predictive values were high, while measures of sensitivity were more variable. Univariate associations between comorbidities and 30-day and 1-year mortality were generally similar in the 2 data sources. Comorbidities retained in the final multivariate stepwise regression models from each data source were almost identical, as were the 2 models' abilities to predict mortality. Conclusions: Hospital discharge data in Québec are, in general, reliably coded and compare favourably with clinical medical record review in their ability to predict mortality. It appears sufficiently reliable to provide useful information about clinical outcomes of cardiac care and to identify problems that warrant investigation. © 2012 Canadian Cardiovascular Society.

Beauchemin C.,University of Montréal | Cooper D.,Institute national dexcellence en sante et en services sociaux INESSS | Lapierre M.-E.,University of Montréal | Yelle L.,University of Montréal | Lachaine J.,University of Montréal
OncoTargets and Therapy | Year: 2014

Background: Progression-free survival (PFS) and time to progression (TTP) are frequently used to establish the clinical efficacy of anti-cancer drugs. However, the surrogacy of PFS/TTP for overall survival (OS) remains a matter of uncertainty in metastatic breast cancer (mBC). This study assessed the relationship between PFS/TTP and OS in mBC using a trial-based approach. Methods: We conducted a systematic literature review according to the PICO method: 'Population' consisted of women with mBC; 'Interventions' and 'Comparators' were standard treatments for mBC or best supportive care; 'Outcomes' of interest were median PFS/TTP and OS. We first performed a correlation analysis between median PFS/TTP and OS, and then conducted subgroup analyses to explore possible reasons for heterogeneity. Then, we assessed the relationship between the treatment effect on PFS/TTP and OS. The treatment effect on PFS/ TTP and OS was quantified by the absolute difference of median values. We also conducted linear regression analysis to predict the effects of a new anti-cancer drug on OS on the basis of its effects on PFS/TTP. Results: A total of 5,041 studies were identified, and 144 fulfilled the eligibility criteria. There was a statistically significant relationship between median PFS/TTP and OS across included trials (r=0.428; P,0.01). Correlation coefficient for the treatment effect on PFS/TTP and OS was estimated at 0.427 (P,0.01). The obtained linear regression equation was ΔOS =-0.088 (95% confidence interval [CI] -1.347-1.172) + 1.753 (95% CI 1.307-2.198) × ΔPFS (R2=0.86). Conclusion: Results of this study indicate a significant association between PFS/TTP and OS in mBC, which may justify the use of PFS/TTP in the approval for commercialization and reimbursement of new anti-cancer drugs in this cancer setting. © 2014 Beauchemin et al.

Fournier M.F.,Institute national dexcellence en sante et en services sociaux INESSS
Health Research Policy and Systems | Year: 2012

Background: Finding measures to enhance the dissemination and implementation of their recommendations has become part of most health technology assessment (HTA) bodies' preoccupations. The Quebec government HTA organization in Canada observed that some of its projects relied on innovative practices in knowledge production and dissemination. A research was commissioned in order to identify what characterized these practices and to establish whether they could be systematized.Methods: An exploratory case study was conducted during summer and fall 2010 in the HTA agency in order to determine what made the specificity of its context, and to conceptualize an approach to knowledge production and dissemination that was adapted to the mandate and nature of this form of HTA organization. Six projects were selected. For each, the HTA report and complementary documents were analyzed, and semi-structured interviews were carried out. A narrative literature review of the most recent literature reviews of the principal knowledge into practice frameworks (2005-2010) and of articles describing such frameworks (2000-2010) was undertaken.Results and discussion: Our observations highlighted an inherent difficulty as regards applying the dominant knowledge translation models to HTA and clinical guidance practices. For the latter, the whole process starts with an evaluation question asked in a problematic situation for which an actionable answer is expected. The objective is to produce the evidence necessary to respond to the decision-maker's request. The practices we have analyzed revealed an approach to knowledge production and dissemination, which was multidimensional, organic, multidirectional, dynamic, and dependent on interactions with stakeholders. Thus, HTA could be considered as a knowledge mobilization process per se.Conclusions: HTA's purpose is to solve a problem by mobilizing the types of evidence required and the concerned actors, in order to support political, organizational or clinical decision-making. HTA relies on the mediation between contextual, colloquial and scientific evidence, as well as on interactions with stakeholders for recommendation making. Defining HTA as a knowledge mobilization process might contribute to consider the different orders of knowledge, the social, political and ethical dimensions, and the interactions with stakeholders, among the essential components required to respond to the preoccupations, needs and contexts of all actors concerned with the evaluation question's issues. © 2012 Fournier; licensee BioMed Central Ltd.

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