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Aoki F.Y.,University of Manitoba | Allen U.D.,Institute of Health Policy | Allen U.D.,Hospital for Sick Children | Stiver H.G.,University of British Columbia | And 2 more authors.
Canadian Journal of Infectious Diseases and Medical Microbiology | Year: 2012

The present article addresses the use of antiviral drugs in the management of seasonal influenza illness for the 2012/2013 season. It updates the previous document published in 2011 (1). Noteworthy guidance updates since 2011 include the following: • Seasonal influenza in 2012/2013 is predicted to be caused by two human influenza A and one influenza B strain, all of which are anticipated to remain generally susceptible to oseltamivir. • The predicted strains are A/California/7/2009 (H1N1) pdm09-like, A/Victoria/361/2011 (H3N2)-like and B/Wisconsin/1/2010-like (Yamagata lineage). All are included in the seasonal influenza vaccine and are susceptible to oseltamivir. • Swine-variant H3N2v, which has rarely caused infection in humans exposed to infected swine within the past year in the United States, is susceptible to oseltamivir. It is not included in the current seasonal influenza vaccine. • It is still considered that initiation of antiviral therapy more than 36 h to 48 h after onset of symptoms is beneficial in patients hospitalized with complicated influenza and severe illness. • Oseltamivir continues to be recommended for the treatment of influenza in pregnant women. • The use of antiviral drugs among measures to control outbreaks of influenza in closed facilities such as correctional institutions is now included in the present document. © 2012 Pulsus Group Inc.


Rabeneck L.,Institute for Clinical Evaluative science | Rabeneck L.,University of Toronto | Rabeneck L.,Institute of Health Policy | Tinmouth J.M.,Institute for Clinical Evaluative science | And 12 more authors.
Cancer Epidemiology Biomarkers and Prevention | Year: 2014

Background: ColonCancerCheck (CCC), Canada's first province-wide colorectal cancer screening program, was publicly launched in Ontario in April 2008. The objective of this article is to report on key indicators ofCCC Program performance since its inception. Methods: The CCC Program recommends biennial guaiac-based fecal occult blood test (gFOBT) for persons 50 to 74 years of age at average risk for colorectal cancer and colonoscopy for those at increased risk (having one or more first-degree relatives with a diagnosis of colorectal cancer). Opportunistic screening with colonoscopy is available in Ontario. Five data sources were used to compute indicators of program performance during 2008 to 2011. The indicators computed were FOBT participation, overdue for screening, FOBT positivity, positive predictive value (PPV) of FOBT for colorectal cancer, diagnostic follow-up, and colorectal cancer detection rate. Results: In 2011, FOBT participation was 29.8% and 46.8% of the target population was overdue for screening. FOBT positivity was higher among men (5.1%) than women (3.5%), and the PPV of FOBT for cancer was 4.3% in 2011. Follow-up colonoscopy within 6 months of a positive FOBT was completed by 74.6% of Program participants in 2011. The cancer detection rates for FOBT and for colonoscopy in those with a family history were 1.3 per 1,000 and 4.0 per 1,000, respectively, in 2011. Conclusion: These results provide an early indication of Program performance and provide findings relevant to other organized colorectal cancer screening programs. Impact: The greater cancer detection rate in those at increased risk due to family history who undergo colonoscopy screening suggests that a strategy of risk stratification will enhance the impact of FOBT-based screening programs. © 2014 American Association for Cancer Research.


Jain S.,Queen's University of Belfast | Loblaw A.,Institute of Health Policy | Loblaw A.,Odette Cancer Center | Vesprini D.,Odette Cancer Center | And 8 more authors.
Journal of Urology | Year: 2015

Purpose: We report the percentage of patients on active surveillance who had disease pathologically upgraded and factors that predict for upgrading on surveillance biopsies. Materials and Methods: Patients in our active surveillance database with at least 1 repeat prostate biopsy were included. Histological upgrading was defined as any increase in primary or secondary Gleason grade on repeat biopsy. Multivariate analysis was used to determine baseline and dynamic factors associated with Gleason upgrading. This information was used to develop a nomogram to predict for upgrading or treatment in patients electing for active surveillance. Results: Of 862 patients in our cohort 592 had 2 or more biopsies. Median followupwas 6.4 years. Of the patients 20% were intermediate risk, 0.3% were highrisk and all others were low risk. During active surveillance 31.3% of cases were upgraded. On multivariate analysis clinical stage T2, higher prostate specific antigen and higher percentage of cores involved with disease at the time of diagnosis predicted for upgrading. A total of 27 cases (15% of those upgraded) were Gleason 8 or higher at upgrading, and 62% of all 114 upgraded cases went onto have active treatment. The nomogram incorporated clinical stage, age, prostate specific antigen, core positivity and Gleason score. The concordance index was 0.61. Conclusions: In this large re-biopsy cohort with medium-term followup, most cases have not been pathologically upgraded to date. A model predicting forupgrading or radical treatment was developed which could be useful in counseling patients considering active surveillance for prostate cancer. © 2015 American Urological Association Education and Research, Inc.


Tu J.V.,University of Toronto | Tu J.V.,Institute of Health Policy | Austin P.C.,University of Toronto | Austin P.C.,Institute of Health Policy | And 5 more authors.
Circulation: Heart Failure | Year: 2013

Background-Cardiac troponins (cTn) may be elevated among patients with acute heart failure syndromes (AHFS). However, the optimal approach to management of AHFS with elevated cTn is unknown. Methods and Results-We compared the care and outcomes of 13 656 patients with AHFS seeking care in the emergency department stratified by presence (cTn+, n=1845, 13.5%) or absence (cTn-) of elevated troponin. Clinically abstracted data on patients who were admitted or discharged from the emergency department in Ontario, Canada (April 1999 to March 2001 and April 2004 to March 2007) were examined. In an exploratory 2:1 propensity-matched analysis, we examined whether early coronary revascularization (within 14 days of emergency department visit) was associated with survival, stratified by cTn status. For cTn+ AHFS, rates of coronary angiography (21.8 vs 11.4 patients/100 personyears; P<0.001) and coronary revascularization (8.8 vs 3.2 patients/100 person-years; P<0.001) were higher than cTn-. Instantaneous 30-day adjusted hazard ratios for cTn+ versus cTn- patients were 9.17 (95% confidence interval [CI], 8.31-10.12; P<0.001) for death, 5.14 (95% CI, 4.66-5.67; P<0.001) for cardiovascular readmission, and 13.08 (95% CI, 10.95-15.62; P<0.001) for ischemic heart disease hospitalization. In propensity-matched analysis of 143 individuals with cTn+ AHFS, early coronary revascularization was associated with reduced mortality (adjusted hazard ratio, 0.29; 95% CI, 0.09-0.92; P=0.036) compared with those who were not revascularized. Mortality was not significantly reduced among 210 cTn- patients undergoing early coronary revascularization (adjusted hazard ratio, 0.61; 95% CI, 0.36-1.03; P=0.065). Conclusions-Elevated cTn was associated with increased risk of death and cardiovascular hospitalizations. Highly selected cTn+ patients who underwent early coronary revascularization for obstructive coronary artery disease experienced improved survival. © 2013 American Heart Association, Inc.


Krueger H.,University of British Columbia | Krueger H.,H. Krueger and Associates Inc. and 200 4866 Delta Street | Lindsay P.,Institute of Health Policy | Cote R.,McGill University | And 7 more authors.
Stroke | Year: 2012

BACKGROUND AND PURPOSE-: Evidence-based stroke care has been shown to improve patient outcomes and may reduce health system costs. Cost savings, however, are poorly quantified. This study assesses 4 aspects of stroke management (rapid assessment and treatment services, thrombolytic therapy, organized stroke units, and early home-supported discharge) and estimates the potential for cost avoidance in Canada if these services were provided in a comprehensive fashion. METHODS-: Several independent data sources, including the Canadian Institute of Health Information Discharge Abstract Database, the 2008-2009 National Stroke Audit, and the Acute Cerebrovascular Syndrome Registry in the province of British Columbia, were used to assess the current status of stroke care in Canada. Evidence literature was used to estimate the effect of providing optimal stroke care on rates of acute care hospitalization, length of stay in hospital, discharge disposition (including death), changes in quality of life, and costs avoided. RESULTS-: Comprehensive and optimal stroke care in Canada would decrease the number of annual hospital episodes by 1062 (3.3%), the number of acute care days by 166 000 (25.9%), and the number of residential care days by 573 000 (12.8%). The number of deaths in the hospital would be reduced by 1061 (14.9%). Total avoidance of costs was estimated at $682 million annually ($307.4 million in direct costs, $374.3 million in indirect costs). CONCLUSIONS-: The costs of stroke care in Canada can be substantially reduced, at the same time as improving patient outcomes, with the greater use of known effective treatment modalities. © 2012 American Heart Association, Inc.


PubMed | Institute of Health Policy, Ministry of Health, App Quality, University of Heidelberg and 2 more.
Type: | Journal: International journal for quality in health care : journal of the International Society for Quality in Health Care | Year: 2016

The 2030 Sustainable Development Agenda emphasizes the importance of quality of care in the drive to achieve universal health coverage. Despite recent progress, challenges in service delivery, efficiency and resource utilization in the health sector remain.The Ministry of Health Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end, the European Practice Assessment (EPA) was adapted to the area of Reproductive and Maternal and Neonatal Health.The adaptation process made use of a ten step-modified RAND Corporation/University of California Los Angeles (UCLA) Appropriateness Method. The steps included a scoping workshop, definition of five critical domains of quality in the Kenyan context (People, Management, Clinical Care, Quality & Safety, Interface between inpatients and outpatients care), a review of policy documents, management and clinical guidelines, grey and scientific literature to identify indicators in use in the Kenyan health system and an expert panel process to rate their feasibility and validity.The resulting 278 indicators, clustered across the five domains, were broken-down into 29 dimensions and assigned measure specifications. A set of data collection tools were developed to furnish the indicators and piloted at two health facilities. They were subsequently finalized for use in 30 health facilities in 3 counties.The integrative and indicator-based aspects of the EPA process could be readily adapted to facilitate the operationalization of a practical quality assurance approach in Kenya.


Sapir-Pichhadze R.,University of Toronto | Sapir-Pichhadze R.,Institute of Health Policy | Tinckam K.J.,University of Toronto | Laupacis A.,University of Toronto | And 9 more authors.
Journal of the American Society of Nephrology | Year: 2016

Cardiovascular mortality is the leaDing cause of death in ESRD. Whereas innate and adaptive immunity have established roles in cardiovascular disease, the role of humoral immunity is unknown.Weconducted a retrospective cohort study in first-time adult kidney transplant candidates (N=161,308) using data from the Scientific Registry of Transplant Recipients and the Centers for Medicare and Medicaid Services to evaluatewhether anti-human leukocyte antigen antibodies,measured as panel reactive antibodies (PRAs), are related to mortality in ESRD. Relationships between time-varying PRAs and all-cause or cardiovascular mortality were assessed using Cox proportional hazards models. The analysis was repeated in subcohorts of candidates at lower risk for significant comorbidities, activated on the waiting list after 2007, or unsensitized at activation. Competing risks analyses were also conducted. Fully adjusted models showed increased hazard ratios (HRs [95% confidence intervals]) for all-cause mortality (HR, 1.02 [95% CI, 0.99 to 1.06]; HR, 1.11 [95% CI,1.07 to 1.16]; and HR,1.21 [95% CI,1.15 to 1.27]) and cardiovascular mortality (HR, 1.05 [95% CI,1.00 to 1.10]; HR,1.11 [95% CI,1.05 to 1.18]; and HR,1.21 [95% CI,1.12 to 1.31]) in PRA 1%-19%, PRA 20%-79%, and PRA 80%-100% categories compared with PRA 0%, respectively. Associations between PRA and the study outcomes were accentuated in competing risks models and in lower-risk patients and persisted in other subcohorts. Our findings suggest that PRA is an independent predictor of mortality in wait-listed kidney transplant candidates. The mechanisms by which PRA confers an incremental mortality risk in sensitized patients, and the role of transplantation in modifying this risk, warrant further study. Copyright © 2016 by the American Society of Nephrology.


Tsasis P.,York University | Evans J.M.,Institute of Health Policy | Forrest D.,Global Vision Consulting Ltd | Keith Jones R.,R Keith Jones and Associates
Journal of Multidisciplinary Healthcare | Year: 2013

Health systems around the world are implementing integrated care strategies to improve quality, reduce or maintain costs, and improve the patient experience. Yet few practical tools exist to aid leaders and managers in building the prerequisites to integrated care, namely a shared vision, clear roles and responsibilities, and a common understanding of how the vision will be realized. Outcome mapping may facilitate stakeholder alignment on the vision, roles, and processes of integrated care delivery via participative and focused dialogue among diverse stakeholders on desired outcomes and enabling actions. In this paper, we describe an outcomemapping exercise we conducted at a Local Health Integration Network in Ontario, Canada, using consensus development conferences. Our preliminary findings suggest that outcome mapping may help stakeholders make sense of a complex system and foster collaborative capital, a resource that can support information sharing, trust, and coordinated change toward integration across organizational and professional boundaries. Drawing from the theoretical perspectives of complex adaptive systems and collaborative capital, we also outline recommendations for future outcome-mapping exercises. In particular, we emphasize the potential for outcome mapping to be used as a tool not only for identifying and linking strategic outcomes and actions, but also for studying the boundaries, gaps, and ties that characterize social networks across the continuum of care. © 2013 Tsasis et al, publisher and licensee Dove Medical Press Ltd.


Berndl A.,McMaster University | El-Chaar D.,University of Toronto | Murphy K.,University of Toronto | Murphy K.,Institute of Health Policy | McDonald S.,McMaster University
Journal of Obstetrics and Gynaecology Canada | Year: 2014

Cervical ripening with a Foley catheter before induction of labour is a common obstetrical intervention. In this study we aimed to evaluate primarily the relationship between high or low volume Foley catheters used for cervical ripening and Caesarean section, and secondarily the relationship between Foley catheter volume, cervical ripeness, and time to delivery. We searched Medline and Embase from their inceptions with the assistance of an experienced librarian. All abstracts and complete articles were independently reviewed by two reviewers, according to predefined inclusion criteria. Six hundred forty-eight abstracts were identified, and 30 complete articles were read in full. Three articles with a total of 575 participating women met the inclusion criteria. The rate of Caesarean section with use of 80 mL Foley catheters was not significantly different from the rate using 30 mL Foley catheters (RR 0.82; 95% CI 0.48 to 1.41). A favourable cervix (which was defined heterogeneously) was more common with high volume catheters (RR 1.72; 95% CI 1.46 to 2.04), and failure to deliver in 24 hours was lower (RR 0.70; 95% CI 0.54 to 0.90). High volume Foley catheters improve the likelihood of a favourable cervix and chance of delivery in 24 hours more than low volume Foley catheters. As a more favourable cervix before induction of labour is associated with a lower rate of Caesarean section, a randomized controlled trial comparing high and low volume Foley catheters for cervical ripening using Caesarean section as the primary outcome is warranted. © 2014 Society of Obstetricians and Gynaecologists of Canada.


Hanson M.D.,University of Toronto | Kulasegaram K.M.,McMaster University | Kulasegaram K.M.,University of Toronto | Woods N.N.,University of Toronto | And 3 more authors.
Academic Medicine | Year: 2012

Purpose: Traditional admissions personal interviews provide flexible faculty-student interactions but are plagued by low inter-interview reliability. Axelson and Kreiter (2009) retrospectively showed that multiple independent sampling (MIS) may improve reliability of personal interviews; thus, the authors incorporated MIS into the admissions process for medical students applying to the University of Toronto's Leadership Education and Development Program (LEAD). They examined the reliability and resource demands of this modified personal interview (MPI) format. Method: In 2010-2011, LEAD candidates submitted written applications, which were used to screen for participation in the MPI process. Selected candidates completed four brief (10-12 minutes) independent MPIs each with a different interviewer. The authors blueprinted MPI questions to (i.e., aligned them with) leadership attributes, and interviewers assessed candidates' eligibility on a five-point Likert-type scale. The authors analyzed inter-interview reliability using the generalizability theory. Results: Sixteen candidates submitted applications; 10 proceeded to the MPI stage. Reliability of the written application components was 0.75. The MPI process had overall inter-interview reliability of 0.79. Correlation between the written application and MPI scores was 0.49. A decision study showed acceptable reliability of 0.74 with only three MPIs scored using one global rating. Furthermore, a traditional admissions interview format would take 66% more time than the MPI format. Conclusions: The MPI format, used during the LEAD admissions process, achieved high reliability with minimal faculty resources. The MPI format's reliability and effective resource use were possible through MIS and employment of expert interviewers. MPIs may be useful for other admissions tasks.

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