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White H.L.,University of Toronto | Macpherson A.K.,York University | Macpherson A.K.,The Institute for Clinical Evaluative science
Injury Prevention

Objective Population-based health surveys are increasingly popular sources of data on injury occurrence. Self-reported surveys can yield estimates of the total incidence of non-fatal injuries while simultaneously capturing a rich repository of contextual data that may be informative for exploring determinants of injury risk. Although survey data are rarely recognised as complete, several researchers have expressed concerns about the sensitivity and validity of self-reported injury data, questioning whether captured cases are representative of the population experience of injury, particularly among children and youth. The present study sought to compare the population incidence of paediatric injury estimated from self-reported survey responses to those documented by a complete-capture health service utilisation database among Ontario children. Methods Injury incidence rates documented from the National Longitudinal Survey of Children and Youth and the National Population Health Survey were compared with those reported in Canada's National Ambulatory Care Reporting System for Ontario youth aged 0-19 years for fiscal year 2002/3, stratified by the child's age and geographical location of residence. Results The two self-reported health surveys underestimated the population incidence of injury among Ontario children by at least 49% and 53%, respectively. Systematic errors exist in survey data capture such that injuries in infants and preschoolers (<4 years of age) and urban residents were most likely to be missed by the population health surveys. Conclusion Injury incidence estimated through selfreport is not representative of the population burden and experience of paediatric injury for Ontario children, and may produce biased estimates of risk when analysed as independent sources of data. Source

Tuite A.R.,University of Toronto | Fisman D.N.,University of Toronto | Kwong J.C.,University of Toronto | Kwong J.C.,The Institute for Clinical Evaluative science | Greer A.L.,Public Health Agency of Canada

Background: The world is currently confronting the first influenza pandemic of the 21st century. Influenza vaccination is an effective preventive measure, but the unique epidemiological features of swine-origin influenza A (H1N1) (pH1N1) introduce uncertainty as to the best strategy for prioritization of vaccine allocation. We sought to determine optimal prioritization of vaccine distribution among different age and risk groups within the Canadian population, to minimize influenzaattributable morbidity and mortality. Methodology/Principal Findings: We developed a deterministic, age-structured compartmental model of influenza transmission, with key parameter values estimated from data collected during the initial phase of the epidemic in Ontario, Canada. We examined the effect of different vaccination strategies on attack rates, hospitalizations, intensive care unit admissions, and mortality. In all scenarios, prioritization of high-risk individuals (those with underlying chronic conditions and pregnant women), regardless of age, markedly decreased the frequency of severe outcomes. When individuals with underlying medical conditions were not prioritized and an age group-based approach was used, preferential vaccination of age groups at increased risk of severe outcomes following infection generally resulted in decreased mortality compared to targeting vaccine to age groups with higher transmission, at a cost of higher population-level attack rates. All simulations were sensitive to the timing of the epidemic peak in relation to vaccine availability, with vaccination having the greatest impact when it was implemented well in advance of the epidemic peak. Conclusions/Significance: Our model simulations suggest that vaccine should be allocated to high-risk groups, regardless of age, followed by age groups at increased risk of severe outcomes. Vaccination may significantly reduce influenza-attributable morbidity and mortality, but the benefits are dependent on epidemic dynamics, time for program roll-out, and vaccine uptake. © 2010 Tuite et al. Source

White H.L.,University of Toronto | Glazier R.H.,University of Toronto | Glazier R.H.,The Institute for Clinical Evaluative science
BMC Medicine

Background: Despite more than a decade of research on hospitalists and their performance, disagreement still exists regarding whether and how hospital-based physicians improve the quality of inpatient care delivery. This systematic review summarizes the findings from 65 comparative evaluations to determine whether hospitalists provide a higher quality of inpatient care relative to traditional inpatient physicians who maintain hospital privileges with concurrent outpatient practices.Methods: Articles on hospitalist performance published between January 1996 and December 2010 were identified through MEDLINE, Embase, Science Citation Index, CINAHL, NHS Economic Evaluation Database and a hand-search of reference lists, key journals and editorials. Comparative evaluations presenting original, quantitative data on processes, efficiency or clinical outcome measures of care between hospitalists, community-based physicians and traditional academic attending physicians were included (n = 65). After proposing a conceptual framework for evaluating inpatient physician performance, major findings on quality are summarized according to their percentage change, direction and statistical significance.Results: The majority of reviewed articles demonstrated that hospitalists are efficient providers of inpatient care on the basis of reductions in their patients' average length of stay (69%) and total hospital costs (70%); however, the clinical quality of hospitalist care appears to be comparable to that provided by their colleagues. The methodological quality of hospitalist evaluations remains a concern and has not improved over time. Persistent issues include insufficient reporting of source or sample populations (n = 30), patients lost to follow-up (n = 42) and estimates of effect or random variability (n = 35); inappropriate use of statistical tests (n = 55); and failure to adjust for established confounders (n = 37).Conclusions: Future research should include an expanded focus on the specific structures of care that differentiate hospitalists from other inpatient physician groups as well as the development of better conceptual and statistical models that identify and measure underlying mechanisms driving provider-outcome associations in quality. © 2011 White and Glazier; licensee BioMed Central Ltd. Source

Awad N.I.,Rutgers University | Awad N.I.,Johnson University | Brunetti L.,Rutgers University | Brunetti L.,Johnson University | And 3 more authors.
Journal of Medical Toxicology

Several pharmacokinetic studies have suggested that dabigatran possesses a number of ideal properties for expedited removal via extracorporeal methods. However, this practice has not been prospectively evaluated in patients with life-threatening bleeding or requiring emergency surgery secondary to dabigatran-associated coagulopathy. The purpose of this literature review is to evaluate the published evidence surrounding extracorporeal removal of dabigatran in the setting of emergency surgery or life-threatening bleeding. A query of MEDLINE, Web of Science, International Pharmaceutical Abstracts, and Google Scholar using the terms dabigatran, dabigatran etexilate, hemodialysis, renal replacement therapy, hemorrhage, and atrial fibrillation was used to retrieve relevant literature. Furthermore, a manual search of the references of the identified literature was performed to capture additional data. Current evidence suggests that extracorporeal removal of dabigatran may play a role in the setting of life-threatening bleeding and emergent surgery. Conflicting evidence exists with regard to the potential for redistribution based on serum dabigatran concentrations. In addition, a number of practicalities must be considered before incorporating this technique in the clinical setting. Extracorporeal removal of dabigatran may be a treatment modality in selected patients who require emergency reversal. © 2014, American College of Medical Toxicology. Source

Rhodes A.E.,Li Ka Shing Knowledge Institute | Rhodes A.E.,University of Toronto | Rhodes A.E.,The Institute for Clinical Evaluative science | Boyle M.H.,McMaster University | And 8 more authors.
Child Abuse and Neglect

Objectives: To determine whether the rates of a first presentation to the emergency department (ED) for suicide-related behavior (SRB) are higher among children/youth permanently removed from their parental home because of substantiated maltreatment than their peers. To describe the health care settings accessed by these children/youth before a first SRB presentation to help design preventive interventions. Methods: A population-based (retrospective) cohort of 12-17-year-olds in Ontario, Canada was established. Children/youth removed from their parental home because of the above noted maltreatment (n=4683) and their population-based peers (n=1,034,546) were individually linked to administrative health care records over time to ascertain health service use and subsequent ED presentations for SRB during follow-up. Person-time incidence rates were calculated and Cox regression models used to estimate adjusted hazard ratios (HR) and corresponding 95% confidence intervals (CI). Results: After controlling for demographic characteristics and prior health service use, maltreated children/youth were about five times more likely to have a first ED presentation for SRB compared to their peers, in both boys (HR: 5.13, 95% CI: 3.94, 6.68) and girls (HR: 5.36, 95% CI: 4.40, 6.54). Conclusions: Children/youth permanently removed from their parental home because of substantiated child maltreatment are at an increased risk of a first presentation to the ED for SRB. The prevention of child maltreatment and its recurrence and the promotion of resilience after maltreatment has occurred are important avenues to study toward preventing ED SRB presentations in children/youth. Provider and system level linkages between care sectors may prevent the need for such presentations by providing ongoing environmental support. © 2012 Elsevier Ltd. Source

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