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Tu J.V.,Institute for Clinical Evaluative science | Tu J.V.,Sunnybrook Schulich Heart Center | Tu J.V.,University of Toronto | Abrahamyan L.,Institute for Clinical Evaluative science | And 3 more authors.
Canadian Journal of Cardiology | Year: 2013

The Canadian Heart Health Strategy and Action Plan recommended that the Canadian Cardiovascular Society (CCS) lead the development of pan-Canadian data definitions and quality indicators (QIs) for evaluating cardiovascular care in Canada. In response to this recommendation, the CCS developed and adopted a standardized QI development methodology. This report provides a brief overview of the CCS "Best Practices" for developing pan-Canadian cardiovascular QIs. A more detailed description is available in Supplemental Material. The CCS Best Practices QI development methodology consists of 3 phases: phase I, plan and organize the QI development initiative; phase II, develop and select QIs; and phase III, operationalize the QIs. Phase I includes identifying the cardiovascular focus or content area, determining the objective and/or purpose of the initiative, the target users of, and the target population for, the QIs, and selection of a QI working group. Phase II involves formulating the QIs including generating a preliminary set of QIs and draft definitions, followed by an indicator rating and ranking process based on the CCS QI rating criteria. Phase III involves finalizing technical specifications and pilot testing the QIs. It also describes the CCS QI approval process and addresses knowledge translation. Adoption of a standardized methodology for QI development will improve the quality, completeness, acceptability, and usability of pan-Canadian cardiovascular QIs developed by the CCS. Public release of the QI definitions and related performance data might help improve patient care quality and outcomes. © 2013 Canadian Cardiovascular Society.


Sander B.,University of Toronto | Sander B.,Toronto Health Economics and Technology Assessment Collaborative | Kwong J.C.,Institute for Clinical Evaluative science | Kwong J.C.,University of Toronto | And 7 more authors.
PLoS Medicine | Year: 2010

Background: In July 2000, the province of Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free seasonal influenza vaccines for the entire population. This is the first large-scale program of its kind worldwide. The objective of this study was to conduct an economic appraisal of Ontario's UIIP compared to a targeted influenza immunization program (TIIP). Methods and Findings: A cost-utility analysis using Ontario health administrative data was performed. The study was informed by a companion ecological study comparing physician visits, emergency department visits, hospitalizations, and deaths between 1997 and 2004 in Ontario and nine other Canadian provinces offering targeted immunization programs. The relative change estimates from pre-2000 to post-2000 as observed in other provinces were applied to pre-UIIP Ontario event rates to calculate the expected number of events had Ontario continued to offer targeted immunization. Main outcome measures were quality-adjusted life years (QALYs), costs in 2006 Canadian dollars, and incremental cost-utility ratios (incremental cost per QALY gained). Program and other costs were drawn from Ontario sources. Utility weights were obtained from the literature. The incremental cost of the program per QALY gained was calculated from the health care payer perspective. Ontario's UIIP costs approximately twice as much as a targeted program but reduces influenza cases by 61% and mortality by 28%, saving an estimated 1,134 QALYs per season overall. Reducing influenza cases decreases health care services cost by 52%. Most cost savings can be attributed to hospitalizations avoided. The incremental cost-effectiveness ratio is Can$10,797/QALY gained. Results are most sensitive to immunization cost and number of deaths averted. Conclusions: Universal immunization against seasonal influenza was estimated to be an economically attractive intervention.


Fischer B.,Simon Fraser University | Fischer B.,Center for Addiction and Mental Health | Jones W.,Simon Fraser University | Krahn M.,Toronto Health Economics and Technology Assessment Collaborative | And 3 more authors.
Pharmacoepidemiology and Drug Safety | Year: 2011

Purpose: To examine qualitative and quantitative levels and trends of prescription opioid analgesics ("opioids") use and the potential impact of prescription monitoring programs (PMPs), in the 10 Canadian provinces, for 2005-2010. Methods: Opioid dispensing data from a representative sample of 2700 retail pharmacies were obtained. Individual opioid dispensing values were translated into defined daily doses per day/1000 population and categorized into "weak opioids" and "strong opioids" by standardized methods. Opioid prescription rates between provinces and over time, as well as the impact of PMPs, were examined using regression analyses techniques (i.e., Poisson, ANOVAs). Results: Significant differences between provinces in the overall standardized rates of dispensing for total opioids, as well as for "weak opioids" and "strong opioids" categories, were found. The majority of provinces featured increases or curvilinear trends in the standardized amounts of opioids dispensed over time, mainly driven by increases in "strong opioids" use. In addition, significant inter-provincial differences in the levels of dispensing of individual opioids were found. Comparisons of changes in opioid dispensing between provinces with and without PMPs did not indicate significant differences. Conclusions: Opioid use featured significant quantitative and qualitative differences between provinces in Canada and showed an overall increasing trend mainly driven by changes in "strong opioids" in the study period. Reasons for the observed differences are not clear yet require systematic examination to allow evidence-based interventions in the interest of equitable pain treatment as well as the reduction of high levels of opioid-related morbidity and mortality in Canada. © 2011 John Wiley & Sons, Ltd.


PubMed | SALt Inc, University of Texas Health Science Center at Houston and Toronto Health Economics and Technology Assessment Collaborative
Type: Journal Article | Journal: Ontario health technology assessment series | Year: 2015

Pressure at the interface between bony prominences and support surfaces, sufficient to occlude or reduce blood flow, is thought to cause pressure ulcers (PrUs). Pressure ulcers are prevented by providing support surfaces that redistribute pressure and by turning residents to reduce length of exposure.We aim to determine optimal frequency of repositioning in long-term care (LTC) facilities of residents at risk for PrUs who are cared for on high-density foam mattresses.We recruited residents from 20 United States and 7 Canadian LTC facilities. Participants were randomly allocated to 1 of 3 turning schedules (2-, 3-, or 4-hour intervals). The study continued for 3 weeks with weekly risk and skin assessment completed by assessors blinded to group allocation. The primary outcome measure was PrU on the coccyx or sacrum, greater trochanter, or heels.Participants were mostly female (731/942, 77.6%) and white (758/942, 80.5%), and had a mean age of 85.1 (standard deviation [SD] 7.66) years. The most common comorbidities were cardiovascular disease (713/942, 75.7%) and dementia (672/942, 71.3%). Nineteen of 942 (2.02%) participants developed one superficial Stage 1 (n = 1) or Stage 2 (n = 19) ulcer; no full-thickness ulcers developed. Overall, there was no significant difference in PrU incidence (P = 0.68) between groups (2-hour, 8/321 [2.49%] ulcers/group; 3-hour, 2/326 [0.61%]; 4-hour, 9/295 [3.05%]. Pressure ulcers among high-risk (6/325, 1.85%) versus moderate-risk (13/617, 2.11%) participants were not significantly different (P = 0.79), nor was there a difference between moderate-risk (P = 0.68) or high-risk allocation groups (P = 0.90).Results support turning moderate- and high-risk residents at intervals of 2, 3, or 4 hours when they are cared for on high-density foam replacement mattresses. Turning at 3-hour and at 4-hour intervals is no worse than the current practice of turning every 2 hours. Less frequent turning might increase sleep, improve quality of life, reduce staff injury, and save time for such other activities as feeding, walking, and toileting.


PubMed | SALt Inc, Toronto Health Economics and Technology Assessment Collaborative and University of Texas Health Science Center at Houston
Type: Journal Article | Journal: Ontario health technology assessment series | Year: 2015

The Turning for Ulcer Reduction (TURN) study was a multisite, randomized controlled trial that aimed to determine the optimal frequency of turning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer (PrU) development. Here we present data from the economic analysis.This economic analysis aims to estimate the economic consequences for Ontario of switching from a repositioning schedule of 2-hour intervals to a schedule of 3-hour or 4-hour intervals.Costs considered in the analysis included those associated with nursing staff time spent repositioning residents and with incontinent care supplies, which included briefs, barrier cream, and washcloths.The total economic benefit of switching to 3-hour or 4-hour repositioning is estimated to be $11.05 or $16.74 per day, respectively, for every resident at moderate or high risk of developing PrUs. For a typical facility with 123 residents, 41 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefit is estimated to be $453 daily for 3-hour or $686 daily for 4-hour repositioning. For Ontario as a whole, assuming that there are 77,933 residents at 634 LTC facilities, 25,927 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefits of switching to 3-hour or 4-hour repositioning are estimated to be $286,420 or $433,913 daily, respectively, equivalent to $104.5 million or $158.4 million per year.We did not consider the savings the Ontario Ministry of Health and Long-Term Care might incur should less frequent repositioning reduce the incidence of work-related injury among nursing staff, so our findings are potentially conservative.A switch to 3-hour or 4-hour repositioning appears likely to yield substantial economic benefits to Ontario without placing residents at greater risk of developing PrUs.


Wijeysundera H.C.,Toronto Health Economics and Technology Assessment Collaborative | Wijeysundera H.C.,University of Toronto | Machado M.,Toronto Health Economics and Technology Assessment Collaborative | Farahati F.,Toronto Health Economics and Technology Assessment Collaborative | And 14 more authors.
JAMA - Journal of the American Medical Association | Year: 2010

Context: Coronary heart disease (CHD) mortality has declined substantially in Canada since 1994. Objective: To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments. Design, Setting, and Patients: Prospective analytic study of the Ontario, Canada, population aged 25 to 84 years between 1994 and 2005, using an updated version of the validated IMPACT model, which integrates data on population size, CHD mortality, risk factors, and treatment uptake changes. Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and (1) evidence-based therapies in 8 distinct CHD subpopulations (acute myocardial infarction [AMI], acute coronary syndromes, secondary prevention post-AMI, chronic coronary artery disease, heart failure in the hospital vs in the community, and primary prevention for hyperlipidemia or hypertension) and (2) population trends in 6 risk factors (smoking, diabetes mellitus, systolic blood pressure, plasma cholesterol level, exercise, and obesity). Main Outcome Measures: The number of deaths prevented or delayed in 2005; secondary outcome measures were improvements in medical treatments and trends in risk factors. Results: Between 1994 and 2005, the age-adjusted CHD mortality rate in Ontario decreased by 35% from 191 to 125 deaths per 100 000 inhabitants, translating to an estimated 7585 fewer CHD deaths in 2005. Improvements in medical and surgical treatments were associated with 43% (range, 11% to 124%) of the total mortality decrease, most notably in AMI (8%; range, -5% to 40%), chronic stable coronary artery disease (17%; range,7%to 35%), and heart failure occurring while in the community (10%; range,6%to 31%). Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed (48% of total; range, 28% to 64%), specifically, reductions in total cholesterol (23%; range, 10% to 33%) and systolic blood pressure (20%; range, 13% to 26%). Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6% (range, 4% to 8%) and 2% (range, 1% to 4%), respectively. Conclusion: Between 1994 and 2005, there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments, each explaining about half of the decrease. ©2010 American Medical Association. All rights reserved.


Wilke D.R.,Dalhousie University | Krahn M.,Toronto Health Economics and Technology Assessment Collaborative | Krahn M.,University of Toronto | Krahn M.,Toronto General Research Institute | And 5 more authors.
Cancer | Year: 2010

BACKGROUND: Combined long-term androgen deprivation (LTAD) and radiation conveys a prostate cancer-specific survival advantage over combined short-term androgen deprivation (STAD) and radiation. The seminal question is whether or not the gains are worth the adverse effects of LTAD with respect to patient preferences. METHODS: Preferences for LTAD compared with STAD were elicited by direct patient interview using the probability trade-off method. "Time trade-off utilities" (TTOu) for erectile dysfunction and osteoporosis were elicited using the time trade-off method. Participants' current prostate cancer-specific health state was assessed using the Patient-Oriented Prostate Utility Scale-Psychometric. Participants' current sexual function was assessed using the International Index of Erectile Function (IIEF). RESULTS: All participants were willing to trade survival rather than undergo LTAD compared with STAD. The mean minimally required increment in prostate cancer-specific survival (MRIS) was 8.2%. The mean TTOu for impotence was 0.78, and the mean TTOu for osteoporosis was 0.71. The MRIS was correlated with the Sexual Desire domain score of the IIEF (Spearman rank-correlation coefficient, r = 0.50; P<.0001). CONCLUSIONS: Patients desired more prostate cancer-specific survival than what was afforded by LTAD and radiotherapy compared with STAD and radiotherapy. © 2010 American Cancer Society.


PubMed | Cancer Care Ontario, University of Toronto, Public Health Ontario and Toronto Health Economics and Technology Assessment Collaborative
Type: Journal Article | Journal: Vaccine | Year: 2016

A universal, publicly funded, school-based human papillomavirus (HPV) vaccination program in grade eight girls was initiated in Ontario in 2007. We present a cost-utility analysis of integrated cervical cancer prevention programs from the healthcare payer perspective.Our analysis was based on linked HPV transmission and disease history models. We obtained data from the literature, provincial surveys and Ontario population-based linked health administrative datasets. We modeled combinations of vaccination and screening strategies. We considered vaccination based on the Ontario experience, as well as conservative and optimistic scenarios, varying coverage, vaccine effectiveness and duration of protection. We considered 900 screening scenarios (screening start age: 21-70 years, screening interval: 3-20 years; 1-year time steps). The current schedule screens every 3 years starting at age 21 years. We examined (1) first vaccinated cohort (low herd-immunity), and (2) steady state, i.e. all cohorts were vaccinated (high herd-immunity).Adding vaccination to the current screening schedule was cost-effective (


Andradattir S.,Georgia Institute of Technology | Chiu W.,Georgia Institute of Technology | Goldsman D.,Georgia Institute of Technology | Lee M.L.,Georgia Institute of Technology | And 5 more authors.
BMC Public Health | Year: 2011

Background. In 2009 and the early part of 2010, the northern hemisphere had to cope with the first waves of the new influenza A (H1N1) pandemic. Despite high-profile vaccination campaigns in many countries, delays in administration of vaccination programs were common, and high vaccination coverage levels were not achieved. This experience suggests the need to explore the epidemiological and economic effectiveness of additional, reactive strategies for combating pandemic influenza. Methods. We use a stochastic model of pandemic influenza to investigate realistic strategies that can be used in reaction to developing outbreaks. The model is calibrated to documented illness attack rates and basic reproductive number (R0) estimates, and constructed to represent a typical mid-sized North American city. Results. Our model predicts an average illness attack rate of 34.1% in the absence of intervention, with total costs associated with morbidity and mortality of US$81 million for such a city. Attack rates and economic costs can be reduced to 5.4% and US$37 million, respectively, when low-coverage reactive vaccination and limited antiviral use are combined with practical, minimally disruptive social distancing strategies, including short-term, as-needed closure of individual schools, even when vaccine supply-chain-related delays occur. Results improve with increasing vaccination coverage and higher vaccine efficacy. Conclusions. Such combination strategies can be substantially more effective than vaccination alone from epidemiological and economic standpoints, and warrant strong consideration by public health authorities when reacting to future outbreaks of pandemic influenza. © 2011 Andradáttir et al; licensee BioMed Central Ltd.


Djalalov S.,Li Ka Shing Knowledge Institute | Djalalov S.,Canadian Center for Applied Research in Cancer Control | Beca J.,Li Ka Shing Knowledge Institute | Beca J.,Canadian Center for Applied Research in Cancer Control | And 8 more authors.
Journal of Clinical Oncology | Year: 2014

Purpose: ALK-targeted therapy with crizotinib offers significant improvement in clinical outcomes for the treatment of EML4-ALK fusion-positive non-small-cell lung cancer (NSCLC). We estimated the cost effectiveness of EML4-ALK fusion testing in combination with targeted first-line crizotinib treatment in Ontario. Patients and Methods: A cost-effectiveness analysis was conducted using a Markov model from the Canadian Public health (Ontario) perspective and a lifetime horizon in patients with stage IV NSCLC with nonsquamous histology. Transition probabilities and mortality rates were calculated from the Ontario Cancer Registry and Cancer Care Ontario New Drug Funding Program (CCO NDFP). Costs were obtained from the Ontario Case Costing Initiative, CCO NDFP, University Health Network, and literature. Results: Molecular testing with first-line targeted crizotinib treatment in the population with advanced nonsquamous NSCLC resulted in a gain of 0.011 quality-adjusted life-years (QALYs) compared with standard care. The incremental cost was Canadian $2,725 per patient, and the incremental cost-effectiveness ratio (ICER) was $255,970 per QALY gained. Among patients with known EML4-ALK-positive advanced NSCLC, first-line crizotinib therapy provided 0.379 additional QALYs, cost an additional $95,043 compared with standard care, and produced an ICER of $250,632 per QALY gained. The major driver of cost effectiveness was drug price. Conclusion: EML4-ALK fusion testing in stage IV nonsquamous NSCLC with crizotinib treatment for ALKpositive patients is not cost effective in the setting of high drug costs and a low biomarker frequency in the population. © 2014 by American Society of Clinical Oncology.

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