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Background: Health inequities among individuals with chronic obstructive pulmonary disease (COPD) are often associated with differential access to health care and health outcomes. A greater understanding of the literature concerning such variation is necessary to determine where gaps or inequities exist along the continuum of COPD care., Methods: A rapid review of the published and grey literature reporting variations in health care access and/or health outcomes for individuals with COPD was completed. Variation was defined as differential patterns in access indicators or outcome measures within sociodemographic categories, including age, ethnicity, geography, race, sex, and socioeconomic status. Emergent themes were identified from the included literature and synthesized narratively., Results: Thirty-five articles were included for final review; the majority were retrospective cohort studies. Twenty-five studies assessed variation in access to health care. Key indicators included: access to spirometry testing, medication adherence, participation in pulmonary rehabilitation, and contact with general practitioners and/or respiratory specialists. Twenty-one studies assessed variation in health outcomes in COPD and key metrics included: hospital-based resource utilization (length of stay and admissions/readmissions), COPD exacerbations, and mortality. Patients who live in rural environments and those of lower socioeconomic status had both poorer access to care and outcomes at the system and patient level. Other sociodemographic variables, including ethnicity, race, age, and sex were associated with variation in health care access and outcomes, although these findings were less consistent., Conclusion: The results of this rapid review suggest that substantial variation in access and outcomes exists for individuals with COPD, highlighting opportunities for targeted interventions and policies., (JCOPDF © 2024.)

Background: To develop a knowledge translation (KT) tool that will provide guidance to stakeholders actively planning or considering implementation of a health technology reassessment (HTR) initiative., Methods: The KT tool is an international and collaborative endeavour between HTR researchers in Canada, Australia, and the United Kingdom. Evidence from a meta-review of documented international HTR experiences and approaches provided the conceptual framing for the KT tool. The purpose, audience, format, and overall scope and content of the tool were established through iterative discussions and consensus. An initial version of the KT tool was beta-tested with an international community of relevant stakeholders (i.e., potential users) at the Health Technology Assessment International 2018 annual meeting., Results: An open access workbook, referred to as the HTR playbook, was developed. As a KT tool, the HTR playbook is intended to simplify the complex HTR planning process by navigating users step-by-step through 6 strategic domains: characteristics of the candidate health technology ( The Stats and Projections ), stakeholders to engage ( The Team ), potential facilitators and/or barriers within the policy context ( The Playing Field ), strategic use of different levers and tools ( The Offensive Plays ), unintended consequences ( The Defensive Plays ), and metrics and methods for monitoring and evaluation ( Winning the Game )., Conclusion: The HTR playbook is intended to enhance a user's ability to successfully complete a HTR by helping them systematically consider the different elements and approaches to achieve the right care for the patient population in question., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children., Methods: A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included., Results: A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations., Conclusions: A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally., Systematic Review Registration: PROSPERO: CRD42020208072., (© 2022. The Author(s).)

Background: Multi-disciplinary rehabilitation is recommended for individuals with post-acute sequelae of COVID-19 infection (i.e., symptoms 3-4 weeks after acute infection). There are emerging reports of use of pulmonary rehabilitation (PR) in the post-acute stages of COVID-19, however the appropriateness of PR for managing post-COVID symptoms remains unclear. To offer practical guidance with regards to post-COVID PR, a greater understanding of the clinical effectiveness literature is required., Methods: A rapid review of the published literature was completed. An electronic database search of the literature published between July 1, 2020 and June 1, 2021 was performed in MEDLINE, Pubmed, and EMBASE. Primary studies evaluating the clinical effectiveness of PR for individuals with post-COVID symptoms were included., Results: Nine studies evaluating the effectiveness of PR were identified; most were small, experimental or quasi-experimental studies, including 1 RCT, and were primarily of low quality. After attending PR, all studies reported improvements in exercise capacity, pulmonary function, and/or quality of life for individuals with post-COVID symptoms who had been hospitalized for their acute COVID-19 infection. Few studies evaluated changes in post-COVID symptom severity or frequency and, of these, improvements in dyspnea, fatigue, anxiety and depression were observed following PR. Further, no studies evaluated non-hospitalized patients or long-term outcomes beyond 3 months after initiating PR., Conclusions: With limited high-quality evidence, any recommendations or practical guidance for PR programmes for those with post-COVID symptoms should consider factors such as feasibility, current PR capacity, and resource constraints., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging., Methods: An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed., Results: The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase., Conclusions: Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts., (© 2021. The Author(s).)

Background: Despite recommendations for restrictive approaches to red blood cell transfusion in the intensive care unit (ICU), variation from best practices persists. The aim of this study was to explore potential facilitators of and barriers to practising a restrictive red blood cell transfusion strategy among intensive care physicians using the theoretical domains framework., Methods: We conducted an online population-based cross-sectional survey of all intensive care physicians in 1 health care system (Alberta). Survey questions were based on 6 key theoretical domains of the theoretical domains framework: Knowledge, Social/professional roles and identity, Motivation and goals, Beliefs about consequences, Social influences and Beliefs about capabilities. The survey was administered between July 27 and Oct. 6, 2017. Descriptive statistics (demographic and Likert scale data) and conventional content analysis (open-ended responses) were conducted., Results: Forty-two intensive care physicians completed the survey (estimated response rate 56%). The respondents identified knowledge of published evidence, use of guidelines, improved outcomes, physician autonomy, and perceived culture of acceptance and collegial support as facilitators of practising a restrictive transfusion strategy. Identified barriers included potential impact on and cost to other clinical goals, conflicting practices and beliefs of physicians in other clinical specialties, deficits in medical trainees' skills and knowledge, and attitudinal barriers related to denial., Interpretation: Using the theoretical domains framework, we identified 9 key self-reported facilitators of and barriers to intensive care physicians' transfusion behaviour. Understanding these determinants will help inform development and implementation of interventions within ICUs to encourage optimal use of red blood cell transfusion practices for nonbleeding patients whose condition is stable., Competing Interests: Competing interests: None declared., (Copyright 2019, Joule Inc. or its licensors.)

Background: Red blood cell (RBC) transfusions are common procedures performed in the intensive care unit (ICU). However, conservative transfusion approaches have been recommended to avoid RBC transfusions that are not clinically necessary and to achieve optimal patient outcomes. The objective of this study was to examine the utilization and costs of RBC transfusions in medical-surgical ICUs and to compare this information against clinical guideline recommendations for best practice., Methods: Retrospective observational analysis of RBC transfusions in stable, non-bleeding adult patients was examined in a geographically-defined, population-based cohort of nine integrated ICUs between April 1, 2014 and December 31, 2016. RBC transfusions associated with a pre-transfusion hemoglobin value of 70 g/L or more were examined through linear and logistic regression. The total costs of RBC transfusions, based on the RBC unit cost, were estimated., Results: A total of 4632 RBC transfusions (2287 ICU admissions) were included. Pre-transfusion hemoglobin values were identified for 4487 transfusions. On average, 61% occurred at or above a hemoglobin value of 70 g/L (mean 73.4 ± 9.2 g/L). Factors associated with such transfusions included being male, age over 75, Sequential Organ Failure Assessment (SOFA) score greater or equal to 10, transfer from operating room, gastrointestinal bleeding, and trauma. A pre-transfusion hemoglobin value at or above 70 g/L was associated with increased odds of ICU mortality; there was no impact on overall hospital mortality. The total estimated cost of RBC transfusions was $2.99M Canadian dollars (CAD), with $1.82M CAD attributed to those with a hemoglobin value at or above 70 g/L., Conclusions: Over half of the examined RBC transfusions may not have aligned with recommended best practice; this suggests significant opportunity for improvement. The present findings are an essential step towards optimizing RBC transfusions in the ICU., Competing Interests: Research ethics approval was obtained from the Conjoint Health Research Ethics Board (CHREB) of the University of Calgary (Ethics ID: REB15-2001). Consent of participants was not required due to the de-identified nature of the data and the retrospective study design.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR)., Methods: An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC)., Results: The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] "do not do" recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely "Top 5" lists) were identified. Using appropriate coding systems for BC's administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment., Conclusions: This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level.

Objective: To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices., Design: Systematic review and meta-analysis., Setting, Participants, Interventions: Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included., Primary and Secondary Outcomes: The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot., Results: Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias., Conclusions: The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?', Prospero Registration Number: CRD42015024757., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Research from 2006 documented substantial variation in medication coverage for residents across Canada. Since then, some provinces have implemented major medication plan reforms. We aimed to update the information on publicly funded medication insurance plans available across Canada and to compare out-of-pocket costs across the country., Methods: We compared provincial medication insurance plans using data from public websites and other public source documents. Using 2 hypothetical clinical examples, we determined the amount and type of a patient's out-of-pocket costs for 5 different patient subtypes that varied based on medication burden, age and income., Results: Each province offers a plan to all residents. Cost-sharing is employed across all provinces. Some residents must pay a premium to receive insurance or must pay 100% of their medication costs until they reach a deductible amount, above which government funding covers a portion of medication costs. With the scenario of low medication burden (medication cost about $500), out-of-pocket costs ranged from $250 to $2100 for higher-income residents and from $0 to $700 for lower-income residents. With the scenario of high medication burden (medication cost about $1800), the corresponding ranges were $250-$2500 and $0-$1100. The variation was due to province of residence, age and income., Interpretation: Variations in out-of-pocket payments continue to exist across the provinces, with some groups facing high expenses. Further work is required to understand the impact of different cost-sharing mechanisms, develop policies to limit out-of-pocket expenses and improve provincial drug plans., Competing Interests: Competing interests: None declared., (Copyright 2017, Joule Inc. or its licensors.)

Objective: To compare cost-related non-adherence (CRNA), serious problems paying medical bills and average annual out-of-pocket cost over time in five countries., Methods: Repeated cross-sectional analysis of the Commonwealth Fund International Health Policy survey from 2004 to 2014. Responses were compared between Canada, the UK, Australia, New Zealand and the US., Results: Compared to the UK, respondents in Canada, Australia and New Zealand were two to three times and respondents in the US were eight times more likely to experience CRNA; these odds remained stable over time. From 2004 to 2014, Canadian respondents paid US $852-1,767 out-of-pocket for care. The US reported the largest risks of serious problems paying for care (13-18.5%), highest out-of-pocket costs (US $2,060-3,319) and greatest rise in expenditures., Interpretation: Over the 10-year period, financial barriers to care were identified in Canada and internationally. Such persistent challenges are of great concern to countries striving for equitable access to healthcare., (Copyright © 2017 Longwoods Publishing.)