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Despite a growing recognition of the need for learning-centered curricula in undergraduate education, very little has been documented about course design in a graduate studies context. This article provides a flexible framework and practical strategies for developing a learning-centered graduate course in Epidemiology. Concepts, principles and interactive strategies from learning-centered education were incorporated into course design and implemented in a graduate studies program at the University of British Columbia. This graduate-level course was designed to meet the needs and circumstances of the learning context. Course design had a significant impact on the quality of teaching and learning in this graduate program. Learners were actively engaged in critical thinking, problem-solving skills, and inter-professional collaboration. A learning-centered approach to graduate-level course design in Epidemiology takes into account context and integrates comprehensive planning, assessment, teaching and learning strategies. From this perspective, course design is viewed as an individual and social contextual process.

Background: Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals.Methods: We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay.Results: For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1-6.1), 12.2% (95% CI 10.3-14.2), and 22.0% (95% CI 17.7-26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay.Conclusion: Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability. [ABSTRACT FROM AUTHOR]

Background: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.Methods: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.Results: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).Interpretation: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons. [ABSTRACT FROM AUTHOR]

Background: Evidence from randomized controlled trials published since 2004 shows that elective laparoscopic colectomy for colon cancer improves short-term postoperative outcomes with equivalent oncologic outcomes compared to open colectomy. The objective of this study was to examine the uptake of elective laparoscopic colectomy in Canada and compare its use among Canadian provinces. Methods: In this descriptive analysis, we identified from hospital discharge abstracts all patients in the Canadian provinces (except Quebec) who underwent elective colectomy for colon cancer between 2004/05 and 2014/15. We compared temporal changes in the proportion of patients who underwent laparoscopic colectomy or open colectomy among provinces using logistic regression. Results: Of 63 504 patients who underwent elective colectomy between 2004/05 and 2014/15, 19 691 (31.0%) underwent laparoscopic colectomy. The annual proportion of patients who underwent laparoscopic colectomy increased from 9.2% in 2004/05 to 51.5% in 2014/15 (mean annual percent increase 4.2%). There were significant differences between provinces in the overall proportion of patients who underwent laparoscopic colectomy (p < 0.001), ranging from 7.6% in Newfoundland and Labrador to 36.9% in Ontario. By 2014/15, most colectomy procedures were performed laparoscopically in 3 provinces; British Columbia (60.2%), Ontario (59.4%) and Alberta (53.1%). In addition to year and province, urban residence, younger age, female sex, fewer medical comorbidities, high surgeon volume, high hospital volume and right-sided tumours were significantly associated with increased likelihood of laparoscopic colectomy. Interpretation: Although the use of laparoscopic colectomy increased rapidly between 2004/05 and 2014/15 in Canada, substantial interprovincial variation exists. Further knowledge-translation strategies are needed to ensure equal access to laparoscopic colectomy for all Canadians. [ABSTRACT FROM AUTHOR]

Background: Reliance on interdisciplinary teams in the delivery of primary care is on the rise. Funding bodies strive to design financial environments that support collaboration between providers. At present, the design of financial arrangements has been fragmented and not based on evidence. The root of the problem is a lack of systematic evidence demonstrating the superiority of any particular financial arrangement, or a solid understanding of options. In this study we develop a framework for the conceptualization and analysis of financial arrangements in interdisciplinary primary care teams.Methods: We use qualitative data from three sources: (i) interviews with 19 primary care decision makers representing 215 clinics in three Canadian provinces, (ii) a research roundtable with 14 primary care decision makers and/or researchers, and (iii) policy documents. Transcripts from interviews and the roundtable were coded thematically and a framework synthesis approach was applied.Results: Our conceptual framework differentiates between team level funding and provider level remuneration, and characterizes the interplay and consonance between them. Particularly the notions of hierarchy, segregation, and dependence of provider incomes, and the link between funding and team activities are introduced as new clarifying concepts, and their implications explored. The framework is applied to the analysis of collaboration incentives, which appear strongest when provider incomes are interdependent, funding is linked to the team as a whole, and accountability does not have multiple lines. Emergent implementation issues discussed by respondents include: (i) centrality of budget negotiations; (ii) approaches to patient rostering; (iii) unclear funding sources for space and equipment; and (iv) challenges with community engagement. The creation of patient rosters is perceived as a surprisingly contentious issue, and the challenges of funding for space and equipment remain unresolved.Conclusions: The development and application of a conceptual framework is an important step to the systematic study of the best performing financial models in the context of interdisciplinary primary care. The identification of optimal financial arrangements must be contextualized in terms of feasibility and the implementation environment. In general, financial hierarchy, both overt and covert, is considered a barrier to collaboration. [ABSTRACT FROM AUTHOR]

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Background: Published decision analyses show that screening for colorectal cancer is cost-effective. However, because of the number of tests available, the optimal screening strategy in Canada is unknown. We estimated the incremental cost-effectiveness of 10 strategies for colorectal cancer screening, as well as no screening, incorporating quality of life, noncompliance and data on the costs and benefits of chemotherapy. Methods: We used a probabilistic Markov model to estimate the costs and quality-adjusted life expectancy of 50- year-old average-risk Canadians without screening and with screening by each test. We populated the model with data from the published literature. We calculated costs from the perspective of a third-party payer, with inflation to 2007 Canadian dollars. Results: Of the 10 strategies considered, we focused on three tests currently being used for population screening in some Canadian provinces: low-sensitivity guaiac fecal occult blood test, performed annually; fecal immunochemical test, performed annually; and colonoscopy, performed every 10 years. These strategies reduced the incidence of colorectal cancer by 44%, 65% and 81%, and mortality by 55%, 74% and 83%, respectively, compared with no screening. These strategies generated incremental cost-effectiveness ratios of $9159, $611 and $6133 per quality-adjusted life year, respectively. The findings were robust to probabilistic sensitivity analysis. Colonoscopy every 10 years yielded the greatest net health benefit. Interpretation: Screening for colorectal cancer is costeffective over conventional levels of willingness to pay. Annual high-sensitivity fecal occult blood testing, such as a fecal immunochemical test, or colonoscopy every 10 years offer the best value for the money in Canada. [ABSTRACT FROM AUTHOR]

Objectives: Solid organ transplantations are among the most expensive treatments yet relatively few investigators have reported well-characterized and reliable information on costs. The objective here was to compare the direct medical costs of kidney, liver, heart, and lung transplantations in British Columbia (BC), Canada. Methods: Using data from a province-wide population-based registry, resource utilization data were collated for 1333 patients who underwent solid organ transplantation between 1995 and 2003. Resource categories included hospital stays, physician fees, laboratory and diagnostic testing, and immunosuppressants. Mean costs (2003 $CDN) were derived for the index hospitalization and each of the 2 years after hospital discharge. To enable valid comparisons, the same costing methodology was applied to all four programs. Results: The mean costs of transplantation varied from $27,695 for kidney recipients to $89,942 for lung recipients, with inpatient hospital stays comprising the largest component. Mean costs for the first and second follow-up years ranged from $27,592 and $11,424 for lung recipients to $21,144 and $8086 for liver recipients. Immunosuppressants accounted for between two-thirds and three-fourths of costs by the second year. Within each program, variations in costs could not be accounted for by demographic factors. Conclusions: We observed in BC a threefold variation in mean costs of organ transplantation procedures, with the variations between programs diminishing during follow-up. Policymakers and decision-makers seeking to better understand the deployment of resources for transplantation may focus on clinical factors at the time of hospitalization and factors that influence use and costs of immunosuppressants during the induction and maintenance phases. [ABSTRACT FROM AUTHOR]

Objective: To elicit societal and patient utilities associated with diabetic symptomatic non-severe hypoglycaemia for three health states: 1) rare (quarterly), 2) intermittent (monthly), 3) and frequent (weekly) hypoglycaemia episodes. Methods: Using validated health states, time trade-off utilities were elicited from 51 Canadian respondents with diabetes, and 79 respondents in Canada and 75 respondents in the United Kingdom (UK) without diabetes. Results and discussion: Each hypoglycaemic episode was associated with a reduction in utility and persons with diabetes consistently reported slightly higher utility values than respondents without diabetes. The utility for diabetes without hypoglycaemia ranged from 0.88 to 0.97, the mean utility for rare hypoglycaemic events (quarterly) ranged between 0.85 and 0.94. The utility for the intermittent state (monthly) ranged from 0.77 to 0.90 and from 0.66 to 0.0.83 for the frequent state (weekly). Differences were observed between respondents without diabetes in Canada and the UK. Using a multivariate linear OLS regression, the estimated utilities associated with a single hypoglycaemic event were -0.0033 and -0.0032 for respondents with diabetes and without diabetes, respectively. Conclusion: Among respondents with and without diabetes, there was a demonstrable utility loss associated with hypoglycaemia. Considering a utility loss of 0.03 as a minimum clinically important difference for persons with diabetes, the evidence from this study indicates that as low as ten symptomatic non-severe hypoglycaemic episodes per year may be of clinical importance and that the importance increases with frequency of episodes. Integrating directly elicited utility values such as those reported here will improve the quality and applicability of economic evaluations of diabetes treatment. [ABSTRACT FROM AUTHOR]

Background: Although the general association between socioeconomic status (SES) and hospitalization has been well established, few studies have considered the relationship between SES and hospital length of stay (LOS), and/or hospital re-admission. The primary objective of this study therefore, was to examine the relationship of SES to LOS and early re-admission among adult patients hospitalized with communityacquired pneumonia in a setting with universal health insurance. Methods: Four hundred and thirty-four (434) individuals were included in this retrospective, longitudinal cohort analysis of adult patients less than 65 years old admitted to a large teaching hospital in Vancouver, British Columbia. Hospital chart review data were linked to population-based health plan administrative data. Chart review was used to gather data on demographics, illness severity, co-morbidity, functional status and other measures of case mix. Two different types of administrative data were used to determine hospital LOS and the occurrence of all-cause re-admission to any hospital within 30 days of discharge. SES was measured by individual-level financial hardship (receipt of income assistance or provincial disability pension) and neighbourhood-level income quintiles. Results: Those with individual-level financial hardship had an estimated 15% (95% CI -0.4%, +32%, p =0.057) longer adjusted LOS and greater risk of early re-admission (adjusted OR 2.65, 95% CI 1.38, 5.09). Neighbourhood-level income quintiles, showed no association with LOS or early re-admission. Conclusion: Among hospitalized pneumonia patients less than 65 years, financial hardship derived from individual-level data, was associated with an over two-fold greater risk of early re-admission and a marginally significant longer hospital LOS. However, the same association was not apparent when an ecological measure of SES derived from neighbourhood income quintiles was examined. The ecological SES variable, while useful in many circumstances, may lack the sensitivity to detect the full range of SES effects in clinical studies. [ABSTRACT FROM AUTHOR]

Background: The proportion of patients who undergo surgery within a clinically safe time is an important performance indicator in health systems that use wait lists to manage access to care. However, little is known about chances of on-time surgery according to variations in existing demand. We sought to determine what proportion of patients have had late coronary bypass surgery after registration on wait lists of different size in a network of hospitals with uniform standards for timing of surgery. Methods: Using records from a population-based registry, we studied wait-list times prospectively collected in a cohort of patients registered on wait lists for coronary artery bypass grafting procedures. We compared the number of weeks from registration to surgery against target access times established for three urgency groups. The chances of undergoing surgery within target time have been evaluated in relation to wait-list size at registration and the number of surgeries performed without registration on a wait list. Results: In 1991-2001, two in three patients were at risk of late surgery when registered on wait lists for isolated coronary bypass procedures in British Columbia, Canada. Although urgent patients had never seen a wait list with clearance time exceeding one week, the odds of on-time surgery were reduced by 25%, odds ratio [OR] = 0.75 (95% confidence interval [CI] 0.65-0.87) for every additional operation performed without registration on a list. When the wait list at registration required a clearance time of over one month, semi-urgent patients had 51% lower odds of on-time surgery as compared to lists with clearance time less than one week, OR = 0.49 (95%CI 0.41-0.60), after adjustment for age, sex, comorbidity, calendar period, hospital and week on the list. In the nonurgent group, the odds were 69% lower, OR = 0.31 (95%CI 0.20-0.47). Every time an operation in the same hospital was performed without registration on a wait list, the odds of on-time surgery for listed patients were reduced by 7%, OR = 0.93 (95%CI 0.91-0.95) in the semi-urgent group, and by 10%, OR = 0.90 (95%CI 0.87- 0.94), in the non-urgent group. Conclusion: Chances of late surgery increase with the wait-list size for semi-urgent and non-urgent patients needing coronary bypass surgery. The weekly number of patients who move immediately from angiography to the operation without registration on a wait list reduced chances of surgery within target time in all urgency groups of listed patients. When advising patients who will be placed on the wait list about the expected time to treatment, hospital managers should take into account the current list size as well as the weekly number of patients who require CABG immediately after undergoing coronary angiography. [ABSTRACT FROM AUTHOR]

Background: In British Columbia, Canada, all necessary medical services are funded publicly. Concerned with growing wait lists in the mid-1990s, the provincial government started providing extra funding for coronary artery bypass grafting (CABG) operations annually. Although aimed at improving access, it is not known whether supplementary funding changed the time that patients spent on wait lists for CABG. We sought to determine whether the period of registration on wait lists had an effect on time to isolated CABG and whether the period effect was similar across priority groups. Methods: Using records from a population-based registry, we studied the wait-list time before and after supplementary funding became available. We compared the number of weeks from registration to surgery for equal proportions of patients in synthetic cohorts defined by five registration periods in the 1990s. Results: Overall, 9,231 patients spent a total of 137,126 person-weeks on the wait lists. The time to surgery increased by the middle of the decade, and decreased toward the end of the decade. Relative to the 1991-92 registration period, the conditional weekly probabilities of undergoing surgery were 30% lower among patients registered on the wait lists in 1995-96, hazard ratio (HR) = 0.70 (0.65-0.76), and 23% lower in 1997-98 patients, HR = 0.77 (0.71-0.83), while there were no differences with 1999-2000 patients, HR = 0.94 (0.88-1.02), after adjusting for priority group at registration, comorbidity, age and sex. We found that the effect of registration period was different across priority groups. Conclusion: Our results provide evidence that time to CABG shortened after supplementary funding was provided on an annual basis to tertiary care hospitals within a single publicly funded health system. One plausible explanation is that these hospitals had capacity to increase the number of operations. At the same time, the effect was not uniform across priority groups indicating that changes in clinical practice should be considered when adding extra funding to reduce wait lists. [ABSTRACT FROM AUTHOR]

Abstract Background: Two programs to reduce expenditures for common gastrointestinal drugs were introduced simultaneously by British Columbia (BC) Pharmacare in 1995. Reference-based pricing restricted reimbursement for all histamine-2 receptor antagonists (H[sub2]RAs) to the cost of the least expensive H[sub2]RA available, generic cimetidine. Special authority restricted reimbursement for proton pump inhibitors (PPIs) to patients who met certain eligibility criteria. We evaluated the effect of reference-based pricing for H[sub2]RAs and special authority for PPIs on dispensing and reimbursement for senior citizen beneficiaries of BC Pharmacare. Methods: Itemized monthly claims data for upper gastrointestinal drugs were obtained from BC Pharmacare for all beneficiaries 65 years of age or older. Periods before and after implementation of reference-based pricing and special authority were compared with respect to defined daily doses dispensed per 100 000 beneficiaries, BC Pharmacare reimbursement per 100 000 beneficiaries, BC Pharmacare reimbursement per defined daily dose and beneficiary contributions per defined daily dose. We used regression models to project forward trends in expenditures observed before implementation of the new policies and hence to estimate accrued cost savings. Results: Before reference-based pricing and special authority, the numbers of defined daily doses that were dispensed and total BC Pharmacare reimbursements for H[sub2]RAs appeared to be declining gradually, whereas those for PPIs were rising. With reference-based pricing, the monthly defined daily dose of cimetidine dispensed increased more than 4-fold, to 116 257 per 100 000 beneficiaries, while those of other restricted H[sub2]RAs decreased by more than half, to 50 927 per 100 000 beneficiaries. Special authority immediately reduced the dispensed volumes of PPIs by one-fourth, but growth in volume then appeared to resume at its previous rate. The estimated annualized cost savings... [ABSTRACT FROM AUTHOR]

We estimate the dynamic Fourier expenditure system to obtain consistent estimates of short-run and long-run Morishima elasticities of substitution for Canadian liquid assets. We argue that the variability of the estimated elasticities and evidence of less than perfect substitution between monetary assets interferes with the successful use of simple-sum aggregates and traditional log-linear money-demand functions. Calibrations semi-non-paramétriques de la substitution pour des actifs monétaires canadiens . Les auteurs calibrent le système dynamique de dépenses à la Fourier pour obtenir des estimations cohérentes des élasticités de substitution à la Morishima à court et à long termes pour des actifs monétaires canadiens. Ils suggèrent que la variabilité des élasticités estimées et la constatation que la substitution n’est pas parfaite entre les actifs monétaires rendent difficile un usage heureux des agrégats de simple somme et des fonctions log-linéaires de demande de monnaie. [ABSTRACT FROM AUTHOR]

Background Psoriasis is a chronic debilitating disease affecting approximately one million Canadians. The objective of this study is to estimate the economic burden in $CDN (2008) of moderate to severe plaque psoriasis among Canadian adults. Methods Using a cross-sectional design, direct resource use, costs, lost productivity, and quality of life were obtained for 90 subjects diagnosed with psoriasis in three dermatology clinics in British Columbia, Ontario, and Québec. An Excel-based economic model was developed to project the annual cost of psoriasis, from the societal perspective. Results The estimated mean annual cost of psoriasis was $7999/subject (95% CI: $3563-$12,434) with direct costs accounting for 57%. Mean lost productivity costs, which accounted for 43% of the mean annual costs of psoriasis, were $3442/subject (95% CI: $1293-$5590). Conclusion Projecting the mean costs per patient to the afflicted population yields an estimated total annual cost of $1.7 billion (95% CI: $0.8-$2.6 billion) attributable to moderate to severe psoriasis in Canada. Understanding the interplay between direct costs, lost productivity, and quality of life is critical for accurately identifying and evaluating effective treatments for this disease. [ABSTRACT FROM AUTHOR]

Hypoglycemia presents a challenge for patients using insulin. The fear and anxiety related to hypoglycemic episodes may inhibit intensified insulin treatment and cause patients to reduce driving, limit social activities and eat snacks. However, published estimates of health-related quality of life values (utilities) for hypoglycemia have been based on database studies and not directly measured in interviews. Our objective was to elicit societal and patient utilities in Canada for five health states including: diabetes, rare (quarterly), intermittent (monthly), frequent (weekly), and nocturnal hypoglycemia episodes. The health state descriptions were based on the validated Hypoglycemia Fear Survey and the opinions of four experts. Time trade-off (TTO) interviews were used to elicit utilities from 79 non-diabetic and 50 diabetic respondents in Canada. The TTO method estimates utilities between 0 and 1, where 1 expresses full health and 0 represents dead. Interviewers used a TTO board that allowed respondents to trade between zero and 30 years of perfect health against 30 years in each health state. The diabetes health state was estimated at 0.92 (SD 0.13) and 0.88 (SD 0.13) by diabetics and non-diabetics, respectively. The disutility was greater with increasing hypoglycemia: rare episodes ranged from -0.01 to -0.03 in the two groups; intermittent -0.05 to -0.11; frequent -0.17 to -0.22; and nocturnal-0.12 to -0.17. In both groups, the disutility of nocturnal hypoglycemia was intermediate between intermittent and frequent rates hypoglycemia. Rare hypoglycemia episodes occurring only a few times a year, was rated as having only a minimal impact, whereas frequent episodes and nocturnal hypoglycemia had substantial impacts. This study is the first to directly estimate utilities for hypoglycemia, incorporating appropriately developed health states, using direct elicitation techniques, and including diabetic and non-diabetic respondents. [ABSTRACT FROM AUTHOR]

Introduction: In Canada, most provinces have established administrative health data repositories to facilitate access to these data for research. Anecdotally, researchers have described delays and substantial inter-provincial variations in the timeliness of data access approvals and receipt of data. Currently, the reasons for these delays and variations in timeliness are not well understood. This paper provides a study protocol for (1) identifying the factors affecting access to administrative health data for research within select Canadian provinces, and (2) comparing factors across provinces to assess whether and how they contribute to inter-provincial variations in access to administrative health data for research., Methods: A qualitative, multiple-case study research design will be used. Three cases will be included, representing three different provinces. For each case, data will be collected from documents and interviews. Specifically, interviews will be carried out with (1) research stakeholders, and (2) regulatory stakeholders (10 individuals/group * 2 groups/province * 3 provinces = 60). During within-case analysis, interview data for each stakeholder group will be analyzed separately using constant comparative analysis. Document analysis will occur iteratively, and will inform interview guide adaptation, and supplement interview data. Cross-case analysis will involve systematic comparison of findings across cases., Discussion: This study represents the first in-depth examination of access to administrative health data in Canada. The main outcome will be an overarching mid-range theory explaining inter-provincial variations in access to administrative health data in Canada. This theory will be strengthened by the inclusion of the perspectives of both researchers and those involved in the regulation of data access. The findings from this study may be used to improve equitable and timely access to administrative health data across provinces, and may be transferable to other jurisdictions where barriers to access to administrative health data have been reported., Competing Interests: Statement on conflicts of interest: The authors have no financial conflicts of interest to disclose. CK, AL, GP, and RU are users of administrative health data for research purposes. CK is a current member of the Data Access Committee at Health Data Nova Scotia. AL is the former Director of Health Data Nova Scotia and financially supports its operation using peer-reviewed funding.

Background: Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations., Study Design and Methods: Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients., Results: Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations)., Conclusion: Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy., (© 2019 AABB.)

Objective: We describe steps to operationalise a published conceptual framework for a contiguous hospitalisation episode using acute care hospital discharge abstracts. We then quantified the degree of bias induced by a first abstract episode, which does not account for hospital transfers., Design: Retrospective observational study., Setting: All acute care hospitals in nine Canadian provinces., Participants: We retrieved acute hospitalisation discharge abstracts for 189 448 patients aged 65 years and older admitted to acute care with hip fracture between 2003 and 2013., Primary and Secondary Outcome Measures: The percentage of patients treated surgically, delayed to surgery (defined as two or more days after admission) and dying, between contiguous hospitalisation episodes and the first abstract episodes of care., Results: Using contiguous hospitalisation episodes, 91.6% underwent surgery, 35.7% were delayed two or more days after admission and 6.7% died postoperatively, whereas, using the first abstract only, these percentages were 83.7%, 32.5% and 6.5%, respectively., Conclusion: We demonstrate that not accounting for hospital transfers when evaluating the association between surgical timing and death underestimates reporting of the percentage of patients treated surgically and delayed to surgery by 9%, and the percentage who die after surgery by 3%. Researchers must be aware of this potential and avoidable bias as, depending on the purpose of the study, erroneous inferences may be drawn., Competing Interests: Competing interests: The authors declare that (1) Boris Sobolev, Pierre Guy and the Collaborative have received grants from the Canadian Institutes of Health Research related to this work. (2) Pierre Guy also receives funding from the Natural Sciences and Engineering Research Council of Canada, the Canadian Foundation for Innovation and the British Columbia Specialists Services Committee for work around hip fracture care not related to this manuscript. He has also received fees from the BC Specialists Services Committee (for a provincial quality improvement project on redesign of hip fracture care) and from Stryker Orthopedics (as a product development consultant). He is a board member and shareholder in Traumis Surgical Systems Inc. and a board member for the Canadian Orthopedic Foundation. He also serves on the speakers’ bureaus of AO Trauma North America and Stryker Canada. (3) Suzanne Morin reports research grants from Amgen Canada, and from Merck, personal fees from Amgen Canada outside the submitted work., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay., Methods: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram., Results: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%)., Interpretation: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons., Competing Interests: Competing interests: Boris Sobolev, Pierre Guy and the Collaborative report receiving grants from the Canadian Institutes of Health Research related to this work. Pierre Guy reports receiving grants from the Natural Sciences and Engineering Research Council of Canada, the Canadian Foundation for Innovation and the British Columbia Specialists Services Committee for work regarding hip fracture care, outside the submitted work. He has also received fees from the BC Specialists Services Committee (for a provincial quality improvement project on redesign of hip fracture care) and from Stryker Orthopaedics (as a product development consultant), outside the submitted work. He is a board member and shareholder in Traumis Surgical Systems Inc. and a board member for the Canadian Orthopaedic Foundation. He also serves on the speakers’ bureaus of AOTrauma North America and Stryker Canada. Suzanne Morin reports research grants from Amgen Canada, outside the submitted work. Jason Kim and Lisa Kuramoto report receiving grants from the Canadian Institutes of Health Research, during the conduct of the study. No other competing interests were declared., (© 2018 Joule Inc. or its licensors.)

Background: The fetal time period is a critical window of immune system development and resulting heightened susceptibility to the adverse effects of environmental exposures. Epidemiologists and toxicologists have hypothesized that persistent organic pollutants, pesticides and metals have immunotoxic properties. Immunotoxic effects may manifest as an altered immune system profile at birth. Immunoglobulin E, thymic stromal lymphopoietin (TSLP), and interleukin-33 (IL-33) may be implicated in the etiology of childhood allergy and are detectable at birth. The objective of this study was to examine the potential relationship between maternal concentrations of metals, persistent organic pollutants, and pesticides and elevated umbilical cord blood concentrations of IgE, TSLP, and IL-33 in a Canadian birth cohort., Methods: This study utilized data collected in the Maternal-Infant Research on Environmental Chemicals (MIREC) Study, a trans-Canada cohort study of 2,001 pregnant women. Of these women, 1258 had a singleton, term birth and cord blood sample. Logistic regression was used to determine associations between log-transformed continuous variables and immune system biomarkers., Results: Inverse relationships were observed between lead, DDE, PCB-118, and a summary index of organophosphorous metabolites and jointly elevated concentrations of IL-33 and TSLP. None of the environmental contaminants were associated with increased odds of a high cord blood immune system biomarker concentration., Conclusions: In this primarily urban Canadian population of pregnant women and their newborns, maternal blood or urine concentrations of persistent organic pollutants, pesticides, and metals were not associated with immunotoxic effects that manifest as increased odds of elevated concentrations of IgE, TSLP or IL-33.

Background Context: Waitlists are commonly used in Canada to manage access to surgical procedures such as elective surgical lumbar discectomy (ESLD). The timing of enrollment onto the waitlist is important as this is a proxy measure for the concordance of preferences for surgery between a patient and surgeon. After enrollment, the waiting time to actual surgery extends the duration of preoperative symptoms, which possibly affects the outcome of ESLD. Waiting time also specifically reflects the delay in service delivery imposed by the limited capacity of the health-care system., Purpose: To determine if a system-imposed delay in treatment, that is, longer waiting time, for ESLD is associated with a higher odds of experiencing residual postoperative pain., Study Design/setting: Ambidirectional cohort study with 2-year retrospective and 3-year prospective components, conducted at a major tertiary care center serving a metropolitan area in Canada., Patient Sample: Patients aged 16 years or older with sciatica because of herniated lumbar disc, confirmed on advanced imaging, were recruited at the time of waitlist enrollment for ESLD. Patients with significant comorbidity or emergency indications for surgery were excluded. Of 391 participants, 291 had complete follow-up information at 6 months postoperatively., Outcome Measure: Intensity of the predominant symptom (worse of either back or leg pain) was assessed on the 11-point numerical rating scale at waitlist enrollment and 6 months postoperatively. Pain scores were highly skewed and therefore categorized into four ordinal levels defined by quartiles., Methods: For the primary analysis, time to surgery from waitlist enrollment was dichotomized based on a predetermined clinically meaningful cut-point of 12 weeks. Ordinal logistic regression was used to compare the odds of experiencing higher pain intensity between wait groups. Control of confounders was achieved using both propensity scores and conventional multivariable modeling., Results: In unadjusted analyses, long-wait patients were 80% more likely than short-wait patients to experience higher ordinal pain intensity at 6 months; unadjusted proportional odds ratio (POR)=1.8 (95% confidence interval [CI], 1.2-2.8). The association held after controlling for all imbalances in measured confounders, with long-wait patients still being 70% more likely to report worse pain; adjusted POR=1.7 (95% CI, 1.0-2.8)., Conclusions: A waiting time of 12 weeks or more after waitlist enrollment for ESLD is associated with a modest likelihood of experiencing worse pain at 6 months postoperatively. This result was not because of differences in measured confounders. Future studies are encouraged to identify other, as-of-yet unmeasured, variables that might be associated with both longer waiting times and worse outcomes among ESLD patients. Until then, in jurisdictions where highly constrained access to ESLD is managed through waitlists, the expected waiting time for the operation could be an informative deciding criterion for patients with otherwise unresolved preferences for operative treatment., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Published decision analyses show that screening for colorectal cancer is cost-effective. However, because of the number of tests available, the optimal screening strategy in Canada is unknown. We estimated the incremental cost-effectiveness of 10 strategies for colorectal cancer screening, as well as no screening, incorporating quality of life, noncompliance and data on the costs and benefits of chemotherapy., Methods: We used a probabilistic Markov model to estimate the costs and quality-adjusted life expectancy of 50-year-old average-risk Canadians without screening and with screening by each test. We populated the model with data from the published literature. We calculated costs from the perspective of a third-party payer, with inflation to 2007 Canadian dollars., Results: Of the 10 strategies considered, we focused on three tests currently being used for population screening in some Canadian provinces: low-sensitivity guaiac fecal occult blood test, performed annually; fecal immunochemical test, performed annually; and colonoscopy, performed every 10 years. These strategies reduced the incidence of colorectal cancer by 44%, 65% and 81%, and mortality by 55%, 74% and 83%, respectively, compared with no screening. These strategies generated incremental cost-effectiveness ratios of $9159, $611 and $6133 per quality-adjusted life year, respectively. The findings were robust to probabilistic sensitivity analysis. Colonoscopy every 10 years yielded the greatest net health benefit., Interpretation: Screening for colorectal cancer is cost-effective over conventional levels of willingness to pay. Annual high-sensitivity fecal occult blood testing, such as a fecal immunochemical test, or colonoscopy every 10 years offer the best value for the money in Canada.

Background and Purpose: Recent innovations in diagnosis, management, and rehabilitation have resulted in measurable improvements in clinical and functional outcomes after acute stroke. However, whether gains in health-related quality of life after stroke have also occurred is not well characterized. Using 2 Canadian population surveys, the purpose of this study was to identify changes in health-related quality of life in individuals with stroke from 1996 to 2005., Methods: Data from the public use files of the National Population Health Survey, Cycle 2 (1996), and the Canadian Community Health Survey, Cycle 3.1. (2005), were used. A total of 847 individuals with stroke were included. Self-reported information on health status based on the Health Utilities Index Mark 3 was used to generate single-attribute and overall health-related quality of life scores. Analysis of covariance and multiple logistic regression were used to determine the relationship between survey year and poststroke impairment adjusting for demographic variables and clinical comorbidities., Results: A statistically significant and clinically important reduction in mean overall Health Utilities Index Mark 3 scores was observed for respondents with stroke from 1996 to 2005. In addition, 2 of the 8 single-attribute Health Utilities Index Mark 3 domains showed a significant change between survey years. Significantly more individuals with stroke reported dexterity and cognitive impairment in 2005 compared with respondents in 1996, indicating reduced health-related quality of life for these domains., Conclusions: Despite improvements in medical management, quality of life is not improving after stroke in the Canadian population. These findings are useful to generate hypotheses about the impact of advances in management on quality of life after stroke and identify specific domains that may benefit from future study in stroke populations.

Spurred by a desire to improve quality of care and to understand the relative value of medical treatments, there has been a recent surge of interest in publicly funded comparative effectiveness research (CER) in the US. As health technology assessment (HTA) shares some of the same goals as CER, and publicly funded HTA has been a feature within other industrialized countries for many years, a review of HTA activities in some of these countries can be a helpful source of information for the US debate. Informed by a literature review, and in two cases augmented by informant interviews, we reviewed the organization of HTA activities in five jurisdictions: Canada, Sweden, Scotland, the Netherlands and Australia. We provide a summary description of the healthcare system in each country as well as a description of the key features of their HTA bodies, with a particular focus on the processes of HTA for listing medications on public formularies. Four of the committees evaluating medications for formulary inclusion are funded by, but remain at arm's length from, the government (Canada, Australia, Sweden and Scotland), while the process is fully embedded within the government in the Netherlands. Each of these jurisdictions has a stated preference for comparative outcomes evidence from randomized controlled trials, but will, under certain circumstances, accept randomized evidence using surrogate markers, other comparators that are not directly relevant or non-randomized evidence. Health technology evaluation committees largely comprise health professionals, with public representatives included in the Canadian, Australian and Scottish committees. Scotland is the only one of the five jurisdictions reviewed to have industry representation on the evaluation committee. We identified seven characteristics that are shared across the jurisdictions reviewed and that potentially serve as insights for development of CER in the US: (i) the process must be responsive to stakeholders' interests, in that the turn-around time for assessments must be minimized, transparency must be maximized, the process must be considered fair using universally agreed standards and the process must be modifiable based on stakeholders' requirements; (ii) the assessment of medical technologies other than drugs may present different challenges and is managed separately in other HTA organizations; (iii) because of the link between HTA and reimbursement decisions, completion of the HTA process following regulatory approval can delay market access to new technologies, thus closer integration between regulatory approval and HTA processes is being explored internationally; (iv) there is a direct or indirect link to reimbursement in the jurisdictions explored - without this link the role of CER in the US will remain advisory; (v) each jurisdiction reviewed benefits from a single payer that is informed by the process - given the diverse multipayer environment in the US, CER in the US may usefully focus on generating comparative effectiveness evidence; (vi) a common metric for assessing intended and unintended effects of treatment allows comparison across different technologies; and (vii) one stated focus of CER is on therapeutic benefit among 'high-priority populations', including specific demographic groups (the elderly and children, racial and ethnic minorities) and individuals with disabilities, multiple chronic conditions and specific genomic factors. This will be difficult to achieve because epidemiological evidence of differences in therapeutic benefit among subgroups is detected through effect modification, or more specifically, statistical evidence of effect measure modification, typically on relative measures of effect. Few randomized trials have enough power to detect effect modification and these have been uncommon in the scientific literature. As consideration is given to the development of a publicly funded CER body in the US, much can be learned from the international experience. Nevertheless, there are some distinctive features of the US healthcare system that must be taken into account when assessing the transferability of these insights.

Despite variation in Canadian privacy laws between provinces and territories, increasing legislative protection of personal privacy has imposed restrictions on health research across the country. The effects of these restrictions on patient recruitment include increased study costs, durations, and decreased participation rates. Low participation rates can jeopardize the validity of research findings and the accuracy of measures of association by introducing non-response, or participation bias. We constructed simulations to assess potential effects of non-response bias on the accuracy of measures of association in a hypothetical case-control study. Small biases that alter the probability of selecting an exposed case can lead to dramatic inflation or attrition of the odds ratio (OR) in case-control studies. ORs are more unstable and subject to error when the true probability of selecting an exposed case is greater, such that strong positive associations are subject to error even at low levels of bias. Well-powered, population-based epidemiological research is a cornerstone of public health. Therefore, when weighing the benefits of protecting personal privacy, the benefits of valid and robust health research must also be considered. Options might include special legislative treatment of health research, or the use of an "opt-out" (vs. the current "opt-in") construct for consent in confidential research.

Reports of preventable illness due to medication errors are widespread in Canada. However, quantifying the magnitude of the problem has been hampered by a lack of measurement tools. Canadian-specific indicators, or performance measures, of safe medication use do not exist. The objective of this study was to develop a set of Canadian consensus-based indicators for the safe use of medication for both in-patient and outpatient settings. A panel of 20 national experts was established from a convenience sample of experts representing medicine, nursing, pharmacy, research and decision-makers in hospitals and community settings across Canada. After creating a list of potential indicators from the literature, the final consensus set was chosen by the panel using a Delphi survey process via e-mail. After three rounds, consensus was obtained on 20 medication-use safety indicators: seven indicators were related to systems of care, five to prescribing/ordering, three to monitoring/assessment, three to medication administration, one to preparation and dispensing and one to purchasing/inventory management. Seventeen of the indicators measure a process of care (in contrast to health outcome); at least 10 have applications outside the in-patient setting. The resulting 20 medication-use safety indicators are diverse in scope and should be applicable in a variety of practice settings. These indicators may provide clinicians and decision-makers with valuable tools to assess the safety of medication-use systems.

Goals: To estimate resource use and expected annual cost of care for subjects with chronic hepatitis B and resulting complications in Canada., Background: Patients chronically infected with hepatitis B virus are at an increased risk of progressing to complications from deteriorating liver function., Study: The direct medical costs for six disease states associated with chronic hepatitis B virus infection were estimated for the year 2001., Methods: Information on resource utilization patterns was obtained from: 1) a questionnaire administered to eight specialists with experience treating hepatitis B patients, and 2) a data set on hospitalizations in nine Canadian provinces for specific diagnostic codes. Unit costs were collected from published literature and provincial physician payment schedules and lists of reimbursed medications. All sources of information were combined to calculate expected annual costs. Uncertainty analysis was performed using Monte Carlo simulations. Costs are reported in 2001 Canadian dollars., Results: The expected annual per-person costs of care and their 95% confidence intervals (CIs) were: 2191 dollars (CI, 1997 dollars-2556 dollars) for chronic hepatitis B, 2987 dollars (CI, 2389 dollars-4462 dollars) for compensated cirrhosis, 11,228 dollars (CI, 8309 dollars-16,388 dollars) for decompensated cirrhosis, 13,350 dollars (CI, 10,608 dollars-17,187 dollars) for hepatocellular carcinoma, 99,066 dollars (CI, 94,328 dollars-106,833 dollars) for liver transplant, and 38,242 dollars (CI, 33,443 dollars-46,087 dollars) for transplant care after the first year. Main cost drivers were hospitalizations and medications., Conclusion: The cost of treating Canadian subjects with hepatitis B-related conditions increases substantially with deteriorating liver function. Any new therapy that proves to be more effective at slowing or preventing the course of liver disease progression would be cost-effective.

Purpose: The objective was to determine whether the year and medical school of graduation, the medical specialty and the sex of the treating physician was associated with prescribing beta-blockers after hospital discharge among survivors of myocardial infarction (MI), after adjusting for patient characteristics., Methods: We carried out a dynamic retrospective cohort study using data from a longitudinal database that contained information on Quebec residents over the age of 65 years sent home from hospital after MI between 1990 and 1993. The outcome was a beta-blocker being dispensed after hospital discharge. Logistic regression was used to estimate the association between training characteristics and beta-blocker dispensation and clustering of patients within physicians was accounted for using Generalized Estimating Equations., Results: The cohort consisted of 14,334 MI survivors who were treated by 3209 physicians, yielding a mean of about 4.5 patients per physician [standard deviation (SD) = 8.2]. Beta-blockers were prescribed to approximately one-third of subjects. After adjusting for patients' demographic characteristics, comorbid medical conditions, and markers of MI severity, physicians who were more likely to prescribe a beta-blocker included cardiologists and the most recent graduates (graduating after 1989). Systematic differences were also observed between graduates of different medical schools., Conclusions: After adjusting for differences between patients', the sex of the physician was largely unrelated to prescribing beta-blockers for secondary prevention of MI. However, prescribing differed by training characteristics such as medical specialty and year and medical school of graduation.

The fiscal "cat" of healthcare spending - drug expenditures - is out of the bag: drug costs are now the fastest rising component of healthcare expenditures in Canada. Laupacis, Anderson and O'Brien describe the current process of listing drugs on the provincial drug formulary in Ontario, identify factors that may contribute to the rapid growth in drug expenditures, and make a number of recommendations for controlling drug expenditures, including (1) improving the evidence on cost-effectiveness; (2) disseminating the evidence to prescribers; (3) re-evaluating the evidence; and (4) increasing the transparency about the acquisition costs of drugs. These are recommendations that, if implemented, would theoretically help decision-makers make more rational decisions about which drugs to list on provincial formularies. The question of how to implement the recommendations remains to be elucidated, as does an evaluation of the trade-offs between costs and benefits of obtaining better information on cost-effectiveness.