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Grams ME, Coresh J, Matsushita K, Ballew SH, Sang Y, Surapaneni A, Alencar de Pinho N, Anderson A, Appel LJ, Ärnlöv J, Azizi F, Bansal N, Bell S, Bilo HJG, Brunskill NJ, Carrero JJ, Chadban S, Chalmers J, Chen J, Ciemins E, Cirillo M, Ebert N, Evans M, Ferreiro A, Fu EL, Fukagawa M, Green JA, Gutierrez OM, Herrington WG, Hwang SJ, Inker LA, Iseki K, Jafar T, Jassal SK, Jha V, Kadota A, Katz R, Köttgen A, Konta T, Kronenberg F, Lee BJ, Lees J, Levin A, Looker HC, Major R, Melzer Cohen C, Mieno M, Miyazaki M, Moranne O, Muraki I, Naimark D, Nitsch D, Oh W, Pena M, Purnell TS, Sabanayagam C, Satoh M, Sawhney S, Schaeffner E, Schöttker B, Shen JI, Shlipak MG, Sinha S, Stengel B, Sumida K, Tonelli M, Valdivielso JM, van Zuilen AD, Visseren FLJ, Wang AYM, Wen CP, Wheeler DC, Yatsuya H, Yamagata K, Yang JW, Young A, Zhang H, Zhang L, Levey AS, Gansevoort RT. Estimated Glomerular Filtration Rate, Albuminuria, and Adverse Outcomes: An Individual-Participant Data Meta-Analysis. JAMA 2023; 330:1266-1277. [PMID: 37787795 PMCID: PMC10548311 DOI: 10.1001/jama.2023.17002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/15/2023] [Indexed: 10/04/2023]
Abstract
Importance Chronic kidney disease (low estimated glomerular filtration rate [eGFR] or albuminuria) affects approximately 14% of adults in the US. Objective To evaluate associations of lower eGFR based on creatinine alone, lower eGFR based on creatinine combined with cystatin C, and more severe albuminuria with adverse kidney outcomes, cardiovascular outcomes, and other health outcomes. Design, Setting, and Participants Individual-participant data meta-analysis of 27 503 140 individuals from 114 global cohorts (eGFR based on creatinine alone) and 720 736 individuals from 20 cohorts (eGFR based on creatinine and cystatin C) and 9 067 753 individuals from 114 cohorts (albuminuria) from 1980 to 2021. Exposures The Chronic Kidney Disease Epidemiology Collaboration 2021 equations for eGFR based on creatinine alone and eGFR based on creatinine and cystatin C; and albuminuria estimated as urine albumin to creatinine ratio (UACR). Main Outcomes and Measures The risk of kidney failure requiring replacement therapy, all-cause mortality, cardiovascular mortality, acute kidney injury, any hospitalization, coronary heart disease, stroke, heart failure, atrial fibrillation, and peripheral artery disease. The analyses were performed within each cohort and summarized with random-effects meta-analyses. Results Within the population using eGFR based on creatinine alone (mean age, 54 years [SD, 17 years]; 51% were women; mean follow-up time, 4.8 years [SD, 3.3 years]), the mean eGFR was 90 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 11 mg/g (IQR, 8-16 mg/g). Within the population using eGFR based on creatinine and cystatin C (mean age, 59 years [SD, 12 years]; 53% were women; mean follow-up time, 10.8 years [SD, 4.1 years]), the mean eGFR was 88 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 9 mg/g (IQR, 6-18 mg/g). Lower eGFR (whether based on creatinine alone or based on creatinine and cystatin C) and higher UACR were each significantly associated with higher risk for each of the 10 adverse outcomes, including those in the mildest categories of chronic kidney disease. For example, among people with a UACR less than 10 mg/g, an eGFR of 45 to 59 mL/min/1.73 m2 based on creatinine alone was associated with significantly higher hospitalization rates compared with an eGFR of 90 to 104 mL/min/1.73 m2 (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.3]; 161 vs 79 events per 1000 person-years; excess absolute risk, 22 events per 1000 person-years [95% CI, 19-25 events per 1000 person-years]). Conclusions and Relevance In this retrospective analysis of 114 cohorts, lower eGFR based on creatinine alone, lower eGFR based on creatinine and cystatin C, and more severe UACR were each associated with increased rates of 10 adverse outcomes, including adverse kidney outcomes, cardiovascular diseases, and hospitalizations.
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Affiliation(s)
- Morgan E Grams
- Division of Precision Medicine, Department of Medicine, Grossman School of Medicine, New York University, New York, New York
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Shoshana H Ballew
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Yingying Sang
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Aditya Surapaneni
- Division of Precision Medicine, Department of Medicine, Grossman School of Medicine, New York University, New York, New York
| | - Natalia Alencar de Pinho
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Amanda Anderson
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Lawrence J Appel
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Johan Ärnlöv
- School of Health and Social Studies, Dalarna University, Falun, Sweden
- Department of Neurobiology, Care Sciences, and Society, Family Medicine and Primary Care Unit, Karolinska Institutet, Huddinge, Sweden
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nisha Bansal
- Division of Nephrology, University of Washington, Seattle
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, Scotland
| | - Henk J G Bilo
- Diabetes Centre and Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Nigel J Brunskill
- Department of Cardiovascular Sciences, University of Leicester, and John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, England
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, and Department of Clinical Science, Danderyd Hospital, Stockholm, Sweden
| | - Steve Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - John Chalmers
- George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Public Health, Imperial College, London, England
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Jing Chen
- Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana
| | | | - Massimo Cirillo
- Department Scuola Medica Salernitana, University of Salerno, Fisciano, Italy
| | - Natalie Ebert
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marie Evans
- Department of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Alejandro Ferreiro
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, School of Medicine, Tokai University, Isehara, Japan
| | - Jamie A Green
- Department of Nephrology, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
- Center for Kidney Health Research, Geisinger, Danville, Pennsylvania
| | | | - William G Herrington
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, England
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, England
| | - Shih-Jen Hwang
- Framingham Heart Study, Framingham, Massachusetts
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Tazeen Jafar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Simerjot K Jassal
- University of California-San Diego, La Jolla
- San Diego VA Health Care System, San Diego, California
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India
- George Institute for Global Health, School of Public Health, Imperial College, London, England
| | - Aya Kadota
- Department of Public Health, NCD Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Anna Köttgen
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Tsuneo Konta
- Department of Public Health and Hygiene, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Brian J Lee
- Kaiser Permanente, Hawaii Region, and Moanalua Medical Center, Honolulu, Hawai'i
| | - Jennifer Lees
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Helen C Looker
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, Arizona
| | - Rupert Major
- Department of Cardiovascular Sciences, University of Leicester, and John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, England
| | - Cheli Melzer Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, Tochigi, Japan
| | - Mariko Miyazaki
- Department of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Olivier Moranne
- Service de Néphrologie Dialyse Aphérèse, Nîmes Hôpital Universitaire, Nîmes, France
- IDESP, UMR-INSERM, Universite de Montpellier, Montpellier, France
| | - Isao Muraki
- Public Health, Osaka University Graduate School of Medicine, Suita, Japan
| | - David Naimark
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dorothea Nitsch
- London School of Hygiene and Tropical Medicine, London, England
| | - Wonsuk Oh
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle Pena
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tanjala S Purnell
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Division of Transplantation, Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Michihiro Satoh
- Division of Public Health, Hygiene, and Epidemiology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Simon Sawhney
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, Scotland
- NHS Grampian, Aberdeen, Scotland
| | - Elke Schaeffner
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Jenny I Shen
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco
- General Internal Medicine Division, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Smeeta Sinha
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Benedicte Stengel
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, Inserm U1018, Versailles Saint-Quentin University, Clinical Epidemiology Team, Villejuif, France
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jose M Valdivielso
- Vascular and Renal Translational Research Group, Biomedical Research Institute of Lleida, IRBLleida and University of Lleida, Lleida, Spain
| | - Arjan D van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Chi-Pang Wen
- Institute of Population Health Science, National Health Research Institutes, Zhunan, Taiwan/China Medical University Hospital, Taichung, Taiwan
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, England
| | - Hiroshi Yatsuya
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Jae Won Yang
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Wonju, South Korea
| | - Ann Young
- Division of Nephrology, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- ICES Western, London, Ontario, Canada
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Luxia Zhang
- Peking University First Hospital, Beijing, China
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Ozaki AF, Ko DT, Chong A, Fang J, Atzema CL, Austin PC, Stukel TA, Tu K, Udell JA, Naimark D, Booth GL, Jackevicius CA. Prescribing patterns and factors associated with sodium-glucose cotransporter-2 inhibitor prescribing in patients with diabetes mellitus and atherosclerotic cardiovascular disease. CMAJ Open 2023; 11:E494-E503. [PMID: 37311594 DOI: 10.9778/cmajo.20220039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors are cardioprotective agents in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease (CVD). Since little is known about their uptake in atherosclerotic CVD, we examined SGLT2 inhibitor prescribing trends and identified potential disparities in prescribing patterns. METHODS We conducted an observational study using linked population-based health data in Ontario, Canada, from April 2016 to March 2020 of patients aged 65 years or older with concomitant type 2 diabetes and atherosclerotic CVD. To examine prevalent prescribing of SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin), we constructed 4 cross-sectional yearly cohorts from Apr. 1 to Mar. 31 (2016/17, 2017/18, 2018/19 and 2019/20). We estimated prevalent SGLT2 inhibitor prescribing by year and by subgroups, and identified factors associated with SGTL2 inhibitor prescribing using multivariable logistic regression. RESULTS There were 208 303 patients in our overall cohort (median age 74.0 yr [interquartile range 68.0-80.0 yr], 132 196 [63.5%] male). Although SGLT2 inhibitor prescribing increased over time, from 7.0% to 20.1%, statin prescribing was initially 10-fold higher and later threefold higher than SGLT2 inhibitor prescribing. In 2019/20, SGLT2 inhibitor prescribing was roughly 50% lower among those aged 75 years or older than among those younger than 75 years (12.9% v. 28.3%, p < 0.001) and in women than in men (15.3% v. 22.9%, p < 0.001). Age 75 years or older, female sex, history of heart failure and kidney disease, and low income were independent factors of lower SGLT2 inhibitor prescribing. Among physician specialists, visits to endocrinologists and family physicians were stronger factors of SGLT2 inhibitor prescribing than cardiologist visits. INTERPRETATION We found that 1 in 5 patients with diabetes and atherosclerotic CVD were prescribed SGLT2 inhibitors in 2019/20, whereas statins were prescribed for 4 of every 5 patients. Although SGLT2 inhibitor prescribing increased over the study period, disparities in adoption by age, sex, socioeconomic status, comorbidities and physician specialty remained.
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Affiliation(s)
- Aya F Ozaki
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Dennis T Ko
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Alice Chong
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Jiming Fang
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Clare L Atzema
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Peter C Austin
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Therese A Stukel
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Karen Tu
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Jacob A Udell
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - David Naimark
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Gillian L Booth
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif
| | - Cynthia A Jackevicius
- University of California, Irvine (Ozaki), Irvine, Calif.; ICES Central (Ko, Chong, Fang, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); University of Toronto (Ko, Atzema, Austin, Stukel, Tu, Udell, Naimark, Booth, Jackevicius); Sunnybrook Health Sciences Centre (Ko, Atzema, Naimark); University Health Network (Tu, Udell, Naimark); Women's College Hospital (Udell, Naimark); Unity Health Toronto (Booth), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Veterans Affairs Greater Los Angeles Healthcare System (Jackevicius), Los Angeles, Calif.
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Peel JK, Pullenayegum EM, Naimark D, Aversa M, Liu M, Del Sorbo L, Barrett K, Sander B, Keshavjee S. Evaluating the Impact of Ex-Vivo Lung Perfusion on Organ Transplantation: A Retrospective Cohort Study. Ann Surg 2023:00000658-990000000-00441. [PMID: 37073734 DOI: 10.1097/sla.0000000000005887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Ex-vivo lung perfusion (EVLP) sustains and allows advanced assessment of potentially useable donor lungs prior to transplantation, potentially relieving resource constraints. OBJECTIVE We sought to characterize the effect of EVLP on organ utilization and patient outcomes. METHODS We performed a retrospective, before-after cohort study using linked institutional data sources of adults wait-listed for lung transplant and donor organs transplanted in Ontario, Canada between 2005-2019. We regressed the annual number of transplants against year, EVLP use, and organ characteristics. Time-to-transplant, waitlist mortality, primary graft dysfunction, tracheostomy insertion, in-hospital mortality, and chronic lung allograft dysfunction (CLAD) were evaluated using propensity score-weighted regression. RESULTS EVLP availability (P=0.01 for interaction) and EVLP use (P<0.001 for interaction) were both associated with steeper increases in transplantation than expected by historical trends. EVLP was associated with more donation after circulatory death (DCD) and extended-criteria donors transplanted, while the numbers of standard-criteria donors remained relatively stable. Significantly faster time-to-transplant was observed after EVLP was available (hazard ratio [HR] 1.64 [1.41-1.92]; P<0.001). Fewer patients died on the waitlist after EVLP was available, but no difference in the hazard of waitlist mortality was observed (HR 1.19 [0.81-1.74]; P=0.176). We observed no difference in the likelihood of CLAD before versus after EVLP was available. CONCLUSIONS We observed a significant increase in organ transplantation since EVLP was introduced into practice, predominantly from increased acceptance of DCD and extended-criteria lungs. Our findings suggest that EVLP-associated increases in organ availability meaningfully alleviated some barriers to transplant.
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Affiliation(s)
- John K Peel
- Department of Anesthesiology, University Health Network, University of Toronto
- Toronto Lung Transplant Program, University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto
| | - Eleanor M Pullenayegum
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto
- Division of Nephrology, Sunnybrook Health Sciences Centre
| | - Meghan Aversa
- Toronto Lung Transplant Program, University Health Network, University of Toronto
| | - Mingyao Liu
- Toronto Lung Transplant Program, University Health Network, University of Toronto
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Toronto Lung Transplant Program, University Health Network, University of Toronto
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto
- Interdepartmental Division of Critical Care Medicine, University of Toronto
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, ON, Canada
- Public Health Ontario, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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4
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Peel JK, Keshavjee S, Naimark D, Liu M, Del Sorbo L, Cypel M, Barrett K, Pullenayegum EM, Sander B. Determining the impact of ex-vivo lung perfusion on hospital costs for lung transplantation: A retrospective cohort study. J Heart Lung Transplant 2023; 42:356-367. [PMID: 36411188 DOI: 10.1016/j.healun.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/04/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ex-vivo lung perfusion (EVLP) has improved organ utilization for lung transplantation, but it is not yet known whether the benefits of this technology offset its additional costs. We compared the institutional costs of lung transplantation before vs after EVLP was available to identify predictors of costs and determine the health-economic impact of EVLP. METHODS We performed a retrospective, before-after, propensity-score weighted cohort study of patients wait-listed for lung transplant at University Health Network (UHN) in Ontario, Canada, between January 2005 and December 2019 using institutional administrative data. We compared costs, in 2019 Canadian Dollars ($), between patients referred for transplant before EVLP was available (Pre-EVLP) to after (Modern EVLP). Cumulative costs were estimated using a novel application of multistate survival models. Predictors of costs were identified using weighted log-gamma generalized linear regression. RESULTS A total of 1,199 patients met inclusion criteria (352 Pre-EVLP; 847 Modern EVLP). Mean total costs for the transplant hospitalization were $111,878 ($94,123-$130,767) in the Pre-EVLP era and $110,969 ($87,714-$136,000) in the Modern EVLP era. Cumulative five-year costs since referral were $278,777 ($82,575-$298,135) in the Pre-EVLP era and $293,680 ($252,832-$317,599) in the Modern EVLP era. We observed faster progression to transplantation when EVLP was available. EVLP availability was not a predictor of waitlist (cost ratio [CR] 1.04 [0.81-1.37]; p = 0.354) or transplant costs (CR 1.02 [0.80-1.29]; p = 0.425) but was associated with lower costs during posttransplant years 1&2 (CR 0.75 [0.58-1.06]; p = 0.05) and posttransplant years 3+ (CR 0.43 [0.26-0.74]; p = 0.001). CONCLUSIONS At our center, EVLP availability was associated with faster progression to transplantation at no significant marginal cost.
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Affiliation(s)
- John Kenneth Peel
- Department of Anesthesiology, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mingyao Liu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor M Pullenayegum
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Ontario, Canada; Public Health Ontario, Ontario, Canada.
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5
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Sud M, Austin P, Naimark D, Wijeysundera H, Chu A, Thanassoulis G, Ko D. IMPACT OF OUTCOME DEFINITIONS ON CARDIOVASCULAR RISK PREDICTION IN A CONTEMPORARY PRIMARY PREVENTION POPULATION. Can J Cardiol 2022. [DOI: 10.1016/j.cjca.2022.08.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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6
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Jauhal A, Reich HN, Hladunewich M, Barua M, Hansen BE, Naimark D, Troyanov S, Cattran DC. Quantifying the benefits of remission duration in focal and segmental glomerulosclerosis. Nephrol Dial Transplant 2022; 38:950-960. [PMID: 35948275 PMCID: PMC10064837 DOI: 10.1093/ndt/gfac238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although the clinical benefit of obtaining a remission in proteinuria in nephrotic patients with focal and segmental glomerulosclerosis (FSGS) is recognized, the long-term value of maintaining it and the impact of relapses on outcome are not well described. METHODS We examined the impact of remissions and relapses on either a 50% decline in kidney function or ESKD (combined event) using time-dependent and landmark analyses in a retrospective study of all patients from the Toronto Glomerulonephritis Registry with biopsy-proven FSGS, established nephrotic-range proteinuria and at least one remission. RESULTS In the 203 FSGS individuals with a remission, 89 never relapsed and 114 experienced at least one relapse. The first recurrence was often followed by a repeating pattern of remission and relapse. The 10-year survival from a combined event was 15% higher in those with no relapse versus those with any relapse. This smaller than anticipated difference was related to the favorable outcome in individuals whose relapses quickly remitted. Relapsers who ultimately ended in remission (n = 46) versus in relapse (n = 68) experienced a 91% and 32% 7-year event survival (p<0.001). Using time-varying survival analyses that considered all periods of remission and relapse in every patient and adjusting for each period's initial eGFR, the state of relapse was associated with a 2.17 (95%CI,1.32-3.58, p = 0.002) greater risk of experiencing a combined event even in this FSGS remission cohort. CONCLUSIONS In FSGS, unless remissions are maintained and relapses avoided, long-term renal survival remains poor. Treatment strategies addressing remission duration remain poorly defined and should be an essential question in future trials.
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Affiliation(s)
- Arenn Jauhal
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Science Center, University of Toronto, Toronto, Ontario, Canada
| | - Moumita Barua
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - David Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Science Center, University of Toronto, Toronto, Ontario, Canada
| | - Stéphan Troyanov
- Division of Nephrology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Daniel C Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Peel JK, Neves Miranda R, Naimark D, Woodward G, Mamas MA, Madan M, Wijeysundera HC. Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis. J Am Heart Assoc 2022; 11:e025085. [PMID: 35411786 PMCID: PMC9238449 DOI: 10.1161/jaha.121.025085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost‐effective investment in TAVI care that should be made at a health system level to meet quality indicator goals. Methods and Results We performed a cost‐utility analysis using probabilistic patient‐level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2‐year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting ≥1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per‐person costs, quality‐adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost‐effectiveness thresholds between $0 and $100 000 per quality‐adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ≈26 wait‐list deaths and 200 wait‐list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ≈$14 to ≈$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost‐effective. Conclusions This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care.
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Affiliation(s)
- John K Peel
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Department of Anesthesiology and Pain Medicine University of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada
| | - Rafael Neves Miranda
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada
| | - David Naimark
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada.,Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group Keele University Keele United Kingdom
| | - Mina Madan
- Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada.,Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada
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8
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Manns BJ, Garg AX, Sood MM, Ferguson T, Kim SJ, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Dixon SN, Alam A, Allu S, Tangri N. Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial. Clin J Am Soc Nephrol 2022; 17:535-545. [PMID: 35314481 PMCID: PMC8993468 DOI: 10.2215/cjn.13191021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Home dialysis therapies (peritoneal and home hemodialysis) are less expensive and provide similar outcomes to in-center hemodialysis, but they are underutilized in most health systems. Given this, we designed a multifaceted intervention to increase the use of home dialysis. In this study, our objective was to evaluate the effect of this intervention on home dialysis use in CKD clinics across Canada. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a cluster randomized controlled trial in 55 CKD clinic clusters in nine provinces in Canada between October 2014 and November 2015. Participants included all adult patients who initiated dialysis in the year following the intervention. We evaluated the implementation of a four-component intervention, which included phone surveys from a knowledge translation broker, a 1-year center-specific audit/feedback on home dialysis use, delivery of an educational package (including tools aimed at both providers and patients), and an academic detailing visit. The primary outcome was the proportion of patients using home dialysis at 180 days after dialysis initiation. RESULTS A total of 55 clinics were randomized (27 in the intervention and 28 in the control), with 5312 patients initiating dialysis in the 1-year follow-up period. In the primary analysis, there was no difference in the use of home dialysis at 180 days in the intervention and control clusters (absolute risk difference, 4%; 95% confidence interval, -2% to 10%). Using a difference-in-difference comparison, the use of home dialysis at 180 days was similar before and after implementation of the intervention (difference of 0% in intervention clinics; 95% confidence interval, -2% to 3%; difference of 0.8% in control clinics; 95% confidence interval, -1% to 3%; P=0.84). CONCLUSIONS A multifaceted intervention did not increase the use of home dialysis in adults initiating dialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER A Cluster Randomized Trial to Assess the Impact of Patient and Provider Education on Use of Home Dialysis, NCT02202018.
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Affiliation(s)
- Braden J Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Public Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie N Dixon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Selina Allu
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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9
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Parmar A, Eskander A, Sander B, Naimark D, Irish JC, Chan KKW. Impact of cancer surgery slowdowns on patient survival during the COVID-19 pandemic: a microsimulation modelling study. CMAJ 2022; 194:E408-E414. [PMID: 35314440 PMCID: PMC9053956 DOI: 10.1503/cmaj.202380] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background: With the declaration of the global pandemic, surgical slowdowns were instituted to conserve health care resources for anticipated surges in patients with COVID-19. The long-term implications on survival of these slowdowns for patients with cancer in Canada is unknown. Methods: We constructed a microsimulation model based on real-world population data on cancer care from Ontario, Canada, from 2019 and 2020. Our model estimated wait times for cancer surgery over a 6-month period during the pandemic by simulating a slowdown in operating room capacity (60% operating room resources in month 1, 70% in month 2, 85% in months 3–6), as compared with simulated prepandemic conditions with 100% resources. We used incremental differences in simulated wait times to model survival using per-day hazard ratios for risk of death. Primary outcomes included life-years lost per patient and per cancer population. We conducted scenario analyses to evaluate alternative, hypothetical scenarios of different levels of surgical slowdowns on risk of death. Results: The simulated model population comprised 22 799 patients waiting for cancer surgery before the pandemic and 20 177 patients during the pandemic. Mean wait time to surgery prepandemic was 25 days and during the pandemic was 32 days. Excess wait time led to 0.01–0.07 life-years lost per patient across cancer sites, translating to 843 (95% credible interval 646–950) life-years lost among patients with cancer in Ontario. Interpretation: Pandemic-related slowdowns of cancer surgeries were projected to result in decreased long-term survival for many patients with cancer. Measures to preserve surgical resources and health care capacity for affected patients are critical to mitigate unintended consequences.
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Affiliation(s)
- Ambica Parmar
- Odette Cancer Centre (Parmar, Chan), Sunnybrook Health Sciences Centre; Department of Otolaryngology-Head and Neck Surgery (Eskander, Irish); Institute of Health Policy, Management and Evaluation (Eskander, Sander, Naimark), University of Toronto; Toronto Health Economic and Technology Assessment Collaboration (Sander), University Health Network; Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre; Department of Surgical Oncology (Irish), Princess Margaret Cancer Centre; Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Antoine Eskander
- Odette Cancer Centre (Parmar, Chan), Sunnybrook Health Sciences Centre; Department of Otolaryngology-Head and Neck Surgery (Eskander, Irish); Institute of Health Policy, Management and Evaluation (Eskander, Sander, Naimark), University of Toronto; Toronto Health Economic and Technology Assessment Collaboration (Sander), University Health Network; Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre; Department of Surgical Oncology (Irish), Princess Margaret Cancer Centre; Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Beate Sander
- Odette Cancer Centre (Parmar, Chan), Sunnybrook Health Sciences Centre; Department of Otolaryngology-Head and Neck Surgery (Eskander, Irish); Institute of Health Policy, Management and Evaluation (Eskander, Sander, Naimark), University of Toronto; Toronto Health Economic and Technology Assessment Collaboration (Sander), University Health Network; Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre; Department of Surgical Oncology (Irish), Princess Margaret Cancer Centre; Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - David Naimark
- Odette Cancer Centre (Parmar, Chan), Sunnybrook Health Sciences Centre; Department of Otolaryngology-Head and Neck Surgery (Eskander, Irish); Institute of Health Policy, Management and Evaluation (Eskander, Sander, Naimark), University of Toronto; Toronto Health Economic and Technology Assessment Collaboration (Sander), University Health Network; Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre; Department of Surgical Oncology (Irish), Princess Margaret Cancer Centre; Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Jonathan C Irish
- Odette Cancer Centre (Parmar, Chan), Sunnybrook Health Sciences Centre; Department of Otolaryngology-Head and Neck Surgery (Eskander, Irish); Institute of Health Policy, Management and Evaluation (Eskander, Sander, Naimark), University of Toronto; Toronto Health Economic and Technology Assessment Collaboration (Sander), University Health Network; Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre; Department of Surgical Oncology (Irish), Princess Margaret Cancer Centre; Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont
| | - Kelvin K W Chan
- Odette Cancer Centre (Parmar, Chan), Sunnybrook Health Sciences Centre; Department of Otolaryngology-Head and Neck Surgery (Eskander, Irish); Institute of Health Policy, Management and Evaluation (Eskander, Sander, Naimark), University of Toronto; Toronto Health Economic and Technology Assessment Collaboration (Sander), University Health Network; Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre; Department of Surgical Oncology (Irish), Princess Margaret Cancer Centre; Canadian Centre for Applied Research in Cancer Control (Chan), Toronto, Ont.
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10
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Yau K, Abe KT, Naimark D, Oliver MJ, Perl J, Leis JA, Bolotin S, Tran V, Mullin SI, Shadowitz E, Gonzalez A, Sukovic T, Garnham-Takaoka J, de Launay KQ, Takaoka A, Straus SE, McGeer AJ, Chan CT, Colwill K, Gingras AC, Hladunewich MA. Evaluation of the SARS-CoV-2 Antibody Response to the BNT162b2 Vaccine in Patients Undergoing Hemodialysis. JAMA Netw Open 2021; 4:e2123622. [PMID: 34473256 PMCID: PMC8414193 DOI: 10.1001/jamanetworkopen.2021.23622] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Patients undergoing hemodialysis have a high mortality rate associated with COVID-19, and this patient population often has a poor response to vaccinations. Randomized clinical trials for COVID-19 vaccines included few patients with kidney disease; therefore, vaccine immunogenicity is uncertain in this population. OBJECTIVE To evaluate the SARS-CoV-2 antibody response in patients undergoing chronic hemodialysis following 1 vs 2 doses of BNT162b2 COVID-19 vaccination compared with health care workers serving as controls and convalescent serum. DESIGN, SETTING, AND PARTICIPANTS A prospective, single-center cohort study was conducted between February 2 and April 17, 2021, in Toronto, Ontario, Canada. Participants included 142 patients receiving in-center hemodialysis and 35 health care worker controls. EXPOSURES BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine. MAIN OUTCOMES AND MEASURES SARS-CoV-2 IgG antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD), and nucleocapsid protein (anti-NP). RESULTS Among the 142 participants undergoing maintenance hemodialysis, 94 (66%) were men; median age was 72 (interquartile range, 62-79) years. SARS-CoV-2 IgG antibodies were measured in 66 patients receiving 1 vaccine dose following a public health policy change, 76 patients receiving 2 vaccine doses, and 35 health care workers receiving 2 vaccine doses. Detectable anti-NP suggestive of natural SARS-CoV-2 infection was detected in 15 of 142 (11%) patients at baseline, and only 3 patients had prior COVID-19 confirmed by reverse transcriptase polymerase chain reaction testing. Two additional patients contracted COVID-19 after receiving 2 doses of vaccine. In 66 patients receiving a single BNT162b2 dose, seroconversion occurred in 53 (80%) for anti-spike and 36 (55%) for anti-RBD by 28 days postdose, but a robust response, defined by reaching the median levels of antibodies in convalescent serum from COVID-19 survivors, was noted in only 15 patients (23%) for anti-spike and 4 (6%) for anti-RBD in convalescent serum from COVID-19 survivors. In patients receiving 2 doses of BNT162b2 vaccine, seroconversion occurred in 69 of 72 (96%) for anti-spike and 63 of 72 (88%) for anti-RBD by 2 weeks following the second dose and median convalescent serum levels were reached in 52 of 72 patients (72%) for anti-spike and 43 of 72 (60%) for anti-RBD. In contrast, all 35 health care workers exceeded the median level of anti-spike and anti-RBD found in convalescent serum 2 to 4 weeks after the second dose. CONCLUSIONS AND RELEVANCE This study suggests poor immunogenicity 28 days following a single dose of BNT162b2 vaccine in the hemodialysis population, supporting adherence to recommended vaccination schedules and avoiding delay of the second dose in these at-risk individuals.
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Affiliation(s)
- Kevin Yau
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Kento T. Abe
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeffrey Perl
- Division of Nephrology, Department of Medicine, Unity Health Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jerome A. Leis
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shelly Bolotin
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Vanessa Tran
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Sarah I. Mullin
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ellen Shadowitz
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anny Gonzalez
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tatjana Sukovic
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Garnham-Takaoka
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Keelia Quinn de Launay
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Alyson Takaoka
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Sharon E. Straus
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | | | | | - Karen Colwill
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Anne-Claude Gingras
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Michelle A. Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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11
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Tangri N, Garg AX, Ferguson TW, Dixon S, Rigatto C, Allu S, Chau E, Komenda P, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Alam A, Kim SJ, Sood MM, Manns B. Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial. J Am Soc Nephrol 2021; 32:1791-1800. [PMID: 33858985 PMCID: PMC8425657 DOI: 10.1681/asn.2020091254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/19/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise. METHODS To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m2). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting. RESULTS The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient. CONCLUSIONS A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.
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Affiliation(s)
- Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Department of Medicine, Western University, London, Ontario, Canada,Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Thomas W. Ferguson
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada,Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Selina Allu
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, Canada,O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elaine Chau
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada,Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gihad E. Nesrallah
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada,Division of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
| | - Steven D. Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada,Nova Scotia Health Authority Renal Program, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal Agency, Vancouver, British Columbia, Canada
| | - Ahsan Alam
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - S. Joseph Kim
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Manish M. Sood
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Braden Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, Canada,O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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12
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Naimark D, Mishra S, Barrett K, Khan YA, Mac S, Ximenes R, Sander B. Simulation-Based Estimation of SARS-CoV-2 Infections Associated With School Closures and Community-Based Nonpharmaceutical Interventions in Ontario, Canada. JAMA Netw Open 2021; 4:e213793. [PMID: 33787909 PMCID: PMC8013816 DOI: 10.1001/jamanetworkopen.2021.3793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/06/2021] [Indexed: 12/22/2022] Open
Abstract
Importance Resurgent COVID-19 cases have resulted in the reinstitution of nonpharmaceutical interventions, including school closures, which can have adverse effects on families. Understanding the associations of school closures with the number of incident and cumulative COVID-19 cases is critical for decision-making. Objective To estimate the association of schools being open or closed with the number of COVID-19 cases compared with community-based nonpharmaceutical interventions. Design, Setting, and Participants This decision analytical modelling study developed an agent-based transmission model using a synthetic population of 1 000 000 individuals based on the characteristics of the population of Ontario, Canada. Members of the synthetic population were clustered into households, neighborhoods, or rural districts, cities or rural regions, day care facilities, classrooms (ie, primary, elementary, or high school), colleges or universities, and workplaces. Data were analyzed between May 5, 2020, and October 20, 2020. Exposures School reopening on September 15, 2020, vs schools remaining closed under different scenarios for nonpharmaceutical interventions. Main Outcomes and Measures Incident and cumulative COVID-19 cases between September 1, 2020, and October 31, 2020. Results Among 1 000 000 simulated individuals, the percentage of infections among students and teachers acquired within schools was less than 5% across modeled scenarios. Incident COVID-19 case numbers on October 31, 2020, were 4414 (95% credible interval [CrI], 3491-5382) cases in the scenario with schools remaining closed and 4740 (95% CrI, 3863-5691) cases in the scenario for schools reopening, with no other community-based nonpharmaceutical intervention. In scenarios with community-based nonpharmaceutical interventions implemented, the incident case numbers on October 31 were 714 (95% CrI, 568-908) cases for schools remaining closed and 780 (95% CrI, 580-993) cases for schools reopening. When scenarios applied the case numbers observed in early October in Ontario, the cumulative case numbers were 777 (95% CrI, 621-993) cases for schools remaining closed and 803 (95% CrI, 617-990) cases for schools reopening. In scenarios with implementation of community-based interventions vs no community-based interventions, there was a mean difference of 39 355 cumulative COVID-19 cases by October 31, 2020, while keeping schools closed vs reopening them yielded a mean difference of 2040 cases. Conclusions and Relevance This decision analytical modeling study of a synthetic population of individuals in Ontario, Canada, found that most COVID-19 cases in schools were due to acquisition in the community rather than transmission within schools and that the changes in COVID-19 case numbers associated with school reopenings were relatively small compared with the changes associated with community-based nonpharmaceutical interventions.
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Affiliation(s)
- David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sharmistha Mishra
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Canada
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Canada
- University Health Network, Toronto, Canada
| | - Yasin A. Khan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Canada
- University Health Network, Toronto, Canada
| | - Stephen Mac
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Canada
| | - Raphael Ximenes
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Escola de Matemática Aplicada, Fundação Getúlio Vargas, Rio de Janeiro, Brasil
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- University Health Network, Toronto, Canada
- ICES, Toronto, Canada
- Public Health Ontario, Toronto, Canada
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13
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Ogunbameru A, Barrett K, Joda A, Khan YA, Pechlivanoglou P, Mac S, Naimark D, Ximenes R, Sander B. Estimating healthcare resource needs for COVID-19 patients in Nigeria. Pan Afr Med J 2020; 37:293. [PMID: 33654515 PMCID: PMC7881931 DOI: 10.11604/pamj.2020.37.293.26017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/17/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION continuous assessment of healthcare resources during the COVID-19 pandemic will help in proper planning and to prevent an overwhelming of the Nigerian healthcare system. In this study, we aim to predict the effect of COVID-19 on hospital resources in Nigeria. METHODS we adopted a previously published discrete-time, individual-level, health-state transition model of symptomatic COVID-19 patients to the Nigerian healthcare system and COVID-19 epidemiology in Nigeria by September 2020. We simulated different combined scenarios of epidemic trajectories and acute care capacity. Primary outcomes included the expected cumulative number of cases, days until depletion resources and the number of deaths associated with resource constraints. Outcomes were predicted over a 60-day time horizon. RESULTS in our best-case epidemic trajectory, which implies successful implementation of public health measures to control COVID-19 spread, assuming all three resource scenarios, hospital resources would not be expended within the 60-days time horizon. In our worst-case epidemic trajectory, assuming conservative resource scenario, only ventilated ICU beds would be depleted after 39 days and 16 patients were projected to die while waiting for ventilated ICU bed. Acute care resources were only sufficient in the three epidemic trajectory scenarios when combined with a substantial increase in healthcare resources. CONCLUSION substantial increase in hospital resources is required to manage the COVID-19 pandemic in Nigeria, even as the infection growth rate declines. Given Nigeria's limited health resources, it is imperative to focus on maintaining aggressive public health measures as well as increasing hospital resources to reduce COVID-19 transmission further.
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Affiliation(s)
- Adeteju Ogunbameru
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Arinola Joda
- Department of Clinical Pharmacy and Biopharmacy, Faculty of Pharmacy, University of Lagos, Lagos, Nigeria
| | - Yasin Azim Khan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children (SickKids) Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Stephen Mac
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Raphael Ximenes
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- Escola de Matemática Aplicada, Fundação Getúlio Vargas, Rio de Janeiro, Brazil
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
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14
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Iragorri N, Gómez-Restrepo C, Barrett K, Herrera S, Hurtado I, Khan Y, Mac S, Naimark D, Pechlivanoglou P, Rosselli D, Toro D, Villamizar P, Ximenes R, Zapata H, Sander B. COVID-19: Adaptation of a model to predicting healthcare resources needs in Valle del Cauca, Colombia. Colomb Med (Cali) 2020; 51:e204534. [PMID: 33402754 PMCID: PMC7744107 DOI: 10.25100/cm.v51i3.4534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/10/2020] [Accepted: 09/19/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Valle del Cauca is the region with the fourth-highest number of COVID-19 cases in Colombia (>50,000 on September 7, 2020). Due to the lack of anti-COVID-19 therapies, decision-makers require timely and accurate data to estimate the incidence of disease and the availability of hospital resources to contain the pandemic. METHODS We adapted an existing model to the local context to forecast COVID-19 incidence and hospital resource use assuming different scenarios: (1) the implementation of quarantine from September 1st to October 15th (average daily growth rate of 2%); (2-3) partial restrictions (at 4% and 8% growth rates); and (4) no restrictions, assuming a 10% growth rate. Previous scenarios with predictions from June to August were also presented. We estimated the number of new cases, diagnostic tests required, and the number of available hospital and intensive care unit (ICU) beds (with and without ventilators) for each scenario. RESULTS We estimated 67,700 cases by October 15th when assuming the implementation of a quarantine, 80,400 and 101,500 cases when assuming partial restrictions at 4% and 8% infection rates, respectively, and 208,500 with no restrictions. According to different scenarios, the estimated demand for reverse transcription-polymerase chain reaction tests ranged from 202,000 to 1,610,600 between September 1st and October 15th. The model predicted depletion of hospital and ICU beds by September 20th if all restrictions were to be lifted and the infection growth rate increased to 10%. CONCLUSION Slowly lifting social distancing restrictions and reopening the economy is not expected to result in full resource depletion by October if the daily growth rate is maintained below 8%. Increasing the number of available beds provides a safeguard against slightly higher infection rates. Predictive models can be iteratively used to obtain nuanced predictions to aid decision-making.
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Affiliation(s)
- Nicolas Iragorri
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) collaborative, University Health Network, Toronto, Canada
| | | | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) collaborative, University Health Network, Toronto, Canada
- University Health Network, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Socrates Herrera
- Comité Público Privado de Expertos en Salud COPESA, Cali, Colombia
- Centro de Investigación Científica Caucaseco, Cali, Colombia
| | | | - Yasin Khan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- University Health Network, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Stephen Mac
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) collaborative, University Health Network, Toronto, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Sunnybrook Hospital, Toronto, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- The Hospital for Sick Children, Toronto, Canada
| | - Diego Rosselli
- Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Dilian Toro
- Comité Público Privado de Expertos en Salud COPESA, Cali, Colombia
| | - Pedro Villamizar
- Facultad de Medicina, Pontificia Universidad Javeriana, Cali, Colombia
| | - Raphael Ximenes
- Toronto Health Economics and Technology Assessment (THETA) collaborative, University Health Network, Toronto, Canada
- Escola de Matemática Aplicada, Fundação Getúlio Vargas, Rio de Janeiro, RJ, Brasil
| | - Helmer Zapata
- Centro de Investigación Científica Caucaseco, Cali, Colombia
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Public Health Ontario, Toronto, Canada
- Institute for Clinical Evaluative Sciences ICES, Toronto, Canada
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15
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Forner D, Hoit G, Noel CW, Eskander A, de Almeida JR, Rigby MH, Naimark D. Decision Modeling for Economic Evaluation in Otolaryngology-Head and Neck Surgery: Review of Techniques. Otolaryngol Head Neck Surg 2020; 164:741-750. [PMID: 32957833 DOI: 10.1177/0194599820957288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decision making in health care is complex, and substantial uncertainty can be involved. Structured, systematic approaches to the integration of available evidence, assessment of uncertainty, and determination of choice are of significant benefit in an era of "value-based care." This is especially true for otolaryngology-head and neck surgery, where technological advancements are frequent and applicable to an array of subspecialties. Decision analysis aims to achieve these goals through various modeling techniques, including (1) decision trees, (2) Markov process, (3) microsimulation, and (4) discrete event simulation. While decision models have been used for decades, many clinicians and researchers continue to have difficulty deciphering them. In this review, we present an overview of various decision analysis modeling techniques, their purposes, how they can be interpreted, and commonly used syntax to promote understanding and use of these approaches. Throughout, we provide a sample research question to facilitate discussion of the advantages and disadvantages of each technique.
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Affiliation(s)
- David Forner
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Institute of Healthy Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Graeme Hoit
- Institute of Healthy Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Institute of Healthy Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Eskander
- Institute of Healthy Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - John R de Almeida
- Institute of Healthy Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University Health Network, Toronto, Ontario, Canada
| | - Matthew H Rigby
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Naimark
- Institute of Healthy Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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16
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Helou J, Naimark D, Morton G, Sanmamed N, Catton C, Raphael J, Loblaw A. 13: Cost-Utility Analysis of Radiation Strategies in the Management of Iintermediate-Risk Prostate Cancer. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(20)30905-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Tam DY, Wijeysundera HC, Naimark D, Gaudino M, Webb JG, Cohen DJ, Fremes SE. Impact of Transcatheter Aortic Valve Durability on Life Expectancy in Low-Risk Patients With Severe Aortic Stenosis. Circulation 2020; 142:354-364. [DOI: 10.1161/circulationaha.119.044559] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Recent clinical trial results showed that transcatheter aortic valve replacement (TAVR) is noninferior and may be superior to surgical aortic valve replacement (SAVR) for mortality, stroke, and rehospitalization. However, the impact of transcatheter valve durability remains uncertain.
Methods:
Discrete event simulation was used to model hypothetical scenarios of TAVR versus SAVR durability in which TAVR failure times were varied to determine the impact of TAVR valve durability on life expectancy in a cohort of low-risk patients similar to those in recent trials. Discrete event simulation modeling was used to estimate the tradeoff between a less invasive procedure with unknown valve durability (TAVR) and that of a more invasive procedure with known durability (SAVR). Standardized differences were calculated, and a difference >0.10 was considered clinically significant. In the base-case analysis, patients with structural valve deterioration requiring reoperation were assumed to undergo a valve-in-valve TAVR procedure. A sensitivity analysis was conducted to determine the impact of TAVR valve durability on life expectancy in younger age groups (40, 50, and 60 years).
Results:
Our cohort consisted of patients with aortic stenosis at low surgical risk with a mean age of 73.4±5.9 years. In the base-case scenario, the standardized difference in life expectancy was <0.10 between TAVR and SAVR until transcatheter valve prosthesis failure time was 70% shorter than that of surgical prostheses. At a transcatheter valve failure time <30% compared with surgical valves, SAVR was the preferred option. In younger patients, life expectancy was reduced when TAVR durability was 30%, 40%, and 50% shorter than that of surgical valves in 40-, 50-, and 60-year-old patients, respectively.
Conclusions:
According to our simulation models, the durability of TAVR valves must be 70% shorter than that of surgical valves to result in reduced life expectancy in patients with demographics similar to those of recent trials. However, in younger patients, this threshold for TAVR valve durability was substantially higher. These findings suggest that durability concerns should not influence the initial treatment decision concerning TAVR versus SAVR in older low-risk patients on the basis of current evidence supporting TAVR valve durability. However, in younger low-risk patients, valve durability must be weighed against other patient factors such as life expectancy.
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Affiliation(s)
- Derrick Y. Tam
- Division of Cardiac Surgery, Departments of Surgery (D.Y.T., S.E.F.), University of Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
| | - Harindra C. Wijeysundera
- Medicine (H.C.W.), University of Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
- ICES, Toronto, ON, Canada (H.C.W.)
| | - David Naimark
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York (M.G.)
| | - John G. Webb
- Center for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (J.G.W.)
| | | | - Stephen E. Fremes
- Division of Cardiac Surgery, Departments of Surgery (D.Y.T., S.E.F.), University of Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
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18
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Mendlowitz AB, Naimark D, Wong WWL, Capraru C, Feld JJ, Isaranuwatchai W, Krahn M. The emergency department as a setting-specific opportunity for population-based hepatitis C screening: An economic evaluation. Liver Int 2020; 40:1282-1291. [PMID: 32267604 DOI: 10.1111/liv.14458] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 03/06/2020] [Accepted: 03/28/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS The World Health Organization's hepatitis C virus (HCV) elimination strategy recognizes the need for interventions that identify populations most affected by infection. The emergency department (ED) has been suggested as a setting for HCV screening. The study objective was to explore the health and economic impact of HCV screening in the ED setting. METHODS We used a microsimulation model to conduct a cost-utility analysis evaluating two ED setting-specific strategies: no screening, and screening and subsequent treatment. Strategies were examined for two populations: (a) the general ED patient population; and (b) ED patients born between 1945 and 1975. The analysis was conducted from a healthcare payer perspective over a lifetime time horizon. A reference and high ED HCV seroprevalence measure were examined in the Canadian healthcare setting.US costs of chronic infection were used for a scenario analysis of screening in the US healthcare setting. RESULTS For birth cohort screening, in comparison to no screening, one liver-related death was averted for every 760 and 123 persons screened for the reference and high seroprevalence measures. For general population screening, one liver-related death was averted for every 831 and 147 persons screened for the reference and high seroprevalence measures. In comparison to no screening, birth cohort screening was cost-effective at CAN$25,584/quality-adjusted life year (QALY) and US$42,615/QALY. General population screening was cost-effective at CAN$19,733/QALY and US$32,187/QALY. CONCLUSIONS ED screening may represent a cost-effective component of population-based strategies to eliminate HCV. Further studies are warranted to explore the feasibility and acceptability of this approach.
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Affiliation(s)
- Andrew B Mendlowitz
- Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David Naimark
- Department of Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - William W L Wong
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Camelia Capraru
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, ON, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, ON, Canada
| | - Wanrudee Isaranuwatchai
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada.,University Health Network - Toronto General Hospital, Toronto, ON, Canada
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19
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Tam DY, Naimark D, Natarajan MK, Woodward G, Oakes G, Rahal M, Barrett K, Khan YA, Ximenes R, Mac S, Sander B, Wijeysundera HC. The Use of Decision Modelling to Inform Timely Policy Decisions on Cardiac Resource Capacity During the COVID-19 Pandemic. Can J Cardiol 2020; 36:1308-1312. [PMID: 32447059 PMCID: PMC7241392 DOI: 10.1016/j.cjca.2020.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/17/2020] [Accepted: 05/17/2020] [Indexed: 11/18/2022] Open
Abstract
In Ontario on March 16, 2020, a directive was issued to all acute care hospitals to halt nonessential procedures in anticipation of a potential surge in COVID-19 patients. This included scheduled outpatient cardiac surgical and interventional procedures that required the use of intensive care units, ventilators, and skilled critical care personnel, given that these procedures would draw from the same pool of resources required for critically ill COVID-19 patients. We adapted the COVID-19 Resource Estimator (CORE) decision analytic model by adding a cardiac component to determine the impact of various policy decisions on the incremental waitlist growth and estimated waitlist mortality for 3 key groups of cardiovascular disease patients: coronary artery disease, valvular heart disease, and arrhythmias. We provided predictions based on COVID-19 epidemiology available in real-time, in 3 phases. First, in the initial crisis phase, in a worst case scenario, we showed that the potential number of waitlist related cardiac deaths would be orders of magnitude less than those who would die of COVID-19 if critical cardiac care resources were diverted to the care of COVID-19 patients. Second, with better local epidemiology data, we predicted that across 5 regions of Ontario, there may be insufficient resources to resume all elective outpatient cardiac procedures. Finally in the recovery phase, we showed that the estimated incremental growth in waitlist for all cardiac procedures is likely substantial. These outputs informed timely data-driven decisions during the COVID-19 pandemic regarding the provision of cardiovascular care.
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Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; COVID-19 Modelling Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Madhu K Natarajan
- Division of Cardiology, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; COVID-19 Modelling Collaborative, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Yasin A Khan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; COVID-19 Modelling Collaborative, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Raphael Ximenes
- COVID-19 Modelling Collaborative, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Stephen Mac
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; COVID-19 Modelling Collaborative, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; COVID-19 Modelling Collaborative, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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20
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Wettstein MS, Naimark D, Hermanns T, Herrera-Caceres JO, Ahmad A, Jewett MAS, Kulkarni GS. Required efficacy for novel therapies in BCG-unresponsive non-muscle invasive bladder cancer: Do current recommendations really reflect clinically meaningful outcomes? Cancer Med 2020; 9:3287-3296. [PMID: 32163677 PMCID: PMC7221312 DOI: 10.1002/cam4.2980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 11/11/2022] Open
Abstract
Background Single‐arm trials are currently an accepted study design to investigate the efficacy of novel therapies (NT) in non‐muscle invasive bladder cancer (NMIBC) unresponsive to intravesical Bacillus Calmette‐Guérin (BCG) immunotherapy as randomized controlled trials are either unfeasible (comparator: early radical cystectomy; ERC), or unethical (comparator: placebo). To guide the design of such single‐arm trials, expert groups published recommendations for clinically meaningful outcomes. The aim of this study was to quantitatively verify the appropriateness of these recommendations. Methods We used a discrete event simulation framework in combination with a supercomputer to find the required efficacy at which a NT can compete with ERC when it comes to quality‐adjusted life expectancy (QALE). In total, 24 different efficacy thresholds (including the recommendations) were investigated. Results After ascertaining face validity with content experts, repeated verification, external validation, and calibration we considered our model valid. Both recommendations rarely showed an incremental benefit of the NT over ERC. In the most optimistic scenario, an increase in the IBCG recommendation by 10% and an increase in the FDA/AUA recommendation by 5% would yield results at which a NT could compete with ERC from a QALE perspective. Conclusions This simulation study demonstrated that the current recommendations regarding clinically meaningful outcomes for single‐arm trials evaluating the efficacy of NT in BCG‐unresponsive NMIBC may be too low. Based on our quantitative approach, we propose increasing these thresholds to at least 45%‐55% at 6 months and 35% at 18‐24 months (complete response rates/recurrence‐free survival) to promote the development of clinically truly meaningful NT.
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Affiliation(s)
- Marian S Wettstein
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Urology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - David Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Thomas Hermanns
- Department of Urology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Jaime O Herrera-Caceres
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ardalan Ahmad
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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21
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Sasal J, Naimark D, Klassen J, Shea J, Bargman JM. Late Renal Transplant Failure: An Adverse Prognostic Factor at Initiation of Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080102100413] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis. Objective To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant. Setting Peritoneal dialysis (PD) unit in a teaching hospital. Patients and Design All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998. Results There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group ( p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease. Conclusions W e conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.
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Affiliation(s)
- Joanna Sasal
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Judy Klassen
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
| | - Judy Shea
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
| | - Joanne M. Bargman
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
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22
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Grams ME, Sang Y, Ballew SH, Matsushita K, Astor BC, Carrero JJ, Chang AR, Inker LA, Kenealy T, Kovesdy CP, Lee BJ, Levin A, Naimark D, Pena MJ, Schold JD, Shalev V, Wetzels JFM, Woodward M, Gansevoort RT, Levey AS, Coresh J. Evaluating Glomerular Filtration Rate Slope as a Surrogate End Point for ESKD in Clinical Trials: An Individual Participant Meta-Analysis of Observational Data. J Am Soc Nephrol 2019; 30:1746-1755. [PMID: 31292199 DOI: 10.1681/asn.2019010008] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/17/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Decline in eGFR is a biologically plausible surrogate end point for the progression of CKD in clinical trials. However, it must first be tested to ensure strong associations with clinical outcomes in diverse populations, including patients with higher eGFR. METHODS To investigate the association between 1-, 2-, and 3-year changes in eGFR (slope) with clinical outcomes over the long term, we conducted a random effects meta-analysis of 3,758,551 participants with baseline eGFR≥60 ml/min per 1.73 m2 and 122,664 participants with eGFR<60 ml/min per 1.73 m2 from 14 cohorts followed for an average of 4.2 years. RESULTS Slower eGFR decline by 0.75 ml/min per 1.73 m2 per year over 2 years was associated with lower risk of ESKD in participants with baseline eGFR≥60 ml/min per 1.73 m2 (adjusted hazard ratio, 0.70; 95% CI, 0.68 to 0.72) and eGFR<60 ml/min per 1.73 m2 (0.71; 95% CI, 0.68 to 0.74). The relationship was stronger with 3-year slope. For a rapidly progressing population with predicted 5-year risk of ESKD of 8.3%, an intervention that reduced eGFR decline by 0.75 ml/min per 1.73 m2 per year over 2 years would reduce the ESKD risk by 1.6%. For a hypothetical low-risk population with a predicted 5-year ESKD risk of 0.58%, the same intervention would reduce the risk by only 0.13%. CONCLUSIONS Slower decline in eGFR was associated with lower risk of subsequent ESKD, even in participants with eGFR≥60 ml/min per 1.73 m2, but those with the highest risk would be expected to benefit the most.
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Affiliation(s)
- Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Brad C Astor
- Departments of Medicine and.,Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Alex R Chang
- Geisinger Health System and Department of Epidemiology and Health Services Research, Geisinger Health System, Kidney Health Research Institute, Danville, Pennsylvania
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Timothy Kenealy
- Departments of Medicine and.,General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Brian J Lee
- Nephrology Division, Kaiser Permanente, Hawaii Region, Moanalua Medical Center, Honolulu, Hawaii
| | - Adeera Levin
- British Columbia Provincial Renal Agency and University of British Columbia, Vancouver, British Columbia, Canada
| | - David Naimark
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jesse D Schold
- Department of Quantitative Health Sciences and.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Varda Shalev
- Medical Division, Maccabi Healthcare Services, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,The George Institute for Global Health, University of Oxford, Oxford, United Kingdom; and.,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ron T Gansevoort
- Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
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23
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Ferguson TW, Garg AX, Sood MM, Rigatto C, Chau E, Komenda P, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Alam A, Kim SJ, Dixon S, Manns B, Tangri N. Association Between the Publication of the Initiating Dialysis Early and Late Trial and the Timing of Dialysis Initiation in Canada. JAMA Intern Med 2019; 179:934-941. [PMID: 31135821 PMCID: PMC6547160 DOI: 10.1001/jamainternmed.2019.0489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Published in 2010, the Initiating Dialysis Early and Late (IDEAL) randomized clinical trial, which randomized patients with an estimated glomerular filtration rate (GFR) between 10 and 15 mL/min/1.73 m2 to planned initiation of dialysis with an estimated GFR between 10 and 14 mL/min/1.73 m2 (early start) or an estimated GFR between 5 and 7 mL/min/1.73 m2 (late start), concluded that early initiation was not associated with improved survival or clinical outcomes. OBJECTIVE To assess the association between the IDEAL trial results and the proportion of early dialysis starts over time. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series analysis used data from the Canadian Organ Replacement Register to study adult (≥18 years of age) patients with incident chronic dialysis between January 1, 2006, and December 31, 2015, in Canada, which has a universal health care system. Patients from the province of Quebec were excluded because its privacy laws preclude submission of deidentified data without first-person consent. The patients included in the study (n = 28 468) had at least 90 days of nephrologist care before starting dialysis and a recorded estimated GFR at dialysis initiation. Data analyses were performed from November 2016 to January 2019. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of early dialysis starts (estimated GFR >10.5 mL/min/1.73 m2), and the secondary outcomes included the proportions of acute inpatient dialysis starts, patients who started dialysis using a home modality, and patients receiving hemodialysis who started with an arteriovenous access. Measures included the trend prior to the IDEAL trial publication, the change in this trend after publication, and the immediate consequence of publication. RESULTS The final cohort comprised 28 468 patients, of whom 17 342 (60.9%) were male and the mean (SD) age was 64.8 (14.6) years. Before the IDEAL trial, a statistically significant increasing trend was observed in the monthly proportion of early dialysis starts (adjusted rate ratio, 1.002; 95% CI, 1.001-1.004; P = .004). After the IDEAL trial, an immediate decrease was observed in the proportion of early dialysis starts (rate ratio, 0.874; 95% CI, 0.818-0.933; P < .001), along with a statistically significant change in trend between the pretrial and posttrial periods (rate ratio, 0.994; 95% CI, 0.992-0.996; P < .001). No statistically significant differences were found in acute inpatient dialysis initiations, the proportion of patients receiving home dialysis as the initial modality, or the proportion of arteriovenous access creation at hemodialysis initiation after the IDEAL trial publication. CONCLUSIONS AND RELEVANCE The publication of the IDEAL trial appeared to be associated with an immediate and meaningful change in the timing of dialysis initiation in Canada.
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Affiliation(s)
- Thomas W Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Amit X Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Medicine, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claudio Rigatto
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Elaine Chau
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Humber River Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,BC Renal Agency, Vancouver, British Columbia, Canada
| | - Ahsan Alam
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - S Joseph Kim
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Braden Manns
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
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24
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Mahmood T, Puckrin R, Sugar L, Naimark D. Staphylococcus-Associated Glomerulonephritis Mimicking Henoch-Schönlein Purpura and Cryoglobulinemic Vasculitis in a Patient With an Epidural Abscess: A Case Report and Brief Review of the Literature. Can J Kidney Health Dis 2018; 5:2054358118776325. [PMID: 29900000 PMCID: PMC5985547 DOI: 10.1177/2054358118776325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/29/2018] [Indexed: 01/31/2023] Open
Abstract
Rationale Staphylococcus-associated glomerulonephritis (SAGN) is a rare immune complex-mediated glomerulonephritis associated with active Staphylococcus infection. We report a case illustrating the importance of clinical history and kidney biopsy findings in establishing the correct diagnosis. Presenting concerns of the patient We report the case of a 64-year-old man with alcohol-associated cirrhosis, type 2 diabetes mellitus, and hypertension who presented to hospital with lower back and abdominal pain, rectal bleeding, a purpuric lower extremity rash, and oliguric acute kidney injury with microscopic hematuria and nephrotic-range proteinuria. Diagnoses Skin biopsy revealed IgA leukocytoclastic vasculitis. Serum cryoglobulins were positive and there was hypocomplementemia with a low C3 level. Magnetic resonance imaging of the lumbar spine revealed septic discitis and epidural abscesses caused by a recent Staphylococcus aureus bacteremia. Kidney biopsy showed IgA-dominant and C3-dominant proliferative glomerulonephritis with subepithelial humps in keeping with SAGN. Interventions Urgent hemodialysis was initiated along with a prolonged course of intravenous cefazolin. Outcomes Remarkably, the patient demonstrated a complete recovery of renal function after 2 months of dialysis dependence and successful treatment of the epidural abscesses. Lessons learned This case shows that SAGN can closely mimic the clinical, laboratory, and histological presentation of Henoch-Schönlein Purpura or cryoglobulinemic vasculitis. Clinical history and kidney biopsy, particularly electron microscopic analysis, are essential to establishing the correct diagnosis to avoid the unnecessary and potentially harmful administration of immunosuppression. Despite the typically poor prognosis of SAGN, this case report illustrates that full renal recovery remains possible with supportive care and eradication of the underlying infection.
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Affiliation(s)
- Tahrin Mahmood
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Robert Puckrin
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Linda Sugar
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Institute of Health Policy, Management and Evaluation, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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25
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Grams ME, Sang Y, Ballew SH, Carrero JJ, Djurdjev O, Heerspink HJL, Ho K, Ito S, Marks A, Naimark D, Nash DM, Navaneethan SD, Sarnak M, Stengel B, Visseren FLJ, Wang AYM, Köttgen A, Levey AS, Woodward M, Eckardt KU, Hemmelgarn B, Coresh J. Predicting timing of clinical outcomes in patients with chronic kidney disease and severely decreased glomerular filtration rate. Kidney Int 2018; 93:1442-1451. [PMID: 29605094 PMCID: PMC5967981 DOI: 10.1016/j.kint.2018.01.009] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/12/2017] [Accepted: 01/11/2018] [Indexed: 12/24/2022]
Abstract
Patients with chronic kidney disease and severely decreased glomerular filtration rate (GFR) are at high risk for kidney failure, cardiovascular disease (CVD) and death. Accurate estimates of risk and timing of these clinical outcomes could guide patient counseling and therapy. Therefore, we developed models using data of 264,296 individuals in 30 countries participating in the international Chronic Kidney Disease Prognosis Consortium with estimated GFR (eGFR)s under 30 ml/min/1.73m2. Median participant eGFR and urine albumin-to-creatinine ratio were 24 ml/min/1.73m2 and 168 mg/g, respectively. Using competing-risk regression, random-effect meta-analysis, and Markov processes with Monte Carlo simulations, we developed two- and four-year models of the probability and timing of kidney failure requiring kidney replacement therapy (KRT), a non-fatal CVD event, and death according to age, sex, race, eGFR, albumin-to-creatinine ratio, systolic blood pressure, smoking status, diabetes mellitus, and history of CVD. Hypothetically applied to a 60-year-old white male with a history of CVD, a systolic blood pressure of 140 mmHg, an eGFR of 25 ml/min/1.73m2 and a urine albumin-to-creatinine ratio of 1000 mg/g, the four-year model predicted a 17% chance of survival after KRT, a 17% chance of survival after a CVD event, a 4% chance of survival after both, and a 28% chance of death (9% as a first event, and 19% after another CVD event or KRT). Risk predictions for KRT showed good overall agreement with the published kidney failure risk equation, and both models were well calibrated with observed risk. Thus, commonly-measured clinical characteristics can predict the timing and occurrence of clinical outcomes in patients with severely decreased GFR.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ognjenka Djurdjev
- Department of Measurement and Reporting, Provincial Health Service Authority, Vancouver, British Columbia, Canada
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Kevin Ho
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Hypertension, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Angharad Marks
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - David Naimark
- Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Mark Sarnak
- Division of Nephrology at Tufts Medical Center, Boston, Massachusetts, USA
| | - Benedicte Stengel
- INSERM UMR1018, CESP Center for Research in Epidemiology and Population Health, Team 5, Villejuif, France, UVSQ and UMRS 1018, Paris-Sud University, Villejuif, France
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Anna Köttgen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center-University of Freiburg, Freiburg, Germany
| | - Andrew S Levey
- Division of Nephrology at Tufts Medical Center, Boston, Massachusetts, USA
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; The George Institute for Global Health, University of Oxford, Oxford, UK; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Brenda Hemmelgarn
- Cumming School of Medicine, Division of Nephrology, and Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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26
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and (select 5863 from (select(sleep(5)))nccq)-- llmm] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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27
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Poon Y, Pechlivanoglou P, Alibhai SMH, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017; 121:17-28. [PMID: 28921820 DOI: 10.1111/bju.14015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Androgen-deprivation therapy (ADT) is an effective treatment for men with advanced prostate cancer, but loss of bone mineral density (BMD) is a major risk factor for fractures. This review compared the efficacy of available treatments to provide prescribing guidance to healthcare professionals. This is the first review to compare the effectiveness of different osteoporotic treatments (bisphosphonates, denosumab, toremifene, and raloxifene) on BMD in patients with non-metastatic prostate cancer on ADT using network meta-analysis. Results suggest that all evaluated treatments are effective in improving BMD compared to placebo. Zoledronic acid (ZA) was found to have a greater improvement in BMD compared to other active treatments at all three studied sites, except for risedronate, which had better BMD improvement compared to ZA at the femoral neck site in one small study. Our study did not identify evidence that one drug is unequivocally more effective than another. All drugs appeared to be effective in reducing the rate of bone loss. Healthcare professionals should also consider patient preference, costs, and local availability as part of the decision process.
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Affiliation(s)
- Yeesha Poon
- The University of Toronto, Toronto, ON, Canada
| | - Petros Pechlivanoglou
- The University of Toronto, Toronto, ON, Canada.,Toronto Health Economic and Technology Assessment Collaborative, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- The University of Toronto, Toronto, ON, Canada.,Toronto Health Economic and Technology Assessment Collaborative, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - David Naimark
- The University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeffrey S Hoch
- The University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.,Department of Public Health Sciences, University of California, Davis, Sacramento, CA, USA
| | | | | | - Murray Krahn
- The University of Toronto, Toronto, ON, Canada.,Toronto Health Economic and Technology Assessment Collaborative, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
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28
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null-- muqg] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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29
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null-- hets] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 order by 2320-- qdof] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 7021=dbms_pipe.receive_message(chr(105)||chr(104)||chr(107)||chr(119),5)-- tlyd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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32
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null,null,null,null,null,null,null-- fzos] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null,null,null-- qhvx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 7021=dbms_pipe.receive_message(chr(105)||chr(104)||chr(107)||chr(119),5)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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35
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null,null,null,null-- qixb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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36
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null,null,null,null,null-- oqme] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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37
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and (select 5863 from (select(sleep(5)))nccq)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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38
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null-- myvn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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39
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 2121=6958-- ytdc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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40
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 7386=(select 7386 from pg_sleep(5))] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 9855=cast((chr(113)||chr(98)||chr(112)||chr(118)||chr(113))||(select (case when (9855=9855) then 1 else 0 end))::text||(chr(113)||chr(122)||chr(98)||chr(98)||chr(113)) as numeric)-- zmhj] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null,null,null,null,null,null-- kkui] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 waitfor delay '0:0:5'-- mani] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 waitfor delay '0:0:5'] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 7386=(select 7386 from pg_sleep(5))-- jpln] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 6632 in (select (char(113)+char(98)+char(112)+char(118)+char(113)+(select (case when (6632=6632) then char(49) else char(48) end))+char(113)+char(122)+char(98)+char(98)+char(113)))] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 2876=(select upper(xmltype(chr(60)||chr(58)||chr(113)||chr(98)||chr(112)||chr(118)||chr(113)||(select (case when (2876=2876) then 1 else 0 end) from dual)||chr(113)||chr(122)||chr(98)||chr(98)||chr(113)||chr(62))) from dual)-- cpnx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 and 2349=9594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 union all select null,null,null,null,null-- iooe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| |
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50
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Poon Y, Pechlivanoglou P, Alibhai SM, Naimark D, Hoch JS, Papadimitropoulos E, Hogan ME, Krahn M. Systematic review and network meta-analysis on the relative efficacy of osteoporotic medications: men with prostate cancer on continuous androgen-deprivation therapy to reduce risk of fragility fractures. BJU Int 2017. [DOI: 10.1111/bju.14015 order by 1-- kpci] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yeesha Poon
- The University of Toronto; Toronto ON Canada
| | - Petros Pechlivanoglou
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- The Hospital for Sick Children; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
| | - Shabbir M.H. Alibhai
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| | - David Naimark
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jeffrey S. Hoch
- The University of Toronto; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital; Toronto ON Canada
- Department of Public Health Sciences; University of California, Davis; Sacramento CA USA
| | | | | | - Murray Krahn
- The University of Toronto; Toronto ON Canada
- Toronto Health Economic and Technology Assessment Collaborative; Toronto ON Canada
- Institute of Health Policy Management and Evaluation; Toronto ON Canada
- University Health Network; Toronto ON Canada
| |
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