Global evidence of gender equity in academic health research: a scoping review

OBJECTIVES

To chart the global literature on gender equity in academic health research.

DESIGN

Scoping review.

PARTICIPANTS

Quantitative studies were eligible if they examined gender equity within academic institutions including health researchers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes related to equity across gender and other social identities in academia: (1) faculty workforce: representation of all genders in university/faculty departments, academic rank or position and salary; (2) service: teaching obligations and administrative/non-teaching activities; (3) recruitment and hiring data: number of applicants by gender, interviews and new hires for various rank; (4) promotion: opportunities for promotion and time to progress through academic ranks; (5) academic leadership: type of leadership positions, opportunities for leadership promotion or training, opportunities to supervise/mentor and support for leadership bids; (6) scholarly output or productivity: number/type of publications and presentations, position of authorship, number/value of grants or awards and intellectual property ownership; (7) contextual factors of universities; (8) infrastructure; (9) knowledge and technology translation activities; (10) availability of maternity/paternity/parental/family leave; (11) collaboration activities/opportunities for collaboration; (12) qualitative considerations: perceptions around promotion, finances and support.

RESULTS

Literature search yielded 94 798 citations; 4753 full-text articles were screened, and 562 studies were included. Most studies originated from North America (462/562, 82.2%). Few studies (27/562, 4.8%) reported race and fewer reported sex/gender (which were used interchangeably in most studies) other than male/female (11/562, 2.0%). Only one study provided data on religion. No other PROGRESS-PLUS variables were reported. A total of 2996 outcomes were reported, with most studies examining academic output (371/562, 66.0%).

CONCLUSIONS

Reviewed literature suggest a lack in analytic approaches that consider genders beyond the binary categories of man and woman, additional social identities (race, religion, social capital and disability) and an intersectionality lens examining the interconnection of multiple social identities in understanding discrimination and disadvantage. All of these are necessary to tailor strategies that promote gender equity.

TRIAL REGISTRATION NUMBER

Open Science Framework: https://osf.io/8wk7e/.

Electroencephalography and psychological assessment datasets to determine the efficacy of a low-cost, wearable neurotechnology intervention for reducing Post-Traumatic Stress Disorder symptom severity

The datasets described here comprise electroencephalography (EEG) data and psychometric data freely available on data.mendeley.com. The EEG data is available in .mat formatted files containing the EEG signal values structured in two-dimensional (2D) matrices, with channel data and trigger information in rows, and samples in columns (having a sampling rate of 250Hz). Twenty-nine female survivors of the 1994 genocide against the Tutsi in Rwanda, underwent a psychological assessment before and after an intervention aimed at reducing Post-Traumatic Stress Disorder (PTSD) symptom severity. Three measures of trauma and four measures of wellbeing were assessed using empirically validated standardised assessments. The pre- and post- intervention psychometric data were analysed using non-parametric statistical methods and the post-intervention data were further evaluated according to diagnostic assessment rules to determine clinically relevant improvements for each group. The participants were assigned to a control group (CG, n = 9), a motor-imagery group (MI, n = 10), and a neurofeedback group (NF, n = 10). Participants in the latter two groups received Brain-Computer Interface (BCI) based training as a treatment intervention over a sixteen-day period, between the pre- and post- clinical interviews. The training involved presenting feedback visually via a videogame, based on real-time analysis of the EEG recorded data during the BCI-based treatment session. Participants were asked to regulate (NF) or intentionally modulate (MI) brain activity to affect/control the game.

Economic Evaluation of Azacitidine in Elderly Patients with Acute Myeloid Leukemia with High Blast Counts

BACKGROUND

Azacitidine is an hypomethylating agent widely adopted for the treatment of acute myeloid leukaemia (AML) in patients who are ineligible for curative-intent chemotherapy. Patients with low bone marrow blast counts (< 30%) experience improved survival with azacitidine, but the benefits are significantly lower in patients with > 30% blasts in the bone marrow. As such, there is uncertainty around the economic benefit of azacitidine in patients with higher blast counts.

OBJECTIVE

We present a cost-utility analysis of azacitidine in patients with AML with > 30% blasts to determine the economic value of azacitidine in this patient population from the perspective of a third-party payer.

METHODS

A Markov model was developed with a time horizon of 25 months divided into 22 cycles of 35 days each. The cost utility of azacitidine was compared with that of conventional care regimens (which include best supportive care, low-dose cytarabine and induction chemotherapy). A Canadian public healthcare system perspective was selected.

RESULTS

In the base case, the incremental cost per quality-adjusted life-year gained (incremental cost-effectiveness ratio [ICER]) for azacitidine compared with conventional care regimens was $Can160,438, year 2018 values. The estimated ICER was insensitive to a longer time horizon but sensitive to the cost of azacitidine and to assumptions relating to survival in both treatment regimens, although the ICER always remained greater than Can$80,000 in all scenarios.

CONCLUSION

Azacitidine is unlikely to be cost effective given that the estimated ICER exceeds the willingness to pay commonly used in the Canadian healthcare system.

Emotion-Inducing Imagery Versus Motor Imagery for a Brain-Computer Interface

Neural correlates of intentionally induced human emotions may offer alternative imagery strategies to control brain-computer interface (BCI) applications. In this paper, a novel BCI control strategy i.e., imagining fictional or recalling mnemonic sad and happy events, emotion-inducing imagery (EII), is compared to motor imagery (MI) in a study involving multiple sessions using a two-class electroencephalogram (EEG)-based BCI paradigm with 12 participants. The BCI setup enabled online continuous visual feedback presentation in a game involving one-dimensional control of a game character. MI and EII are compared across different signal-processing frameworks which are based on neural-time-series-prediction-preprocessing (NTSPP), filter bank common spatial patterns (FBCSP) and hemispheric asymmetry (ASYM). Online single-trial classification accuracies (CA) results indicate that MI performance across all participants is 77.54% compared to EII performance of 68.78% ( ). The results show that an ensemble of the NTSPP, FBCSP and ASYM frameworks maximizes performance for EII with average CA of 71.64% across all participants. Furthermore, the participants' subjective responses indicate that they preferred MI over emotion-inducing imagery (EII) in controlling the game character, and MI was perceived to offer most control over the game character. The results suggest that EII is not a viable alternative to MI for the majority of participants in this study but may be an alternative imagery for a subset of BCI users based on acceptable EII performance (CA >70%) observed for some participants.

Wage losses among spouses of women with nonmetastatic breast cancer

BACKGROUND

The aim of this study was to evaluate the wage losses incurred by spouses of women with nonmetastatic breast cancer in the 6 months after the diagnosis.

METHODS

A prospective cohort study of spouses of women diagnosed with nonmetastatic breast cancer who were recruited in 8 hospitals in the province of Quebec (Canada) was performed. Information for estimating wage losses was collected by telephone interviews conducted 1 and 6 months after the diagnosis. Log-binomial regressions were used to identify personal, medical, and employment characteristics associated with experiencing wage losses, and generalized linear models were used to identify characteristics associated with the proportion of usual wages lost.

RESULTS

Overall, 829 women (86% participation) and 406 spouses (75% participation) consented to participate. Among the 279 employed spouses, 78.5% experienced work absences because of breast cancer. Spouses were compensated for 66.3% of their salary on average during their absence. The median wage loss was $0 (mean, $1820) (2003 Canadian dollars). Spouses were more likely to experience losses if they were self-employed or lived 50 km or farther from the hospital. Among spouses who experienced wage losses, those who were self-employed or whose partners had invasive breast cancer lost a higher proportion of wages.

CONCLUSIONS

Although spouses took some time off work, for many, the resulting wage losses were modest because of compensation received. Still, the types of compensation used may hide other forms of burden for families facing breast cancer.

Involving Service Users in Professional Nurse Education in Wales

A small scale survey was conducted among nurse educationalists within Wales as part of the ongoing monitoring of Welsh Office targets for learning disability nursing. This survey showed that there has been very little service user involvement in professional nurse education in Wales. The authors discuss the possible reasons for such low level involvement. Examples of involvement of people with learning disabilities are compared to the much more favourable situation within the mental health field. Possible reasons for the barriers to progress in this area are discussed. The history of service user involvement and the development of advocacy both within the UK and other countries is also highlighted. The impact of various government initiatives on this situation is considered.

Health system costs of potentially inappropriate prescribing in Ontario, Canada: a protocol for a population-based cohort study

INTRODUCTION

Adverse drug events (ADEs) are common in older persons and contribute significantly to emergency department visits, hospitalisations and mortality. ADEs are often due to potentially inappropriate prescriptions (PIP) or potentially inappropriate omissions (PIO), and are avoidable if inappropriate prescriptions or omissions are identified and prevented. Identifying PIP/PIO at the population level through the application of PIP/PIO assessment tools to health administrative data can provide a unique opportunity to assess the economic burden of PIP/PIO on the healthcare system beyond medication costs which is yet to be done. The objective of this study is to assess the economic burden associated with PIP/PIO and to estimate the incremental costs associated with distinct PIP/PIO in the province of Ontario.

METHODS AND ANALYSIS

We will conduct a retrospective cohort study using Ontario's health administrative databases. Eligible patients aged 66 years and older who were prescribed at least one medication between 1 April 2003 and 31 March 2014 (approximately 2.4 million patients) will be included. Population attributable fraction methodology will be used to assess the overall burden of PIP in Ontario, while regression analyses will be used to estimate the incremental costs of having specific PIP criteria and aid in prioritising targets for intervention.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board at Sunnybrook Health Sciences Centre, Toronto, Canada. Dissemination will occur via publication, presentation at national and international conferences, and knowledge exchange with various stakeholders.

E3D hand movement velocity reconstruction using power spectral density of EEG signals and neural network

Three dimensional (3D) limb motion trajectory is predictable with a non-invasive brain-computer interface (BCI). To date, most non-invasive motion trajectory prediction BCIs use potential values of electroencephalographic (EEG) signals as the input to a multiple linear regression (mLR) based kinetic data estimator. We investigated the possible improvement in accuracy of 3D hand movement prediction (i.e., the correlation of registered and reconstructed hand velocities) by replacing raw EEG potentials with spectrum power values of specific EEG bands. We also investigated if a non-linear neural network based estimator outperformed the mLR approach. The spectrum power model provided significantly higher accuracy (R~0.60) compared to the similar EEG potentials based approach (R~0.45). Additionally, when replacing the mLR based kinetic data estimation module with a feed-forward neural network (NN) we found the NN based spectrum power model provided higher accuracy (R~0.70) compared to the similar mLR based approach (R~0.60).

Cost effectiveness of the addition of a comprehensive CT scan to the abdomen and pelvis for the detection of cancer after unprovoked venous thromboembolism

IMPORTANCE

Unprovoked venous thromboembolism (VTE) can be the first manifestation of cancer. It is unclear if extensive screening for occult cancer including a comprehensive computed tomography (CT) scan of the abdomen/pelvis is cost-effective in this patient population.

OBJECTIVE

To assess the health care related costs, number of missed cancer cases and health related utility values of a limited screening strategy with and without the addition of a comprehensive CT scan of the abdomen/pelvis and to identify to what extent testing should be done in these circumstances to allow early detection of occult cancers.

PARTICIPANTS AND SETTING

Cost effectiveness analysis using data that was collected alongside the SOME randomized controlled trial which compared an extensive occult cancer screening including a CT of the abdomen/pelvis to a more limited screening strategy in patients with a first unprovoked VTE, was used for the current analyses.

MAIN OUTCOMES AND MEASURES

Analyses were conducted with a one-year time horizon from a Canadian health care perspective. Primary analysis was based on complete cases, with sensitivity analysis using appropriate multiple imputation methods to account for missing data.

RESULTS

Data from a total of 854 patients with a first unprovoked VTE were included in these analyses. The addition of a comprehensive CT scan was associated with higher costs ($551 CDN) with no improvement in utility values or number of missed cancers. Results were consistent when adopting multiple imputation methods.

CONCLUSIONS AND RELEVANCE

The addition of a comprehensive CT scan of the abdomen/pelvis for the screening of occult cancer in patients with unprovoked VTE is not cost effective, as it is both more costly and not more effective in detecting occult cancer.

Cost Effectiveness of Elidel in the Management of Patients with Atopic Dermatitis in Canada

Background:

With increasing pressure on health care resources, it is necessary to demonstrate that new treatments are both effective and cost effective. ObjectiveThe purpose of this study was to assess the cost effectiveness of pimecrolimus (Elidel) compared to usual therapy in the treatment of both adults and children with atopic eczema in Canada.

Methods:

Analysis was performed using a decision model which estimated the incremental cost per quality adjusted life year (QALY) gained from both a societal and health care perspective.

Results:

For children, Elidel leads an incremental cost per QALY of $38,000 from a societal perspective. For adults, the incremental cost per QALY was $35,000.

Conclusion:

Elidel will lead to an overall increase in costs but with an improvement in clinical outcomes. The cost effectiveness ratios for Elidel were consistently below $50,000 per QALY gained. Given previous funding decisions in Canada, Elidel may be considered a cost-effective use of health care resources.

3D hand motion trajectory prediction from EEG mu and beta bandpower

A motion trajectory prediction (MTP) - based brain-computer interface (BCI) aims to reconstruct the three-dimensional (3D) trajectory of upper limb movement using electroencephalography (EEG). The most common MTP BCI employs a time series of bandpass-filtered EEG potentials (referred to here as the potential time-series, PTS, model) for reconstructing the trajectory of a 3D limb movement using multiple linear regression. These studies report the best accuracy when a 0.5-2Hz bandpass filter is applied to the EEG. In the present study, we show that spatiotemporal power distribution of theta (4-8Hz), mu (8-12Hz), and beta (12-28Hz) bands are more robust for movement trajectory decoding when the standard PTS approach is replaced with time-varying bandpower values of a specified EEG band, ie, with a bandpower time-series (BTS) model. A comprehensive analysis comprising of three subjects performing pointing movements with the dominant right arm toward six targets is presented. Our results show that the BTS model produces significantly higher MTP accuracy (R~0.45) compared to the standard PTS model (R~0.2). In the case of the BTS model, the highest accuracy was achieved across the three subjects typically in the mu (8-12Hz) and low-beta (12-18Hz) bands. Additionally, we highlight a limitation of the commonly used PTS model and illustrate how this model may be suboptimal for decoding motion trajectory relevant information. Although our results, showing that the mu and beta bands are prominent for MTP, are not in line with other MTP studies, they are consistent with the extensive literature on classical multiclass sensorimotor rhythm-based BCI studies (classification of limbs as opposed to motion trajectory prediction), which report the best accuracy of imagined limb movement classification using power values of mu and beta frequency bands. The methods proposed here provide a positive step toward noninvasive decoding of imagined 3D hand movements for movement-free BCIs.

3D graphics, virtual reality, and motion-onset visual evoked potentials in neurogaming

A brain-computer interface (BCI) offers movement-free control of a computer application and is achieved by reading and translating the cortical activity of the brain into semantic control signals. Motion-onset visual evoked potentials (mVEP) are neural potentials employed in BCIs and occur when motion-related stimuli are attended visually. mVEP dynamics are correlated with the position and timing of the moving stimuli. To investigate the feasibility of utilizing the mVEP paradigm with video games of various graphical complexities including those of commercial quality, we conducted three studies over four separate sessions comparing the performance of classifying five mVEP responses with variations in graphical complexity and style, in-game distractions, and display parameters surrounding mVEP stimuli. To investigate the feasibility of utilizing contemporary presentation modalities in neurogaming, one of the studies compared mVEP classification performance when stimuli were presented using the oculus rift virtual reality headset. Results from 31 independent subjects were analyzed offline. The results show classification performances ranging up to 90% with variations in conditions in graphical complexity having limited effect on mVEP performance; thus, demonstrating the feasibility of using the mVEP paradigm within BCI-based neurogaming.

Use of evidence in decision models: an appraisal of health technology assessments in the UK since 1997

Objectives: To review the sources and quality of evidence used in the development of economic decision models in health technology assessments (HTAs).

Methods: All economic decision models developed as part of the NHS Research and Development HTA Programme between 1997 and 2003 were reviewed. Quality of evidence was assessed using a hierarchy of data sources developed for economic analyses.

Results: Decision models are parameterized using diverse sources of evidence (e.g. randomized controlled trials, observational studies, expert opinion). Evidence on the main clinical effect was mostly identified and quality assessed as part of the companion systematic review/meta-analysis of the HTA and therefore reported in a transparent and reproducible way. For the other model inputs (i.e. adverse events, baseline clinical data, resource use and utilities), the search strategies for identifying relevant evidence were rarely made explicit and in a number of reports the sources of specific evidence were unclear due to poor reporting.

Conclusions: A more formal and replicable approach to identification and assessment of quality of model inputs is required to reduce the 'black box' nature of decision models, and lead to less scepticism regarding model outputs.

Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes

Background

Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage.

Methods

A 2-group effectiveness study was completed comparing patients who received the ‘Ottawa Model’ for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups.

Results

The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001).

Conclusions

Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.

Transient Elastography and Controlled Attenuation Parameter for Diagnosing Liver Fibrosis and Steatosis in Ontario: An Economic Analysis

BACKGROUND

Liver fibrosis is characterized by a buildup of connective tissue due to chronic liver damage. Steatosis is the collection of excessive amounts of fat inside liver cells. Liver biopsy remains the gold standard for the diagnosis of liver fibrosis and steatosis, but its use as a diagnostic tool is limited by its invasive nature and high cost.

OBJECTIVES

To evaluate the cost-effectiveness and budget impact of transient elastography (TE) with and without controlled attenuation parameter (CAP) for the diagnosis of liver fibrosis or steatosis in patients with hepatitis B, hepatitis C, alcoholic liver disease, and nonalcoholic fatty liver disease.

DATA SOURCES

An economic literature search was performed using computerized databases. For primary economic and budget impact analyses, we obtained data from various sources, such as the Health Quality Ontario evidence-based analysis, published literature, and the Institute for Clinical Evaluative Sciences.

REVIEW METHODS

A systematic review of existing TE cost-effectiveness studies was conducted, and a primary economic evaluation was undertaken from the perspective of the Ontario Ministry of Health and Long-Term Care. Decision analytic models were used to compare short-term costs and outcomes of TE compared to liver biopsy. Outcomes were expressed as incremental cost per correctly diagnosed cases gained. A budget impact analysis was also conducted.

RESULTS

We included 10 relevant studies that evaluated the cost-effectiveness of TE compared to other noninvasive tests and to liver biopsy; no cost-effectiveness studies of TE with CAP were identified. All studies showed that TE was less expensive but associated with a decrease in the number of correctly diagnosed cases. TE also improved quality-adjusted life-years in patients with hepatitis B and hepatitis C. Our primary economic analysis suggested that TE led to cost savings but was less effective than liver biopsy in the diagnosis of liver fibrosis. TE became more economically attractive with a higher degree of liver fibrosis. TE with CAP was also less expensive and less accurate than liver biopsy.

LIMITATIONS

The model did not take into account long-term costs and consequences associated with TE and liver biopsy and did not include costs to patients and their families, or patient preferences related to diagnostic information.

CONCLUSIONS

TE showed potential cost savings compared to liver biopsy. Further investigation is needed to determine the long-term impacts of TE on morbidity and mortality in Canada and the optimal diagnostic modality for liver fibrosis and steatosis.

Communication Development in Early-Identified Children With Mild Bilateral and Unilateral Hearing Loss

PURPOSE

This clinical focus article provides preliminary findings from a multicenter longitudinal study investigating auditory and communication development in children with mild bilateral or unilateral hearing loss of any degree.

METHOD

A total of 100 children (55 with mild bilateral or unilateral hearing loss and 45 with normal hearing) underwent 1 or more assessments from a battery of auditory and language measures.

RESULTS

Children up to age 4 years demonstrated auditory and language skills similar to those of children with normal hearing.

CONCLUSIONS

Factors that affect outcomes in communication development will be explored as additional data are collected in this ongoing study.

Pattern of Change in Renal Function Following Radical Nephrectomy for Renal Cell Carcinoma

Radical nephrectomy (RN) is an independent risk factor for the development of chronic kidney disease (CKD) in those with renal cell carcinoma (RCC). We aimed to examine the pattern of change in post-operative renal function in patients who underwent RN for RCC over a 3 year period at our institution. We performed a retrospective review of histological and biochemical findings in patients undergoing RN for RCC over a 38 month period. Estimated glomerular filtration rate (eGFR) was recorded pre- and post-operatively and at follow-up. We analysed data on 131 patients (median follow-up 24 months). The proportion of patients with advanced CKD increased significantly at follow-up with 48 (85.7%) patients, classified as having stage 2 CKD pre-operatively, being re-classified as stage 3-5. Mean eGFR was significantly lower pre-operatively (76.6 mL/min/1.73 m2) compared to hospital discharge (61 mL/min/1.73 m2, p < 0.001) and follow-up (55.5 mL/min/1.73 m2, p < 0.001). Those with pT1 tumours sustained a significantly greater decline in eGFR compared to other stages. In conclusion, patients with pT1 a and pT1 b tumours sustain a disproportionate decline in renal function and may benefit the most from NSS.

Real-Time Polymerase Chain Reaction Detection of Methicillin-ResistantStaphylococcus aureus:Impact on Nosocomial Transmission and Costs

Objectives.

To assess the impact of real-time polymerase chain reaction (PCR) detection of methicillin-resistantStaphylococcus aureus(MRSA) on nosocomial transmission and costs.

Design.

Monthly MRSA detection rates were measured from April 1, 2000, through December 31, 2005. Time series analysis was used to identify changes in MRSA detection rates, and decision analysis was used to compare the costs of detection by PCR and by culture.

Setting.

A 1,200-bed, tertiary care hospital in Canada.

Patients.

Admitted patients at high risk for MRSA colonization. MRSA detection using culture-based screening was compared with a commercial PCR assay.

Results.

The mean monthly incidence of nosocomial MRSA colonization or infection was 0.37 cases per 1,000 patient-days. The time-series model indicated an insignificant decrease of 0.14 cases per 1,000 patient-days per month (95% confidence interval, —0.18 to 0.46) after the introduction of PCR detection (P= .39). The mean interval from a reported positive result until contact precautions were initiated decreased from 3.8 to 1.6 days (P<.001). However, the cost of MRSA control increased from Can$605,034 to Can$771,609. Of 290 PCR-positive patients, 120 (41.4%) were placed under contact precautions unnecessarily because of low specificity of the PCR assay used in the study; these patients contributed 37% of the increased cost. The modeling study predicted that the cost per patient would be higher with detection by PCR (Can$96) than by culture (Can$67).

Conclusion.

Detection of MRSA by the PCR assay evaluated in this study was more costly than detection by culture for reducing MRSA transmission in our hospital. The cost benefit of screening by PCR varies according to incidences of MRSA colonization and infection, the predictive values of the assay used, and rates of compliance with infection control measures.

Validity of standard gamble estimated quality of life in acute venous thrombosis

INTRODUCTION

The standard gamble is considered the 'gold standard' technique for measuring quality of life. We recently used the standard gamble to estimate quality of life in acute venous thrombosis, and found unexpected variability in the responses. The current study aimed to explore the reasons for variability by comparing the standard gamble technique in patients with acute venous thrombosis to other quality of life measurement tools.

MATERIALS AND METHODS

Thrombosis clinic patients treated for venous thrombosis were eligible to participate. Patients evaluated their current health state by performing a standard gamble interview, reporting on a visual analogue scale, completing the SF-36 and disease specific questionnaires (PEmb-Qol and VEINES-QOL/Sym). Validity was assessed by correlating the standard gamble utilities with the other methods. Test-retest reliability, responsiveness and acceptability were also assessed.

RESULTS

Forty-four patients were interviewed, with 16 attending for a repeat interview. The median standard gamble utility was 0.97 (0.84-1.0), SF-6D 0.64 (0.59 - 0.80) and visual analogue score 70 (60 - 80). Participants with pulmonary embolism had lower standard gamble estimates than those with deep vein thrombosis. There was good discriminant validity in that the standard gamble estimates were not associated with risk taking behavior, negative outlook, sex or education. Test-retest reliability with the standard gamble was moderate and there was evidence of a ceiling effect.

CONCLUSIONS

Standard gamble utilities are higher than other methods of measuring quality of life in venous thrombosis. The choice of utility values adopted in studies will impact on future economic studies.

Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada

Introduction

Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalisation. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. We modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction (AMI), unstable angina (UA), heart failure (HF), and chronic obstructive pulmonary disease (COPD).

Methods

We completed a cost-effectiveness analysis based on a decision-analytic model to assess smokers hospitalised in Ontario, Canada for AMI, UA, HF, and COPD, their risk of continuing to smoke and the effects of quitting on re-hospitalisation and mortality over a 1-year period. We calculated short-term and long-term cost-effectiveness ratios. Our primary outcome was 1-year cost per quality-adjusted life year (QALY) gained.

Results

From the hospital payer's perspective, delivery of the OMSC can be considered cost effective with 1-year cost per QALY gained of $C1386, and lifetime cost per QALY gained of $C68. In the first year, we calculated that provision of the OMSC to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths. Results were robust within numerous sensitivity analyses.

Discussion

The OMSC appears to be cost-effective from the hospital payer perspective. Important consideration is the relatively low intervention cost compared to the reduction in costs related to readmissions for illnesses associated with continued smoking.

Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: a multiple baseline time-series design

OBJECTIVE

To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL).

DESIGN

Multiple baseline time-series design.

SETTING

Canadian province of Ontario.

POPULATION

A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010.

METHODS

International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution.

MAIN OUTCOME MEASURE

Rate of obstetrical hospital admission for PTL.

RESULTS

Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (-0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], -1.02 to -0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation.

CONCLUSIONS

Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

Delayed diagnosis of anorectal malformation--a persistent problem

Delayed diagnosis of anorectal malformation (ARM) is an avoidable event associated with significant complications and morbidity. Previous studies have suggested higher than expected rates of delayed diagnosis, especially when a threshold of 24 hours of life is used to define delayed diagnosis. The aim of this study is to highlight the prevalence of delayed diagnosis of ARM in Ireland and to determine if any improvement in rates of delayed diagnosis of ARM has occurred since we previously examined this problem over a 10 year period in 2010. We compared trends in the incidence of delayed diagnosis of ARM between two cohorts, A (1999-2009) and B (2010-2012). Delayed diagnosis was defined as one occurring after 48 hours of life. Delayed diagnosis occurred in 29 cases (21.3%) in total, with no difference in the incidence of delayed diagnosis between cohort A (21 patients [21.2%]) and cohort B (8 patients [21.6%) being recorded. The rate of bowel perforation in patients with delayed diagnosis was 10.3% (3 cases). Our findings highlight the importance of a careful, comprehensive clinical examination in diagnosing ARM and suggest this is still sub-optimal. We strongly support the use of a nationally devised algorithm to aid diagnosis of ARM in order to avoid life-threatening complications.

Estimating quality of life in acute venous thrombosis

IMPORTANCE

Future funding for new treatments in venous thromboembolism will be guided by cost-utility analyses. There is little available information on the utility of acute venous thromboembolism, limiting the validity of economic analyses.

OBJECTIVE

To measure the quality of life in the health states relating to thromboembolism cost-utility analyses.

DESIGN

A prospective cohort study.

SETTING

A single-center, university-affiliated thrombosis clinic.

PARTICIPANTS

Two hundred sixteen thrombosis clinic patients with a history of lower limb deep vein thrombosis (DVT) or pulmonary embolism (PE).

EXPOSURES

Participants consented to take a standard gamble interview. Each participant rated the quality of life in acute DVT, acute PE, and bleeding complication health states.

MAIN OUTCOMES AND MEASURES

The standard gamble measured quality of life (utility value) for acute DVT, acute PE, major intracranial bleeding event, minor intracranial bleeding event, and gastrointestinal bleeding event.

RESULTS

Two hundred fifteen responses were included in the analysis. Twenty-six percent had experienced both PE and DVT; 54%, DVT alone; and 20%, PE alone. Forty-two percent had experienced more than 1 episode of thrombosis, and 23% had had cancer-associated thrombosis. We found the median utility for acute DVT was 0.81 (interquartile range [IQR], 0.55-0.94); acute PE, 0.75 (IQR, 0.45-0.91); major intracranial bleeding event, 0.15 (IQR, 0.00-0.65); minor intracranial bleeding event, 0.75 (IQR, 0.55-0.92); and gastrointestinal bleeding event, 0.65 (IQR, 0.15-0.86). The median length of symptoms for DVT or PE was 1 week (IQR, <1-3 weeks).

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the largest published study on utilities in which the participants had personal experience of venous thromboembolism. We present unique information for economic analyses but have also identified future challenges for research in this area. Our summary results differ from those previously published, and we found wide variation in individual responses.

Recurrent dedifferentiated paratesticular liposarcoma with synchronous renal cell carcinoma and prostate cancer

Paratesticular liposarcoma is a very rare cause of scrotal mass. It is thought that they arise from spermatic cord lipomas most commonly. While well differentiated tumors tend to share many histological similarities with dedifferentiated tumors, the latter has a much more aggressive phenotype. We present an unusual case of a 69-year-old male with synchronous prostate adenocarcinoma and unilateral renal cell carcinoma who was found to have a dedifferentiated paratesticular liposarcoma. Treatment was with radical resection, preserving the testis, followed by radiotherapy. Unusually recurrence did not occur until 4 years following initial treatment. This case demonstrates the high propensity of dedifferentiated liposarcoma to recur locally and examines the most frequently employed management strategies.

Out-of-pocket costs in the year after early breast cancer among Canadian women and spouses

BACKGROUND

We lack comprehensive information about the extent of out-of-pocket costs after diagnosis of early breast cancer and their effects on the family's financial situation.

METHODS

This longitudinal study assessed out-of-pocket costs and wage losses during the first year after diagnosis of early breast cancer among Canadian women and spouses. Out-of-pocket costs for treatments and follow-up, consultations with other practitioners, home help, clothing, and natural health products were estimated, with information collected from telephone interviews. Generalized linear models were used to identify women at risk of having higher costs and the effects of out-of-pocket costs on perceptions of the family's financial situation.

RESULTS

Overall, 829 women (participation, 86.2%) and 391 spouses participated. Women's median net out-of-pocket costs during the year after diagnosis were $1002 (2003 Canadian dollars; mean = $1365; SD = $1238), and 74.4% of these costs resulted from treatments and follow-up. Spouses' median costs were $111 (mean = $234; SD = $320), or 9% of couples' total expenses. In multivariable analyses, the percentage of women with out-of-pocket costs of $1773 or more (upper quartile) was statistically significantly associated with higher education, working at diagnosis, living more than 50 km from the hospital where surgery was performed, and having two and three different types of adjuvant treatment (all 2-sided P values ≤ .01). However, when considered simultaneously with wage losses, out-of-pocket costs were not associated with perceived deterioration in the family's financial situation; rather, wage losses were the driving factor.

CONCLUSIONS

Overall, out-of-pocket costs from breast cancer for the year after diagnosis are probably not unmanageable for most women. However, some women were at higher risk of experiencing financial burden resulting from these costs.

Successful introduction of ring-fenced inpatient surgical beds in a general hospital setting

This study aimed to assess the impact of ring-fenced inpatient general surgical beds on day of surgery (DOS) admission, duration of elective inpatient stay (DEIS), and cancellation rates over a 6 month period. In June 2010 17 of 60 surgical inpatient beds were decommissioned. The remainder (43) were ring-fenced for general surgery patients only. Comparative analysis examining admission rates, cancellation rates, and theatre activity was performed between a reference period (January-June 2010) and the study period (July-December 2010). Complexity of all operations was graded according to an index schedule of procedures. There was no difference between the reference and study periods in volumes of elective admissions (472 [53.03%] vs. 418 [4797%]) and emergency admissions (928 [50.03%] vs. 927 [49.97%]). DOS admissions increased 5-fold during the study period (38 [8.1%] vs. 190 [45.5%], P < 0.001). Average duration of elective inpatient stay reduced from 4.3 days to 3.06 days in the study period (P < 0.001). No difference was observed in volume of operations performed at all levels of complexity. There were 78 (58.2%) cancellations during the reference period and 56 (41.8%) during the study period with patient non-attendance the most common cause for cancellation in both periods. Ring-fenced surgical beds facilitated higher DOS admission rates and shorter duration of elective inpatient stay, leading to more efficient use of hospital resources.

Treatment cost effectiveness in acute otitis media: A watch-and-wait approach versus amoxicillin

In Canada, antimicrobial treatment is the most common approach for acute otitis media. The aim of the present study was to compare the cost effectiveness of treatment with amoxicillin versus a watch-and-wait approach (WAIT) within a Canadian pediatric setting. Four hundred eighty-eight children, six months to five years of age, who participated in a randomized controlled trial were included in the study. The average medication costs per patient were higher for the amoxicillin group ($17.26) than for the WAIT group ($4.33). However, both health care ($148.44 versus $162.48) and patient costs ($23.50 versus $31.87) were greater for the WAIT group. The mean cost of treatment for the amoxicillin group was $189.20, compared with $198.68 for the WAIT group. Amoxicillin may be cost effective in treating children with acute otitis media. The potential development of antimicrobial resistance was not addressed in the present study.

Impact of person-centred thinking and personal budgets in mental health services: reporting a UK pilot

This paper will report an innovation in the delivery of support in three early intervention teams in the North West of England. The paper will draw on a data set from an evaluative study exploring individual budgets and discuss the approaches' impact. Narrative analysis methodology is described and the method's application in revealing how individual budgets supported recovery is demonstrated. The service users reported progressive narrative towards recovery. These data signpost options for mental health service delivery. Early intervention team staff report support planning and person-centred thinking tools provided different insights about service users' needs and what assists their recovery. Challenges for mental health nurses and the services they work for are discussed and the roles person-centred care planning should play are identified.

Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer

PURPOSE

An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes.

PATIENTS AND METHODS

Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures.

RESULTS

Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005).

CONCLUSION

The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.

Out-of-pocket costs for accessing adjuvant radiotherapy among Canadian women with breast cancer

PURPOSE

Patients with breast cancer incur out-of-pocket costs when they receive adjuvant radiation. These treatments are administered in dedicated centers on a daily basis over 4 to 5 weeks. We assessed the extent of out-of-pocket costs to access radiotherapy and identified women at risk of experiencing higher costs.

PATIENTS AND METHODS

This prospective study was conducted among 800 women from eight Quebec hospitals (participation, 86%), of whom 693 women received adjuvant radiotherapy. Costs to access treatment (transportation, parking, lodging, and meals) were estimated on the basis of information collected by telephone interviews. Generalized linear models were used to identify women at risk of having higher costs.

RESULTS

Mean and median total costs (including financial aid received) to access radiotherapy were 445 Canadian dollars (Can$; standard deviation, Can$407) and Can$311, respectively. Women who lived at home but far from the radiotherapy center had the highest risk of experiencing weekly costs of at least Can$122 (highest quartile; prevalence ratio [PR], 5.8; 95% CI, 4.7 to 7.1) followed by women who lived away from home and farther from the center (PR, 4.5; 95% CI, 3.4 to 6.0) and by women who lived away from home and closer to the center (PR, 2.14; 95% CI, 1.3 to 3.5). When women stayed at a cancer lodge during treatment, costs were reduced by 80%.

CONCLUSION

Considered in and of themselves, out-of-pocket costs for access to radiotherapy appeared relatively modest. Financial assistance initiatives for women who lived away from home during treatments contributed to a substantial reduction of access costs. These efforts should be maintained, but financial assistance should also target patients with cancer who live at home during treatments but have to travel relatively long distances on a daily basis.

(Correcting) misdiagnoses of asthma: a cost effectiveness analysis

BACKGROUND

The prevalence of physician-diagnosed-asthma has risen over the past three decades and misdiagnosis of asthma is potentially common.

OBJECTIVE

to determine whether a secondary-screening-program to establish a correct diagnosis of asthma in those who report a physician diagnosis of asthma is cost effective.

METHOD

Randomly selected physician-diagnosed-asthmatic subjects from 8 Canadian cities were studied with an extensive diagnostic algorithm to rule-in, or rule-out, a correct diagnosis of asthma. Subjects in whom the diagnosis of asthma was excluded were followed up for 6-months and data on asthma medications and heath care utilization was obtained. Economic analysis was performed to estimate the incremental lifetime costs associated with secondary screening of previously diagnosed asthmatic subjects. Analysis was from the perspective of the Canadian healthcare system and is reported in Canadian dollars.

RESULTS

Of 540 randomly selected patients with physician diagnosed asthma 150 (28%; 95%CI 19-37%) did not have asthma when objectively studied. 71% of these misdiagnosed patients were on some asthma medications. Incorporating the incremental cost of secondary-screening for the diagnosis of asthma, we found that the average cost savings per 100 individuals screened was $35,141 (95%CI $4,588-$69,278).

CONCLUSION

Cost savings primarily resulted from lifetime costs of medication use averted in those who had been misdiagnosed.

Effect of exercise training on physical fitness in type II diabetes mellitus

Few studies have compared changes in cardiorespiratory fitness between aerobic training only or in combination with resistance training. In addition, no study to date has compared strength gains between resistance training and combined exercise training in type II diabetes mellitus (T2DM).

PURPOSE

We evaluated the effects of aerobic exercise training (A group), resistance exercise training (R group), combined aerobic and resistance training (A + R group), and sedentary lifestyle (C group) on cardiorespiratory fitness and muscular strength in individuals with T2DM.

METHODS

Two hundred and fifty-one participants in the Diabetes Aerobic and Resistance Exercise trial were randomly allocated to A, R, A + R, or C. Peak oxygen consumption (V O(2peak)), workload, and treadmill time were determined after maximal exercise testing at 0 and 6 months. Muscular strength was measured as the eight-repetition maximum on the leg press, bench press, and seated row. Responses were compared between younger (aged 39-54 yr) and older (aged 55-70 yr) adults and between sexes.

RESULTS

VO(2peak) improved by 1.73 and 1.93 mL O(2)*kg(-1)*min(-1) with A and A + R, respectively, compared with C (P < 0.05). Strength improvements were significant after A + R and R on the leg press (A + R: 48%, R: 65%), bench press (A + R: 38%, R: 57%), and seated row (A + R: 33%, R: 41%; P < 0.05). There was no main effect of age or sex on training performance outcomes. There was, however, a tendency for older participants to increase VO(2peak) more with A + R (+1.5 mL O(2)*kg(-1)*min(-1)) than with A only (+0.7 mL O(2)*kg(-1)*min(-1)).

CONCLUSIONS

Combined training did not provide additional benefits nor did it mitigate improvements in fitness in younger subjects compared with aerobic and resistance training alone. In older subjects, there was a trend to greater aerobic fitness gains with A + R versus A alone.

Cost-effectiveness of epinephrine and dexamethasone in children with bronchiolitis

OBJECTIVE

Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis.

METHODS

An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping.

RESULTS

The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919-1325) for the combination therapy, $1210 (95% CI: 1004-1441) for no active treatment, $1322 (95% CI: 1093-1571) for epinephrine alone, and $1360 (95% CI: 1124-1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11-13) for the combination therapy, 12.7 days (95% CI: 12-13) for no active treatment, 13.0 days (95% CI: 12-14) for epinephrine alone, and 12.6 days (95% CI: 12-13) for dexamethasone alone.

CONCLUSION

Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most cost-effective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs.

Recent onset neck pain with associated neurological deficit--Pott's disease remains an important differential diagnosis

The incidence of spinal tuberculosis is increasing in developed nations. In Ireland, half of all cases seen in the most recent decade for which figures are available were diagnosed in 2005-2007, the three most recent years for which there is complete data. We discuss a patient who presented with neurological complications due to destructive spinal tuberculous disease affecting the sixth cervical vertebra.

Effects of aerobic exercise, resistance exercise or both, on patient-reported health status and well-being in type 2 diabetes mellitus: a randomised trial

AIMS/HYPOTHESIS

The Diabetes Aerobic and Resistance Exercise (DARE) study showed that aerobic and resistance exercise training each improved glycaemic control and that a combination of both was superior to either type alone in patients with type 2 diabetes mellitus. Here we report effects on patient-reported health status and well-being in the DARE Trial.

METHODS

We randomised 218 inactive participants with type 2 diabetes mellitus in parallel to 22 weeks of aerobic exercise (n = 51), resistance exercise (n = 58), combined aerobic and resistance exercise (n = 57) or no exercise (control; n = 52). Intervention allocation was managed by a central office. Outcomes included health status as assessed by the physical and mental component scores of the Medical Outcomes Trust Short-Form 36-item version (SF-36) and well-being as measured by the Well-Being Questionnaire 12-item version (WBQ-12); these were measured at the Ottawa Hospital.

RESULTS

Using a p value of 0.0125 for statistical significance due to multiple comparisons, mixed model analyses indicated that resistance exercise led to clinically but not statistically significant improvements in the SF-36 physical component score compared with aerobic exercise (Delta = 2.7 points; p = 0.048) and control (i.e. no exercise; Delta = 3.3 points; p = 0.015). For mental component scores, there were clinically important improvements favouring no (control) compared with resistance (Delta = 7.6 points; p < 0.001) and combined (Delta = 7.2 points; p < 0.001) exercise. No effects on WBQ-12 scores were noted. Overall, 59/218 (27%) of participants included in this analysis sustained an adverse event during the course of the study, including 16 participants in the combined exercise group, 19 participants in the resistance exercise group, 16 participants in the aerobic exercise group, and eight participants in the control group. All participants were included in the intent-to-treat analyses. The trial is now closed to follow-up.

CONCLUSIONS/INTERPRETATION

Resistance exercise was better than aerobic or no exercise for improving physical health status in these patients. No exercise was superior to resistance or combined exercise for improving mental health status. Well-being was unchanged by intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00195884

FUNDING

This study was funded by the Canadian Institutes of Health Research (grant MCT-44155) and the Canadian Diabetes Association (The Lillian Hollefriend Grant).

Cancer antigen 125 in ovarian cancer surveillance: a decision analysis model

We used decision analysis techniques with Markov cohort modeling to examine the role of cancer antigen 125 (CA-125) in follow-up surveillance strategies among patients with advanced ovarian cancer. Utilities were derived from a societal perspective.

Using quality-adjusted life years (qalys) as the outcome variable, the value of CA-125 monitoring for asymptomatic women with ovarian cancer was found to be reduced as compared with a strategy that includes CA-125 testing. Decisions to include CA-125 in surveillance strategies for ovarian cancer patients should be made after discussion with full disclosure of the preference-sensitive nature of CA-125. The model demonstrates that preferences and perspective can influence decisions in cancer care.