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Conombo B, Guertin JR, Hoch JS, Grimshaw J, Bérubé M, Malo C, Berthelot S, Lauzier F, Stelfox HT, Turgeon AF, Archambault P, Belcaid A, Moore L. Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study. BMC Health Serv Res 2024; 24:479. [PMID: 38632593 PMCID: PMC11025277 DOI: 10.1186/s12913-024-10969-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
| | - Jason R Guertin
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California at Davis, Davis, CA, USA
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Christian Malo
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
- Centre de Recherche Intégrée Pour Un Système Apprenant en Santé Et Services Sociaux, Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, Lévis, Québec, Canada
| | - François Lauzier
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
- VITAM-Centre de Recherche en Santé Durable, Québec City, Québec, Canada
| | - Amina Belcaid
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada.
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Moore L, Ben Abdeljelil A, Tardif PA, Zemek R, Reed N, Yeates KO, Emery CA, Gagnon IJ, Yanchar N, Bérubé M, Dawson J, Berthelot S, Stang A, Beno S, Beaulieu E, Turgeon AF, Labrosse M, Lauzier F, Pike I, Macpherson A, Freire GC. Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review. Ann Emerg Med 2024; 83:327-339. [PMID: 38142375 DOI: 10.1016/j.annemergmed.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/25/2023]
Abstract
STUDY OBJECTIVE Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada; Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada.
| | - Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada; Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nick Reed
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberts, Canada
| | - Isabelle J Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montréal Children's Hospital, Montréal, Québec, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada; Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Jennifer Dawson
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Emilie Beaulieu
- Département de Pédiatrie, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada; Department of Anesthesiology and Critical Care Medicine Université Laval, Québec City, Québec, Canada
| | - Melanie Labrosse
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada; Department of Anesthesiology and Critical Care Medicine Université Laval, Québec City, Québec, Canada
| | - Ian Pike
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alison Macpherson
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Gabrielle C Freire
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, Peter Gilgan Institute for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
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Gnanvi JE, Yanchar N, Freire G, Beaulieu E, Tardif PA, Bérubé M, Macpherson A, Pike I, Zemek R, Gagnon IJ, Carsen S, Gabbe B, Gnanou S, Duval C, Moore L. Social determinants of health and disparities in pediatric trauma care: protocol for a systematic review and meta-analysis. Syst Rev 2024; 13:94. [PMID: 38519996 PMCID: PMC10958897 DOI: 10.1186/s13643-024-02510-7] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Social determinants of health (SDH), including "the conditions in which individuals are born, grow, work, live and age" affect child health and well-being. Several studies have synthesized evidence about the influence of SDH on childhood injury risks and outcomes. However, there is no systematic evidence about the impact of SDH on accessing care and quality of care once a child has suffered an injury. We aim to evaluate the extent to which access to care and quality of care after injury are affected by children and adolescents' SDH. METHODS Using Cochrane methodology, we will conduct a systematic review including observational and experimental studies evaluating the association between social/material elements contributing to health disparities, using the PROGRESS-Plus framework: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital and care received by children and adolescents (≤ 19 years of age) after injury. We will consult published literature using PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, and Academic Search Premier and grey literature using Google Scholar from their inception to a maximum of 6 months prior to submission for publication. Two reviewers will independently perform study selection, data extraction, and risk of bias assessment for included studies. The risk of bias will be assessed using the ROBINS-E and ROB-2 tools respectively for observational and experimental study designs. We will analyze data to perform narrative syntheses, and if enough studies are identified, we will conduct a meta-analysis using random effects models. DISCUSSION This systematic review will provide a synthesis of evidence on the association between SDH and pediatric trauma care (access to care and quality of care) that clinicians and policymakers can use to better tailor care systems and promote equitable access and quality of care for all children. We will share our findings through clinical rounds, conferences, and publication in a peer-reviewed journal. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023408467.
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Affiliation(s)
- Janyce Eunice Gnanvi
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, QC, Canada.
- Department of Social and Preventive Medicine, Faculté de Médecine, Université Laval, Quebec City, QC, Canada.
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emilie Beaulieu
- Department of Pediatrics, Faculté de Médecine, Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, QC, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, QC, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, QC, Canada
- Faculty of Nursing, Université Laval, Quebec City, QC, Canada
| | | | - Ian Pike
- Department of Pediatrics, BC Injury Research and Prevention Unit, The University of British Columbia, Vancouver, BC, Canada
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Isabelle J Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children's Hospital, Montreal, QC, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Soualio Gnanou
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, QC, Canada
- Department of Social and Preventive Medicine, Faculté de Médecine, Université Laval, Quebec City, QC, Canada
| | - Cécile Duval
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, QC, Canada
- Department of Social and Preventive Medicine, Faculté de Médecine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, QC, Canada
- Department of Social and Preventive Medicine, Faculté de Médecine, Université Laval, Quebec City, QC, Canada
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Isaac CJ, Moore L, Bérubé M, Belzile É, Malo C, Giroux M, Belcaid A, Abiala G, Trépanier D, Émond M, Dionne CE. Predictors of adverse outcomes in elders hospitalised for isolated orthopaedic trauma: a multicentre cohort study. Emerg Med J 2024; 41:168-175. [PMID: 38233107 DOI: 10.1136/emermed-2023-213088] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Patients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury. METHODS We conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination). RESULTS Increasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes. CONCLUSION We identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.
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Affiliation(s)
- Chartelin Jean Isaac
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Étienne Belzile
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
- Department of Orthopedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Christian Malo
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
- Department of Emergency Medicine and Family Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Marianne Giroux
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et en Services Sociaux du Québec, Québec City, Québec, Canada
| | - Godwill Abiala
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
- Institut National d'Excellence en Santé et en Services Sociaux du Québec, Québec City, Québec, Canada
| | - David Trépanier
- Department of Emergency Medicine and Family Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Marcel Émond
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
- Department of Emergency Medicine and Family Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Clermont E Dionne
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Québec City, Québec, Canada
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O'Farrell R, Maguire S, Moore L, Murray K, Gorman A, Ball E, Riddell C, O'Neill M, Jordan N, O'Shea F, Veale D, Donnelly S, Murphy G, Fitzgerald G. Delivering Care for Pregnant Women with Rheumatic and Musculoskeletal Diseases. Ir Med J 2024; 117:894. [PMID: 38259237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
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Boucher V, Frenette J, Neveu X, Tardif PA, Mercier É, Chauny JM, Berthelot S, Archambault P, Lee J, Perry JJ, McRae A, Lang E, Moore L, Cameron P, Ouellet MC, de Guise E, Swaine B, Émond M, Le Sage N. Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury. J Clin Neurosci 2023; 118:34-43. [PMID: 37857062 DOI: 10.1016/j.jocn.2023.10.007] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/07/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.
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Affiliation(s)
- Valérie Boucher
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada
| | - Jérôme Frenette
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada
| | - Xavier Neveu
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada
| | - Pier-Alexandre Tardif
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada
| | - Éric Mercier
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada
| | - Jean-Marc Chauny
- Faculté de médecine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montréal, Québec H3T 1J4, Canada
| | - Simon Berthelot
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada
| | - Patrick Archambault
- Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada; Centre de recherche du CISSS de Chaudière-Appalaches, 143 Rue Wolfe, Lévis, Québec, QC G6V 3Z1, Canada
| | - Jacques Lee
- Sunnybrook Health Science Center, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada; Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario M5G 1X5, Canada
| | - Jeffrey J Perry
- The Ottawa Hospital Research Institute, 501 Smyth Box 511, Ottawa, Ontario K1H 8L6, Canada; Department of Emergency Medicine, University of Ottawa, 75 Laurier Ave E, Ottawa, Ontario K1N 6N5, Canada
| | - Andrew McRae
- Department of Emergency Medicine, University of Calgary, 2500 University Dr NW, Calgary, Alberta T2N 1N4, Canada; Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta T2N 2T9, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, 2500 University Dr NW, Calgary, Alberta T2N 1N4, Canada; Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta T2N 2T9, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada
| | - Peter Cameron
- Alfred Emergency and Trauma Centre, Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Marie-Christine Ouellet
- Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), 525 Bd Wilfrid-Hamel, Québec, Québec G1M 2S8, Canada
| | - Elaine de Guise
- Département de psychologie, Université de Montréal, 2900, boul. Édouard-Montpetit, Montréal, Québec H3T 1J4, Canada; Centre de recherche interdisciplinaire en réadaptation (CRIR) du Montréal métropolitain, 6363, chemin Hudson, Montréal, Québec H3S 1M9, Canada
| | - Bonnie Swaine
- Faculté de médecine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montréal, Québec H3T 1J4, Canada; Centre de recherche interdisciplinaire en réadaptation (CRIR) du Montréal métropolitain, 6363, chemin Hudson, Montréal, Québec H3S 1M9, Canada
| | - Marcel Émond
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada
| | - Natalie Le Sage
- CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Québec, Québec G1J 1Z4, Canada; Faculté de médecine, Université Laval, 1050 Av. de la Médecine, Québec, Québec G1V 0A6, Canada; VITAM-Centre de recherche en santé durable, 2480 Chem. de la Canardière, Québec, Québec G1J 2G1, Canada.
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Freire GC, Beno S, Yanchar N, Weiss M, Stang A, Stelfox T, Bérubé M, Beaulieu E, Gagnon IJ, Zemek R, Berthelot S, Tardif PA, Moore L. Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review. Ann Surg 2023; 278:858-864. [PMID: 37325908 DOI: 10.1097/sla.0000000000005966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps. BACKGROUND Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care. METHODS We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II." RESULTS We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning. CONCLUSIONS We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.
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Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine at University of Toronto
- Child Health Evaluative Sciences
| | - Suzanne Beno
- Division of Emergency Medicine at University of Toronto
| | | | | | | | - Thomas Stelfox
- Department of Critical Care Medicine at University of Calgary
| | - Melanie Bérubé
- Population Health at Laval University
- Faculty of nursing at Laval University
| | | | | | - Roger Zemek
- Department of Pediatrics at Children's Hospital of Eastern Ontario
| | - Simon Berthelot
- Department of social and preventative medicine at Laval University
| | - Pier-Alexandre Tardif
- Population Health at Laval University
- Department of social and preventative medicine at Laval University
| | - Lynne Moore
- Population Health at Laval University
- Department of social and preventative medicine at Laval University
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8
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Moore L, Drager J, Freire G, Yanchar N, Miller AN, Ben Abdel A, Bérubé M, Tardif PA, Gnanvi J, Stelfox HT, Beaudin M, Stang A, Beno S, Weiss M, Labrosse M, Zemek R, Gagnon IJ, Beaulieu E, Berthelot S, Klassen T, Turgeon AF, Lauzier F, Gabbe B, Carsen S. Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review. J Pediatr Orthop 2023; 43:e790-e797. [PMID: 37606069 DOI: 10.1097/bpo.0000000000002496] [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: 08/23/2023]
Abstract
BACKGROUND Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE Level II-therapeutic study.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
- Department of Social and Preventative Medicine
| | - Justin Drager
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario (CHEO)
| | | | | | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Anis Ben Abdel
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
- Faculty of Nursing
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
| | - Janyce Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
| | - Henry T Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health
| | - Marianne Beaudin
- Department of Pediatric surgery, CHU Sainte-Justine, Université de Montréal
| | - Antonia Stang
- Department of Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON
| | - Matthew Weiss
- Département de pédiatrie, Faculté de médecine, Centre Hospitalier Universitaire de Québec
| | - Melanie Labrosse
- Department of Pediatrics, Division of Emergency Medicine, CHU Sainte-Justine, Université de Montréal
| | | | - Isabelle J Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children's Hospital, Montréal, QC, Canada
| | - Emilie Beaulieu
- Département de pédiatrie, Faculté de médecine, Centre Hospitalier Universitaire de Québec
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
| | - Terry Klassen
- George & Fay Yee Centre for Health Care Innovation, Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
- Department of Social and Preventative Medicine
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus)
- Department of Social and Preventative Medicine
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, Ottawa
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Ben Abdeljelil A, Freire GC, Yanchar N, Turgeon AF, Beno S, Bérubé M, Stang A, Stelfox T, Zemek R, Beaulieu E, Gagnon IJ, Gabbe B, Lauzier F, Labrosse M, Tardif PA, Deshommes T, Gnanvi J, Moore L. Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations. J Neurotrauma 2023; 40:2270-2281. [PMID: 37341019 DOI: 10.1089/neu.2023.0149] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.
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Affiliation(s)
- Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Gabrielle C Freire
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto,Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, Peter Gilgan Institute for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Natalie Yanchar
- Department of Surgery, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Quebec City, Quebec, Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Faculty of Nursing, Université Laval, Quebec City, Quebec, Canada
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Emilie Beaulieu
- Department of Department of Pediatrics, Université Laval, Quebec City, Quebec, Canada
| | - Isabelle J Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Francois Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Quebec City, Quebec, Canada
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Melanie Labrosse
- Department of Pediatrics, Division of Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
| | - Theony Deshommes
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Janyce Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Quebec City, Quebec, Canada
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Anderson BM, Moore L, Moore KL, Bojechko C. EPIDEEP: Using a Deep Learning Model to Predict In Vivo Electronic Portal Imaging Device (EPID) Transit Images. Int J Radiat Oncol Biol Phys 2023; 117:e645. [PMID: 37785921 DOI: 10.1016/j.ijrobp.2023.06.2060] [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] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To create a deep-learning model to predict in-vivo electronic portal imaging device (EPID) transit images for IMRT treatments. This model was created to predict in-vivo images to identify machine and patient-related errors that occur during beam delivery and are undetectable with current QA approaches. The deep-learning model can make image predictions much faster than Monte Carlo approaches, making image prediction feasible for application in online adaptive radiotherapy. Additionally, the model does not rely on any proprietary information and can be easily utilized by other clinics. MATERIALS/METHODS Our approach separates the primary and scatter components of in-vivo transit images. The attenuation of primary radiation reaching the EPID panel is modeled analytically, using attenuation measurements from phantoms of known thicknesses. The scatter component is estimated using a convolutional neural network (CNN). The CNN training uses information from the on-treatment cone-beam CTs (CBCTs), and a pretreatment EPID image with no patient in the beam. We acquired 193 IMRT fields/images from 118 patients previously treated on the Varian Halcyon. Treatment sites included the pelvis, abdomen, lungs, and extremities. CBCTs were collected immediately before treatment, to provide an accurate representation of the anatomy. A 3-channel input image was used, consisting of the pretreatment EPID image, a ray tracing projection through the CBCT to the EPID panel, and a projection to isocenter. Model training:validation:test set ratios were 133:20:40 images. The primary and scatter components are added together to give the predicted transit image. Prediction accuracy was assessed by comparing model-predicted and measured in-vivo EPID images with a 3%/3mm and 5%/3mm gamma pass rate. RESULTS The gamma pass rate for the patients in the training:validation:test was 91.5%:90.4%:92.1% for 3%/3mm and 96.7%:96.6%:97.0% for 5%/3mm. The model can make image predictions in 20 milliseconds. The poor passing rates of some images may be due to CBCT artifacts and patient motion that occurs between the time of CBCT and treatment. CONCLUSION This model can predict in-vivo EPID images with an average gamma pass rate greater than 90%. Image predictions from this model can be used to detect in-vivo treatment errors and changes in patient anatomy, providing an additional layer of patient-specific quality assurance. The speed of image predictions is 20 milliseconds, making use feasible for online adaptive treatments, which currently do not utilize patient-specific measurements of the delivered radiation. Upcoming studies will assess the model's ability in detecting clinically relevant errors and changes in patient anatomy that can adversely affect treatment. Future goals include acquiring more data to further improve the model and extending the model to make predictions for VMAT treatments.
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Affiliation(s)
- B M Anderson
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA
| | - L Moore
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA
| | - K L Moore
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - C Bojechko
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA
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Moore L, Freire G, Turgeon AF, Bérubé M, Boukar KM, Tardif PA, Stelfox HT, Beno S, Lauzier F, Beaudin M, Zemek R, Gagnon IJ, Beaulieu E, Weiss MJ, Carsen S, Gabbe B, Stang A, Ben Abdeljelil A, Gnanvi E, Yanchar N. Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2334266. [PMID: 37721752 PMCID: PMC10507486 DOI: 10.1001/jamanetworkopen.2023.34266] [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: 05/26/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Importance Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking. Objective To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma. Data Sources MEDLINE, Embase, and Web of Science through March 2023. Study Selection Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years). Data Extraction and Synthesis This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence. Main Outcome(s) and Measure(s) Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI). Results A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes. Conclusions and Relevance In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Khadidja Malloum Boukar
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Henry T. Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Marianne Beaudin
- Sainte-Justine Hospital, Department of Paediatric Surgery, Université de Montréal, Montréal, Québec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Isabelle J. Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children’s Hospital, Montréal, Québec, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Emilie Beaulieu
- Département de pédiatrie, Faculté de médecine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Matthew John Weiss
- Centre Mère-Enfant Soleil du CHU de Québec, Transplant Québec, Québec, Québec, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Eunice Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
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Conombo B, Guertin JR, Hoch JS, Lauzier F, Turgeon AF, Stelfox HT, Moore L. Potential Avoidable Costs of Low-Value Clinical Practices in Acute Injury Care in an Integrated Canadian Provincial Trauma System. JAMA Surg 2023; 158:977-979. [PMID: 37436756 PMCID: PMC10339214 DOI: 10.1001/jamasurg.2023.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/06/2023] [Indexed: 07/13/2023]
Abstract
This economic evaluation estimated the direct health care costs associated with 11 low-value clinical practices in acute trauma care in the integrated health care system of Quebec, Canada.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval, Québec City, Québec, Canada
| | - Jason R. Guertin
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval, Québec City, Québec, Canada
| | - Jeffrey S. Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California at Davis, Davis
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval, Québec City, Québec, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval, Québec City, Québec, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval, Québec City, Québec, Canada
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Yanchar N, Tardif PA, Freire G, Bérubé M, Stelfox HT, Beaudin M, Stang A, Beno S, Weiss M, Labrosse M, Zemek R, Gagnon IJ, Beaulieu E, Berthelot S, Turgeon AF, Lauzier F, Gabbe B, Moore L. Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review. J Trauma Acute Care Surg 2023; 95:442-450. [PMID: 37272747 DOI: 10.1097/ta.0000000000004015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs. METHODS We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria. RESULTS We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries. CONCLUSION We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level III.
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Affiliation(s)
- Natalie Yanchar
- From the Department of Surgery (N.Y.), University of Calgary, Calgary; Population Health and Optimal Health Practices Research Unit (P.-A.T., M.B., S.B., A.F.T., F.L., L.M.), Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus); Department of Social and Preventative Medicine (L.M.), Université Laval, Quebec City, Quebec; Division of Emergency Medicine, Department of Paediatrics (G.F.), University of Toronto, Toronto; Faculty of Nursing (M.Bérubé), Université Laval, Quebec City, Quebec; Departments of Critical Care Medicine (H.T.S.), Medicine (H.T.S.), and Community Health Sciences (H.T.S.), O'Brien Institute for Public Health, University of Calgary, Calgary; Department of Paediatric Surgery (M.Beaudin), Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec; Pediatrics, Emergency Medicine, and Community Health Sciences (A.S.), Cumming School of Medicine, University of Calgary, Calgary, Alberta; Division of Emergency Medicine (S.B.), Hospital for Sick Children, University of Toronto, Toronto, Ontario; Centre Mère-Enfant Soleil du CHU de Québec (M.W.), Transplant Quebec, Quebec City, Quebec; Division of Emergency Medicine, Department of Pediatrics (M.L.), CHU Sainte-Justine, Université de Montréal, Montreal; Department of Pediatrics (R.Z.), Children's Hospital of Eastern Ontario, Ottawa; Division of Pediatric Emergency Medicine (I.J.G.), McGill University Health Centre, Montreal Children's Hospital, Montréal; Département de Pédiatrie (E.B.), Faculté de Médecine, Centre Hospitalier Universitaire de Québec, and Department of Anesthesiology and Critical Care Medicine (A.F.T., F.L.), Division of Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada; and School of Public Health and Preventive Medicine (B.G.), Monash University, Melbourne, Victoria, Australia
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14
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Villemure-Poliquin N, Costerousse O, Lessard Bonaventure P, Audet N, Lauzier F, Moore L, Zarychanski R, Turgeon AF. Tracheostomy versus prolonged intubation in moderate to severe traumatic brain injury: a multicentre retrospective cohort study. Can J Anaesth 2023; 70:1516-1526. [PMID: 37505417 PMCID: PMC10447593 DOI: 10.1007/s12630-023-02539-7] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/29/2023] [Accepted: 02/16/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE Tracheostomy is a surgical procedure that is commonly performed in patients admitted to the intensive care unit (ICU). It is frequently required in patients with moderate to severe traumatic brain injury (TBI), a subset of patients with prolonged altered state of consciousness that may require a long period of mechanical respiratory assistance. While many clinicians favour the use of early tracheostomy in TBI patients, the evidence in favour of this practice remains scarce. The aims of our study were to evaluate the potential clinical benefits of tracheostomy versus prolonged endotracheal intubation, as well as whether the timing of the procedure may influence outcome in patients with moderate to severe TBI. METHODS We conducted a retrospective multicentre cohort study based on data from the provincial integrated trauma system of Quebec (Québec Trauma Registry). The study population was selected from adult trauma patients hospitalized between 2013 and 2019. We included patients 16 yr and older with moderate to severe TBI (Glasgow Coma Scale score < 13) who required mechanical ventilation for 96 hr or longer. Our primary outcome was 30-day mortality. Secondary outcomes included hospital and ICU mortality, six-month mortality, duration of mechanical ventilation, ventilator-associated pneumonia, ICU and hospital length of stay as well as orientation of patients upon discharge from the hospital. We used propensity score covariate adjustment. To overcome the effect of immortal time bias, an extended Cox shared frailty model was used to compare mortality between groups. RESULTS From 2013 to 2019, 26,923 patients with TBI were registered in the Québec Trauma Registry. A total of 983 patients who required prolonged endotracheal intubation for 96 hr or more were included in the study, 374 of whom underwent a tracheostomy and 609 of whom remained intubated. We observed a reduction in 30-day mortality (adjusted hazard ratio, 0.33; 95% confidence interval, 0.21 to 0.53) associated with tracheostomy compared with prolonged endotracheal intubation. This effect was also seen in the ICU as well as at six months. Tracheostomy, when compared with prolonged endotracheal intubation, was associated with an increase in the duration of mechanical respiratory assistance without any increase in the length of stay. No effect on mortality was observed when comparing early vs late tracheostomy procedures. An early procedure was associated with a reduction in the duration of mechanical respiratory support as well as hospital and ICU length of stay. CONCLUSION In this multicentre cohort study, tracheostomy was associated with decreased mortality when compared with prolonged endotracheal intubation in patients with moderate to severe TBI. This effect does not appear to be modified by the timing of the procedure. Nevertheless, the generalization and application of these results remains limited by potential residual time-dependent indication bias.
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Affiliation(s)
- Noémie Villemure-Poliquin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Ophthalmology and Otolaryngology - Head and Neck Surgery, Université Laval, Quebec City, QC, Canada
| | - Olivier Costerousse
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
| | - Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Division of Neurosurgery, Department of Surgery, CHU de Québec -Université Laval, Quebec City, QC, Canada
| | - Nathalie Audet
- Department of Ophthalmology and Otolaryngology - Head and Neck Surgery, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Medicine, Université Laval, Quebec City, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Preventive and Social Medicine, Université Laval, Quebec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Hematology and of Medical Oncology, Rady Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute of Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada.
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada.
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15
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Bérubé M, Côté C, Gagnon MA, Moore L, Tremblay L, Turgeon AF, Evans D, Berry G, Turcotte V, Belzile ÉL, Dale C, Orrantia E, Verret M, Dercksen J, Martel MO, Dupuis S, Chatillon CE, Lauzier F. Interdisciplinary strategies to prevent long-term and detrimental opioid use following trauma: a stakeholder consensus study. Pain Med 2023; 24:933-940. [PMID: 36944264 PMCID: PMC10391591 DOI: 10.1093/pm/pnad037] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. DESIGN A consensus study using the nominal group technique. SETTING Four trauma systems in Canada. SUBJECTS Participants included expert clinicians and decision makers, and people with lived experience. METHODS Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. RESULTS A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. CONCLUSION This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.
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Affiliation(s)
- Mélanie Bérubé
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Faculty of Nursing, Université Laval, Québec City, Quebec G1V 0A6, Canada
- Quebec Pain Research Network, Sherbrooke, Quebec J1H 5N4, Canada
| | - Caroline Côté
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Faculty of Nursing, Université Laval, Québec City, Quebec G1V 0A6, Canada
- Quebec Pain Research Network, Sherbrooke, Quebec J1H 5N4, Canada
| | - Marc-Aurèle Gagnon
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Department of Social Preventive Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
| | - Lorraine Tremblay
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario M4N 3M5, Canada
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia V5Z 1M9, Canada
| | - Greg Berry
- Departement of Orthopaedic Surgery, McGill University Health Centre, Montréal, Quebec H3G 1A4, Canada
| | - Valérie Turcotte
- Department of Nursing, CIUSSS du Nord-de-l’île-de-Montréal, Montréal, Quebec H4J 1C5, Canada
| | - Étienne L Belzile
- Department of Surgery, Division of Orthopeadic Surgery, CHU de Québec-Université Laval, Québec City, Quebec GIV 1Z4, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario M5T 1P8, Canada
- University of Toronto Centre for the Study of Pain (UTCSP), Toronto, Ontario M5T 1P8, Canada
| | - Eli Orrantia
- Marathon Family Health Team, Marathon, Ontario P0T 2E0, Canada
| | - Michael Verret
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario K1H 8L6, Canada
| | - Judy Dercksen
- Quesnel Primary Care Clinic, Quesnel, British Columbia V2J 2K8, Canada
| | - Marc-Olivier Martel
- Quebec Pain Research Network, Sherbrooke, Quebec J1H 5N4, Canada
- Faculty of Medicine & Dentistry, McGill University, Montréal, Quebec H3A 1G1, Canada
| | - Sébastien Dupuis
- Department of Pharmacy, CIUSSS du Nord-de-l’île-de-Montréal,Montréal, Quebec H4J 1C5, Canada
| | - Claude-Edouard Chatillon
- Division of Neurosurgery, CIUSSS de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Quebec G9A 5C5, Canada
| | - François Lauzier
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma—Emergency—Critical Care Medicine), Québec City, Quebec G1V 0A6, Canada
- Department of Medicine, Université Laval, Québec City, Quebec G1V 0A6, Canada
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16
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Moore L, Thakore J, Evans D, Stelfox HT, Razek T, Kortbeek J, Watson I, Evans C, Erdogan M, Engels P, Haas B, Esmail R, Green R, Lampron J, Wiebe M, Clément J, Gezer R, McMillan J, Neveu X, Tardif PA, Coates A, Yanchar NL. Injury outcomes across Canadian trauma systems: a historical cohort study. Can J Anaesth 2023; 70:1350-1361. [PMID: 37386268 DOI: 10.1007/s12630-023-02522-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 07/01/2023] Open
Abstract
PURPOSE Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.
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Affiliation(s)
- Lynne Moore
- Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Quebec City, QC, Canada.
- Department of Social and Preventive Medicine, Enfant-Jésus Hospital, Université Laval, 1401, 18e rue, local H-012a, Quebec City, QC, G1J 1Z4, Canada.
| | - Jaimini Thakore
- Department of Surgery, The University of British Columbia, Vancouver, BC, Canada
| | - David Evans
- Department of Surgery, The University of British Columbia, Vancouver, BC, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Tarek Razek
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ian Watson
- New Brunswick Trauma Program, Saint John, NB, Canada
| | - Christopher Evans
- Kingston Health Sciences Centre, Kingston, ON, Canada
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Mete Erdogan
- Nova Scotia Health Trauma Program, Nova Scotia Health, Halifax, NS, Canada
| | - Paul Engels
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Barbara Haas
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rosmin Esmail
- Trauma Services, Foothills Medical Centre, Alberta Health Services, Calgary, AB, Canada
- Departments of Oncology and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Robert Green
- Nova Scotia Health Trauma Program, Nova Scotia Health, Halifax, NS, Canada
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Jacinthe Lampron
- Division of General Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Micheline Wiebe
- BC Trauma Registry, Provincial Health Services Authority of British Columbia, Vancouver, BC, Canada
| | - Julien Clément
- Institut National d'Excellence en Santé et en Services Sociaux, Quebec City, QC, Canada
- Department of Surgery, Université Laval, Quebec City, QC, Canada
| | - Recep Gezer
- Trauma Services BC, Provincial Health Services Authority of British Columbia, Vancouver, BC, Canada
| | - Jennifer McMillan
- BC Trauma Registry, Provincial Health Services Authority of British Columbia, Vancouver, BC, Canada
| | - Xavier Neveu
- Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Quebec City, QC, Canada
| | - Pier-Alexandre Tardif
- Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Quebec City, QC, Canada
| | - Angela Coates
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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17
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Benhamed A, Isaac CJ, Boucher V, Yadav K, Mercier E, Moore L, D'Astous M, Bernard F, Dubucs X, Gossiome A, Emond M. Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study. Eur J Emerg Med 2023; 30:271-279. [PMID: 37161755 DOI: 10.1097/mej.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | | | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Krishan Yadav
- Department of Emergency Medicine-University of Ottawa
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec
| | | | - Francis Bernard
- Services de soins intensifs, Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM)-Université de Montréal, Montréal, Québec, Canada
| | - Xavier Dubucs
- Service d'urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
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18
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Marc I, Lavoie PM, McPhee AJ, Collins CT, Simonyan D, Pronovost E, Guillot M, Gould JF, Mohamed I, Beltempo M, Boutin A, Fortier I, Sullivan TR, Moore L, Makrides M. Enteral supplementation with high-dose docosahexaenoic acid on the risk of bronchopulmonary dysplasia in very preterm infants: a collaborative study protocol for an individual participant data meta-analysis. BMJ Open 2023; 13:e076223. [PMID: 37518076 PMCID: PMC10387660 DOI: 10.1136/bmjopen-2023-076223] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION Severe bronchopulmonary dysplasia (BPD) is a well-known factor consistently associated with impaired cognitive outcomes. Regarding reported benefits on long-term neurodevelopmental outcomes, the potential adverse effects of high-dose docosahexaenoic acid (DHA) supplementation on this short-term neonatal morbidity need further investigations in infants born very preterm. This study will determine whether high-dose DHA enteral supplementation during the neonatal period is associated with the risk of severe BPD at 36 weeks' postmenstrual age (PMA) compared with control, in contemporary cohorts of preterm infants born at less than 29 weeks of gestation. METHODS AND ANALYSIS As part of an Australian-Canadian collaboration, we will conduct an individual participant data (IPD) meta-analysis of randomised controlled trials targeting infants born at less than 29 weeks of gestation and evaluating the effect of high-dose DHA enteral supplementation in the neonatal period compared with a control. Primary outcome will be severe grades of BPD (yes/no) at 36 weeks' PMA harmonised according to a recent definition that predicts early childhood morbidities. Other outcomes will be survival without severe BPD, death, BPD severity grades, serious brain injury, severe retinopathy of prematurity, patent ductus arteriosus and necrotising enterocolitis requiring surgery, sepsis, combined neonatal morbidities and growth. Severe BPD will be compared between groups using a multivariate generalised estimating equations log-binomial regression model. Subgroup analyses are planned for gestational age, sex, small-for-gestational age, presence of maternal chorioamnionitis and mode of delivery. ETHICS AND DISSEMINATION The conduct of each trial was approved by institutional research ethics boards and written informed consent was obtained from participating parents. A collaboration and data sharing agreement will be signed between participating authors and institutions. This IPD meta-analysis will document the role of DHA in nutritional management of BPD. Findings will be disseminated through conferences, media interviews and publications to peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42023431063. TRIAL REGISTRATION NUMBER NCT05915806.
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Affiliation(s)
- Isabelle Marc
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec City, Québec, Canada
| | - Pascal M Lavoie
- Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew J McPhee
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Carmel T Collins
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - David Simonyan
- Clinical and Evaluative Research Platform, CHU de Québec-Université Laval, Quebec City, Québec, Canada
| | - Etienne Pronovost
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec City, Québec, Canada
| | - Mireille Guillot
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec City, Québec, Canada
| | - Jacqueline F Gould
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine and School of Psychology, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ibrahim Mohamed
- Department of Pediatrics, Université de Montréal, Montreal, Québec, Canada
| | - Marc Beltempo
- Department of Pediatrics, McGill University Health Centre, Montreal, Québec, Canada
| | - Amélie Boutin
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec City, Québec, Canada
| | - Isabel Fortier
- Maelstrom Research, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Thomas R Sullivan
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Quebec City, Québec, Canada
| | - Maria Makrides
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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Moore L, Bérubé M, Belcaid A, Turgeon AF, Taljaard M, Fowler R, Yanchar N, Mercier É, Paquet J, Stelfox HT, Archambault P, Berthelot S, Guertin JR, Haas B, Ivers N, Grimshaw J, Lapierre A, Ouyang Y, Sykes M, Witteman H, Lessard-Bonaventure P, Gabbe B, Lauzier F. Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial. Implement Sci 2023; 18:27. [PMID: 37420284 DOI: 10.1186/s13012-023-01279-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Faculty of Nursing, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Amina Belcaid
- Institut national d'excellence en santé et services sociaux, Bd Laurier, Québec, Qc, 2535, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Robert Fowler
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, On, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, 3280 Hospital Dr. NW, Calgary, Ab, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jérôme Paquet
- Department of Surgery, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr. NW, Calgary, Al, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jason R Guertin
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, 149 College St, Toronto, On, Canada
| | - Noah Ivers
- Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4Th Floor, Toronto, On, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, Chem. de La Côte-Sainte-Catherine, Montréal, Qc, 2375, Canada
| | - Yongdong Ouyang
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Michael Sykes
- Department of Nursing, Midwifery, and Health, Northumbria University, Ellison PI, Newcastle, UK
| | - Holly Witteman
- Department of Family and Emergency Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Paule Lessard-Bonaventure
- Department of Surgery, Division of Neurosurgery, Université Laval, 1050 Av. de La Médecine, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Rd, Melbourne, Victoria, VIC 3004, Australia
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
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Giroux M, Sirois MJ, Gagnon MA, Émond M, Bérubé M, Morin M, Moore L. Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature. J Am Med Dir Assoc 2023; 24:929-936. [PMID: 37094747 DOI: 10.1016/j.jamda.2023.03.019] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/01/2023] [Accepted: 03/12/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs. DESIGN Scoping review of the scientific and gray literature. METHODS Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives. RESULTS Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy. CONCLUSION AND IMPLICATIONS Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.
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Affiliation(s)
- Marianne Giroux
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada.
| | - Marie-Josée Sirois
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada; Centre de recherche en santé durable VITAM - Centre intégré de santé et service sociaux de la capitale nationale, Quebec City, Quebec, Canada
| | - Marc-Aurèle Gagnon
- Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada
| | - Marcel Émond
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada; Centre de recherche en santé durable VITAM - Centre intégré de santé et service sociaux de la capitale nationale, Quebec City, Quebec, Canada
| | - Méanie Bérubé
- Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada; Faculty of Nursing, Université Laval, Québec City, Quebec, Canada
| | - Michèle Morin
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CISSS de Chaudière-Appalaches, Lévis, Québec, Canada
| | - Lynne Moore
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada
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21
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Gansaonré RJ, Moore L, Kobiané JF, Sié A, Haddad S. Birthweight, gestational age, and early school trajectory. BMC Public Health 2023; 23:1032. [PMID: 37259123 DOI: 10.1186/s12889-023-15913-3] [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: 12/23/2022] [Accepted: 05/17/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Birthweight and gestational age are important factors of not only newborn health by also child development and can contribute to delayed cognitive abilities. However, no study has analyzed the association of birthweight and gestational age with school trajectory measured simultaneously by school entry, grade repetition, and school dropout. This study aims, first, to analyze the association of birthweight or gestational age with school entry, and second, to explore the relationship between birthweight or gestational age and grade repetition and school dropout among children in Ouagadougou, Burkina Faso. METHODS This study used longitudinal data from the Ouagadougou Health and Demographic Surveillance System. Our samples consisted of children born between 2008 and 2014 who were at least three years old at the beginning of the 2017-18 school year. Samples included 13,676, 3152, and 3498 children for the analysis of the school entry, grade repetition, and dropout, respectively. A discrete-time survival model was used to examine the relationship between birthweight or gestational age and school entry, grade repetition, and dropout. The association between birthweight or gestational age and age at school entry were assessed using a Poisson regression. RESULTS The incidence rate of school entry was 18.1 per 100 people-years. The incidence of first repetition and dropout were 12.6 and 5.9, respectively. The probability of school entry decreased by 31% (HR:0.69, 95%CI: 0.56-0.85) and 8% (HR:0.92, 95%CI: 0.85-0.99) for children weighing less than 2000 g and those weighing between 2000 and 2499 g, respectively, compared to those born with a normal weight (weight ≥ 2500 g). The age at school entry of children with a birthweight less than 2000 g and between 2000 and 2499 g was 7% (IRR: 1.07, 95%CI: 1.06-1.08) and 3% (IRR: 1.03, 95%CI: 1.00-1.06) higher than children born at a normal birthweight, respectively. Gestational age was not associated with school entry or age at school entry. Similarly, birthweight and gestational age were not associated with grade repetition or dropout. CONCLUSION This study shows that low birthweight is negatively associated with school entry and age at school entry in Ouagadougou. Efforts to avoid low birthweights should be part of maternal and prenatal health care because the associated difficulties may be difficult to overcome later in the child's life. Further longitudinal studies are needed to better understand the relationship between development at birth and school trajectory.
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Affiliation(s)
- Rabi Joël Gansaonré
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada.
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, QC, Canada.
| | - Lynne Moore
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant- Jésus), Université Laval, Québec, QC, Canada
| | - Jean-François Kobiané
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Slim Haddad
- Direction de la Santé Publique, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Québec, QC, Canada
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, QC, Canada
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MacDougall W, Jiang X, Sobhan S, Balshaw R, Haas B, Moore L, Yanchar N, McGavock J. Severity of All-Terrain Vehicle-Related Injuries by Age in Canada, 2002-2019. JAMA Netw Open 2023; 6:e2316060. [PMID: 37256619 DOI: 10.1001/jamanetworkopen.2023.16060] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Importance Rates of pediatric hospitalizations following an injury while riding an all-terrain vehicle (ATV) are increasing. Few studies have compared the rates of severe injuries among children, adolescents, and adults. Objectives To investigate whether younger ATV riders are at risk for more severe ATV-related injuries. Design, Setting, and Participants This cross-sectional study was conducted using administrative data from hospitals in 9 provinces in Canada. Participants included patients admitted to hospitals with ATV-related injuries between 2002 and 2019. Statistical analysis was performed from June 2020 to September 2021. Exposures The primary exposure was age younger than 16 years. Comparison groups were youths aged 16 to 20 years and adults aged 21 years and older. Main Outcomes and Measures The main outcomes of interest were death, spinal cord injury, and an Injury Severity Score (ISS) greater than 25. Secondary outcomes were less severe injuries, including head injuries, crush type injuries, and fractures. Results Among 52 745 patients with complete data, 15% were youths younger than 16 years, 13% were youths aged 16 to 20 years, 82% were male, and 47% lived in rural areas. After adjusting for covariates, the odds of dying were higher among youths aged 16 to 20 years (adjusted odds ratio [aOR], 1.64; 95% CI, 1.04-2.60) compared with those younger than 16 years. Youths aged 16 to 20 years also had higher odds of spinal cord injury (aOR, 2.72; 95% CI, 1.80-4.20) and an injury severity score greater than 25 (aOR, 1.63; 95% CI, 1.36-1.96) compared with youths 16 years of age or less. Sex-specific analyses revealed these associations were greater for male youths aged 16 to 20 years (spinal cord injury: aOR, 3.81; 95% CI, 1.38-11.10, and dying in a hospital: aOR, 4.37; 95% CI, 1.19-21.02) than female youths aged 16 to 20 years. Conclusions and Relevance In this cross-sectional study of patients hospitalized for ATV injuries in Canada, youths aged 16 to 20 years and adults aged 21 years and older were at an increased risk of death and severe injuries compared with youths younger than 16 years. The increased risk of death and severe injuries was most evident among male patients.
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Affiliation(s)
- William MacDougall
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Xuejing Jiang
- George and Fay Yee Centre for Healthcare Innovation University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shamsia Sobhan
- George and Fay Yee Centre for Healthcare Innovation University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Balshaw
- George and Fay Yee Centre for Healthcare Innovation University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Barbara Haas
- Evaluative Clinical Sciences, Trauma, Emergency & Critical Care Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Universite de Laval, Quebec City, Quebec, Canada
| | - Natalie Yanchar
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan McGavock
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Mutchmore A, Lamontagne F, Chassé M, Moore L, Mayette M. Automated APACHE II and SOFA score calculation using real-world electronic medical record data in a single center. J Clin Monit Comput 2023:10.1007/s10877-023-01010-8. [PMID: 37074523 PMCID: PMC10113718 DOI: 10.1007/s10877-023-01010-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/01/2023] [Indexed: 04/20/2023]
Abstract
The integration of illness severity and organ dysfunction scores into clinical practice, including the APACHE II and SOFA scores, has been challenging due to constraints associated to manual score calculation. With electronic medical records (EMR), score calculation automation using data extraction scripts has emerged as a solution. We aimed to demonstrate that APACHE II and SOFA scores calculated with an automated EMR-based data extraction script predict important clinical endpoints. In this retrospective cohort study, every adult patient admitted to one of our three ICUs, between July 1, 2019, and December 31, 2020, were enrolled. For every patient, an automated ICU admission APACHE II score was calculated using EMR data and minimal clinician input. Fully automated daily SOFA scores were calculated for every patient. 4 794 ICU admissions met our selection criteria. Of these ICU admissions, 522 deaths were recorded (10.9% in-hospital mortality rate). The automated APACHE II was discriminant for in-hospital mortality (AU-ROC = 0.83 (95% CI 0.81-0.85)). We observed an association between the APACHE II score and ICU LOS, with a statistically significant mean increase of 1.1 days of ICU LOS (1.1 [1-1.2]; p = < .0001) for each 10 units increase in APACHE score. SOFA score curves did not discrimate significantly between survivors and non-survivors. A partially automated APACHE II score, calculated with real-world EMR data using an extraction script, is associated with in-hospital mortality risk. The automated APACHE II score could potentially constitute an acceptable surrogate of ICU acuity to be used in resource allocation and triaging, especially in time of high demand for ICU beds.
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Affiliation(s)
- Alexandre Mutchmore
- Department of Medicine, Division of Critical Care Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - François Lamontagne
- Department of Medicine, Division of Critical Care Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, 3001, 12Th Avenue N, Sherbrooke, QC, J1H 5N4, Canada
| | - Michaël Chassé
- Department of Medicine (Critical Care), University of Montreal Hospital, Montreal, Canada
- University of Montreal Hospital Research Center (CRCHUM), Montreal, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Québec City, Canada
| | - Michael Mayette
- Department of Medicine, Division of Critical Care Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada.
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, 3001, 12Th Avenue N, Sherbrooke, QC, J1H 5N4, Canada.
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24
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Marx T, Moore L, Talbot D, Guertin JR, Lachapelle P, Blais S, Singbo N, Simonyan D, Lavallée J, Zada N, Shahrigharahkoshan S, Huard B, Olivier P, Mallet M, Létourneau M, Lafrenière M, Archambault PM, Berthelot S. A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments. CAN J EMERG MED 2023; 25:394-402. [PMID: 37004679 DOI: 10.1007/s43678-023-00481-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/04/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVES Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. METHODS A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing. RESULTS The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6). CONCLUSIONS This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.
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Affiliation(s)
- Tania Marx
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Jason R Guertin
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Philippe Lachapelle
- Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada
| | - Sébastien Blais
- Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada
| | - Narcisse Singbo
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - David Simonyan
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jeanne Lavallée
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Nawid Zada
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Shaghayegh Shahrigharahkoshan
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Benoit Huard
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Pascale Olivier
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Myriam Mallet
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Mélanie Létourneau
- Clinical and Organizational Performance Department of the CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Patrick M Archambault
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- VITAM - Centre de Recherche en Santé Durable, Université Laval, Québec, QC, Canada
| | - Simon Berthelot
- Axe Santé des Populations et Pratiques Optimales en Sante, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada.
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Canitrot E, Turgeon AF, Moore L, Diendéré E, St-Onge M. Effect of Taste Additives on the Palatability of Activated Charcoal: a Systematic Review. J Med Toxicol 2023:10.1007/s13181-023-00934-6. [PMID: 37000410 DOI: 10.1007/s13181-023-00934-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 04/01/2023] Open
Abstract
INTRODUCTION Activated charcoal is a decontaminating agent used for acute intoxication. It can be mixed with taste additives to overcome its poor palatability. Our purpose was to evaluate the taste additives used to improve activated charcoal's palatability. METHODS We conducted a systematic review of comparative studies on taste additives used to improve activated charcoal's palatability. We searched PubMed, Embase, Web of Science, Cochrane, and CINAHL. We included controlled trials and observational studies that evaluate the effect of at least one taste additive, compared with activated charcoal alone. Our primary outcome was palatability. Our secondary outcomes included treatment adherence, adsorption efficacy, and adverse events. The risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies. RESULTS Among 38 eligible articles, seven observational studies and three crossover clinical trials met our inclusion criteria. The risk of bias was found to be high for seven studies and intermediate for three others. The preferred flavoring agents were cola and chocolate milk for children, and sweetening agents for adults. All taste additives studied seemed to improve activated charcoal's palatability, except for yogurt (n = 1). The addition of bentonite, sorbitol, carboxymethylcellulose, or yogurt showed no impact on the in-vivo adsorption capacity of activated charcoal, whereas the results were inconclusive for chocolate. No meta-analysis was performed due to insufficient data. CONCLUSION Strategies to improve activated charcoal's palatability seem to enhance the taste. Descriptive data are in favor of a limited impact on activated charcoal's adsorption capacity when adding binding agents or sweeteners. TRIAL REGISTRATION ON PROSPERO This review is registered as PROSPERO CRD42019135092.
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Affiliation(s)
- Elisabeth Canitrot
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada.
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada.
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada
| | - Ella Diendéré
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada
- VITAM, Research Center in Sustainable Health, CIUSSS de la Capitale-Nationale, Québec, Québec City, Canada
| | - Maude St-Onge
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
- Centre Antipoison du Québec, CIUSSS de la Capitale Nationale, Québec, Québec City, Canada
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Mercier É, Nadeau A, Le Sage N, Moore L, Malo C, Blanchard PG, Fleet R, Émond M. A Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions to assess the accuracy of prehospital trauma triage protocols: a modified Delphi study. Can J Surg 2023; 66:E181-E188. [PMID: 37001975 PMCID: PMC10069413 DOI: 10.1503/cjs.019920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Injury severity scales have traditionally been used to assess the performance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area. METHODS Based on a list of potential participants we obtained using data on training, experience, geographic location, affiliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round. RESULTS Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained. CONCLUSION We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools.
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Affiliation(s)
- Éric Mercier
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Alexandra Nadeau
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Natalie Le Sage
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Lynne Moore
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Christian Malo
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Pierre-Gilles Blanchard
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Richard Fleet
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
| | - Marcel Émond
- From VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Que. (Mercier, Nadeau, Le Sage, Blanchard, Fleet, Émond); the Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Nadeau, Moore, Malo); the Département de médecine d'urgence, CHU de Québec, Québec, Que. (Mercier, Le Sage, Malo, Blanchard, Émond); and the Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, Que. (Moore)
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Beaumont-Boileau R, Nadeau A, Tardif PA, Malo C, Emond M, Moore L, Clément J, Mercier E. Performance of a provincial prehospital trauma triage protocol: A retrospective audit. Trauma 2023. [DOI: 10.1177/14604086231156263] [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] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Objective To assess the accuracy of a five-step prehospital trauma triage protocol ( Échelle québécoise de triage préhospitalier en traumatologie (EQTPT)) to identify patients requiring urgent and specialized in-hospital trauma care in the Capitale-Nationale region – Québec. Methods The medical records of trauma patients transported by ambulance to one of the five participating emergency departments (EDs) between November 2016 and March 2017 were reviewed. Our primary outcome was the need for one of the following urgent and specialized trauma care: endotracheal intubation in the ED, administration of ≥ 2 blood products in the ED, angioembolization or surgery (excluding single limb surgery) < 24 h and admission to the intensive care unit (ICU) or in-hospital trauma-related death. Results A total of 902 patients were included. The median age was 63 (interquartile range (IQR) 51) and 494 (54.8%) were female. The main trauma mechanism was falls (n = 592), followed by motor vehicle accidents (n = 201). Eighty-two (9.1%) patients required at least one urgent and specialized trauma care. Of those, 44 (53.6%) were identified as requiring transport to a level one trauma centre (steps 1–3), 16 were identified as requiring transport to a centre with a lower level of trauma designation (steps 4–5) while 22 (26.8%) did not meet any of the EQTPT criteria. For steps 1 to 3, the sensitivity was 53.7% (95% confidence interval (CI) 42.9–64.4) and the specificity was 81.7% (95% CI 79.1–84.4) in identifying patients requiring specialized trauma care. Conclusion The EQTPT lacked sensitivity and was poorly specific to identify trauma patients who need specialized in-hospital trauma care.
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Affiliation(s)
- Roxane Beaumont-Boileau
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Alexandra Nadeau
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Pier-Alexandre Tardif
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Christian Malo
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Marcel Emond
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Lynne Moore
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Julien Clément
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
- Département de Chirurgie, CHU de Québec, Québec, Canada
| | - Eric Mercier
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
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Marc I, Boutin A, Pronovost E, Perez Herrera NM, Guillot M, Bergeron F, Moore L, Sullivan TR, Lavoie PM, Makrides M. Association Between Enteral Supplementation With High-Dose Docosahexaenoic Acid and Risk of Bronchopulmonary Dysplasia in Preterm Infants: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e233934. [PMID: 36943265 PMCID: PMC10031388 DOI: 10.1001/jamanetworkopen.2023.3934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
IMPORTANCE High-dose docosahexaenoic acid (DHA), a long-chain polyunsaturated fatty acid, may affect the risk of bronchopulmonary dysplasia (BPD). However, high-level summative evidence supporting such clinical association in very preterm infants is lacking. OBJECTIVE To examine the association between enteral supplementation with high-dose DHA during the neonatal period and the risk of BPD in preterm infants born at less than 29 weeks' gestation. DATA SOURCES PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, medRxiv, and ClinicalTrials.gov were searched from inception to August 1, 2022, for eligible articles with no language restrictions. STUDY SELECTION Randomized clinical trials (RCTs) were eligible for inclusion (1) if their interventions involved direct administration of a minimum DHA supplementation of 40 mg/kg/d or breast milk or formula feeding of at least 0.4% of total fatty acids, and (2) if they reported data on either BPD, death, BPD severity, or a combined outcome of BPD and death. DATA EXTRACTION AND SYNTHESIS Two investigators completed independent review of titles and abstracts, full text screening, data extraction, and quality assessment using the Cochrane Risk of Bias 2.0. Risk ratios (RRs) with 95% CIs were pooled using random-effect meta-analyses. MAIN OUTCOMES AND MEASURES Primary outcome was BPD using trial-specific definitions, which was further stratified for RCTs that used a more stringent BPD definition based on systematic pulse oximetry assessment at 36 weeks' postmenstrual age. Other outcomes were BPD, death, BPD severity, or combined BPD and death. RESULTS Among the 2760 studies screened, 4 RCTs were included, which involved 2304 infants (1223 boys [53.1%]; mean [SD] gestational age, 26.5 [1.6] weeks). Enteral supplementation with high-dose DHA was associated with neither BPD (4 studies [n = 2186 infants]; RR, 1.07 [95% CI, 0.86-1.34]; P = .53; I2 = 72%) nor BPD or death (4 studies [n = 2299 infants]; RR, 1.04 [95% CI, 0.91-1.18]; P = .59; I2 = 61%). However, an inverse association with BPD was found in RCTs that used a more stringent BPD definition (2 studies [n = 1686 infants]; RR, 1.20 [95% CI, 1.01-1.42]; P = .04; I2 = 48%). Additionally, DHA was inversely associated with moderate-to-severe BPD (3 studies [n = 1892 infants]; RR, 1.16 [95% CI, 1.04-1.29]; P = .008; I2 = 0%). CONCLUSIONS AND RELEVANCE Results of this study showed that enteral supplementation with high-dose DHA in the neonatal period was not associated overall with BPD, but an inverse association was found in the included RCTs that used a more stringent BPD definition. These findings suggest that high-dose DHA supplementation should not be recommended to prevent BPD in very preterm infants.
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Affiliation(s)
- Isabelle Marc
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
| | - Amélie Boutin
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
| | - Etienne Pronovost
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
| | - Norma Maria Perez Herrera
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
| | - Mireille Guillot
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
| | | | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, Québec, Canada
| | - Thomas R Sullivan
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Pascal M Lavoie
- Department of Pediatrics, Division of Neonatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maria Makrides
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Bouderba S, Lecky F, Soltana K, Neveu X, Kumar DS, Bouamra O, Coats TJ, Tardif PA, Belcaid A, Gonthier C, Moore L. Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada. Can J Surg 2023; 66:E32-E41. [PMID: 36653031 PMCID: PMC9854907 DOI: 10.1503/cjs.001822] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 04/28/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. METHODS We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. RESULTS The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. "scoop and run" in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09-1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries. CONCLUSION We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.
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Affiliation(s)
- Samy Bouderba
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Fiona Lecky
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Kahina Soltana
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Xavier Neveu
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Dhushy Surendra Kumar
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Omar Bouamra
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Timothy J Coats
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Pier-Alexandre Tardif
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Amina Belcaid
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Catherine Gonthier
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
| | - Lynne Moore
- From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Quebec - Université Laval, Hôpital de l'Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Bérubé M, Côté C, Moore L, Turgeon AF, Belzile ÉL, Richard-Denis A, Dale CM, Berry G, Choinière M, Pagé GM, Guénette L, Dupuis S, Tremblay L, Turcotte V, Martel MO, Chatillon CÉ, Perreault K, Lauzier F. Strategies to prevent long-term opioid use following trauma: a Canadian practice survey. Can J Anaesth 2023; 70:87-99. [PMID: 36163458 PMCID: PMC9513000 DOI: 10.1007/s12630-022-02328-8] [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] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/10/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Practices Research Unit Research Unit (Trauma - Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC, G1V 1Z4, Canada. .,Faculty of Nursing, Université Laval, Quebec City, QC, Canada. .,Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - Caroline Côté
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Faculty of Nursing, Université Laval, Quebec City, QC Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Department of Social Preventive Medicine, Université Laval, Quebec City, QC Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada
| | - Étienne L. Belzile
- Division of Orthopedic Surgery, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC Canada
| | - Andréane Richard-Denis
- Department of Medicine, Université de Montréal, Montreal, Quebec Canada ,Research Centre of the CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON Canada ,University of Toronto Centre for the Study of Pain (UTCSP), Toronto, ON Canada
| | - Gregory Berry
- Department of Orthopaedic Surgery, McGill University Health Centre, Montreal, QC Canada
| | - Manon Choinière
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Gabrielle M. Pagé
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Line Guénette
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Pharmacy, Université Laval, Quebec City, QC Canada
| | - Sébastien Dupuis
- Department of Pharmacy, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Lorraine Tremblay
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Valérie Turcotte
- Department of Nursing, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Marc-Olivier Martel
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Medicine & Dentistry, McGill University, Montreal, QC Canada
| | - Claude-Édouard Chatillon
- Division of Neurosurgery, CIUSSS de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, QC Canada
| | - Kadija Perreault
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), CIUSSS de la Capitale-Nationale, Quebec City, QC Canada
| | - François Lauzier
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada ,Department of Medicine, Université Laval, Quebec City, QC Canada
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31
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Benhamed A, Batomen B, Boucher V, Yadav K, Mercier É, Isaac CJ, Bérubé M, Bernard F, Chauny JM, Moore L, Sirois MJ, Tazarourte K, Gossiome A, Émond M. Epidemiology, injury pattern and outcome of older trauma patients: A 15-year study of level-I trauma centers. PLoS One 2023; 18:e0280345. [PMID: 36716316 PMCID: PMC9886263 DOI: 10.1371/journal.pone.0280345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/26/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients. METHODS A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes. RESULTS A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively). CONCLUSIONS Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.
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Affiliation(s)
- Axel Benhamed
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, QC, Canada
- Hospices Civils de Lyon, Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, France
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Brice Batomen
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Dalla Lana school of public health, University of Toronto, Toronto, Ontario, Canada
| | - Valérie Boucher
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Éric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Mélanie Bérubé
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Faculty of Nursing, Université Laval, Québec, QC, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, Canada
| | - Jean- Marc Chauny
- Department of Emergency Medicine, Research Center, CIUSSS-Nord-de-l’Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, QC, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, QC, Canada
| | - Marie Josée Sirois
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Karim Tazarourte
- Hospices Civils de Lyon, Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, France
- Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Amaury Gossiome
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Hospices Civils de Lyon, Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, France
| | - Marcel Émond
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, QC, Canada
- * E-mail:
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Abernathy S, Moore L, Morales M. PATIENT CHARACTERISTICS AND RESPONSE TO BIOLOGIC THERAPIES IN MODERATE-TO-SEVERE PEDIATRIC ASTHMA. Ann Allergy Asthma Immunol 2022. [DOI: 10.1016/j.anai.2022.08.644] [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: 11/11/2022]
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Marc I, Boutin A, Pronovost E, Guillot M, Bergeron F, Moore L, Makrides M. High doses of enteral docosahexaenoic acid omega-3 supplementation for prevention of bronchopulmonary dysplasia in very preterm infants: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e064515. [PMID: 36253040 PMCID: PMC9577938 DOI: 10.1136/bmjopen-2022-064515] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Docosahexaenoic acid (DHA) supplementation in the neonatal period has been proposed to prevent bronchopulmonary dysplasia (BPD) in very preterm infants. We aim to determine the effects of an enteral supplementation with high doses of DHA on the risk for BPD at 36 weeks' postmenstrual age (PMA) in very preterm infants born less than 29 weeks' gestation compared with a control. METHODS AND ANALYSIS We will conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) searching PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, MedRxiv, ClinicalTrials.gov (up to 1 November 2021) as well as reference lists and citations of included articles and previous reviews. RCTs targeting infants born less than 29 weeks' gestation and evaluating the effect of high doses of DHA enteral supplementation in the neonatal period compared with a control will be eligible. Primary outcome will be BPD defined as the need for oxygen and/or ventilation at 36 weeks' PMA. Two authors will independently screen for inclusion, extract data and assess data quality using the Cochrane instrument (risk-of-bias tool 2.0). We will perform meta-analysis using random effects models. Prespecified subgroup analyses are planned for the infant gestational age and sex, the marine source of DHA, mode of administration and duration of exposure. Sensitivity analysis will be performed according to the accuracy of the BPD definition (ie, physiological definition) and according to the risk of bias of the RCTs. ETHICS AND DISSEMINATION This protocol for a systematic review and meta-analysis does not require ethics approval, as no primary data are collected. This study will assess the effectiveness of high doses of enteral DHA supplementation on BPD and provide evidence to clinicians and families for decision-making. Findings will be disseminated through conferences, media interviews and publications to peer review journals. PROSPERO REGISTRATION NUMBER CRD42021286705.
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Affiliation(s)
- Isabelle Marc
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Amélie Boutin
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Etienne Pronovost
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Mireille Guillot
- Department of Pediatrics, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Frédéric Bergeron
- Department of Consulting Services, Library, Université Laval, Quebec, Quebec, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Quebec, Quebec, Canada
| | - Maria Makrides
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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34
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Turgeon AF, Fergusson DA, Clayton L, Patton MP, Zarychanski R, English S, Docherty A, Walsh T, Griesdale D, Kramer AH, Scales D, Burns KEA, Boyd JG, Marshall JC, Kutsogiannis DJ, Ball I, Hébert PC, Lamontagne F, Costerousse O, St-Onge M, Lessard Bonaventure P, Moore L, Neveu X, Rigamonti A, Khwaja K, Green RS, Laroche V, Fox-Robichaud A, Lauzier F. Haemoglobin transfusion threshold in traumatic brain injury optimisation (HEMOTION): a multicentre, randomised, clinical trial protocol. BMJ Open 2022; 12:e067117. [PMID: 36216432 PMCID: PMC9557781 DOI: 10.1136/bmjopen-2022-067117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the leading cause of mortality and long-term disability in young adults. Despite the high prevalence of anaemia and red blood cell transfusion in patients with TBI, the optimal haemoglobin (Hb) transfusion threshold is unknown. We undertook a randomised trial to evaluate whether a liberal transfusion strategy improves clinical outcomes compared with a restrictive strategy. METHODS AND ANALYSIS HEMOglobin Transfusion Threshold in Traumatic Brain Injury OptimizatiON is an international pragmatic randomised open label blinded-endpoint clinical trial. We will include 742 adult patients admitted to an intensive care unit (ICU) with an acute moderate or severe blunt TBI (Glasgow Coma Scale ≤12) and a Hb level ≤100 g/L. Patients are randomly allocated using a 1:1 ratio, stratified by site, to a liberal (triggered by Hb ≤100 g/L) or a restrictive (triggered by Hb ≤70 g/L) transfusion strategy applied from the time of randomisation to the decision to withdraw life-sustaining therapies, ICU discharge or death. Primary and secondary outcomes are assessed centrally by trained research personnel blinded to the intervention. The primary outcome is the Glasgow Outcome Scale extended at 6 months. Secondary outcomes include overall functional independence measure, overall quality of life (EuroQoL 5-Dimension 5-Level; EQ-5D-5L), TBI-specific quality of life (Quality of Life after Brain Injury; QOLIBRI), depression (Patient Health Questionnaire; PHQ-9) and mortality. ETHICS AND DISSEMINATION This trial is approved by the CHU de Québec-Université Laval research ethics board (MP-20-2018-3706) and ethic boards at all participating sites. Our results will be published and shared with relevant organisations and healthcare professionals. TRIAL REGISTRATION NUMBER NCT03260478.
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Affiliation(s)
- Alexis F Turgeon
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lucy Clayton
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Centre de Recherche du CHU Sainte-Justine, Montréal, Québec, Canada
| | - Marie-Pier Patton
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Hematology/Oncology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Shane English
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Annemarie Docherty
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Center for Clinical Epidemiology & Evaluation, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Andreas H Kramer
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Damon Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Gordon Boyd
- Department of Medicine, Division of Neurology, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Division of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Ian Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Paul C Hébert
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Centre de Recherche du CHU de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Olivier Costerousse
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Maude St-Onge
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Paule Lessard Bonaventure
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec City, Québec, Canada
| | - Xavier Neveu
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
| | - Andrea Rigamonti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kosar Khwaja
- Department of Critical Care Medicine, McGill University, Montréal, Québec, Canada
| | - Robert S Green
- Departments of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vincent Laroche
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Francois Lauzier
- Population Health and Optimal Practices Research Unit (Trauma- Emergency-Critical Care Medicine), CHU de Québec-Universite Laval Research Center, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- Department of Medicine, Université Laval, Québec City, Québec, Canada
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Duval C, Sirois C, Savoie-White FH, Tardif PA, Bérubé M, Turgeon AF, Cook DJ, Lauzier F, Moore L. Effect of Intermittent Pneumatic Compression in Addition to Pharmacologic Prophylaxis for Thromboprophylaxis in Hospitalized Adult Patients: A Systematic Review and Meta-Analysis. Crit Care Explor 2022; 4:e0769. [PMID: 36212735 PMCID: PMC9532044 DOI: 10.1097/cce.0000000000000769] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Venous thromboembolic events (VTE) are frequent complications in hospitalized patients and a leading cause of preventable death in hospital. Pharmacologic prophylaxis is a standard of care to prevent VTE in patients at risk, the additional value of intermittent pneumatic compression (IPC) is uncertain. We aimed to evaluate the efficacy of adding IPC to pharmacologic prophylaxis to prevent VTE in hospitalized adults. DATA SOURCES We searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the International Clinical Trials Registry Platform from inception to July 2022. STUDY SELECTION We included randomized controlled trials comparing the use of IPC in addition to pharmacological thromboprophylaxis to pharmacological thromboprophylaxis alone in hospitalized adults. DATA EXTRACTION Meta-analyses were performed to calculate risk ratio (RR) of VTE, deep venous thrombosis (DVT), and pulmonary embolism (PE). We assessed the risk of bias using the Cochrane Risk of Bias Tool for Randomized Trials, Version 2 and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS We included 17 trials enrolling 8,796 participants. The IPC was mostly applied up to the thigh and pharmacological thromboprophylaxis was primarily low-molecular-weight heparin. Adjunctive IPC was associated with a decreased risk of VTE (15 trials, RR = 0.53; 95% CI [0.35-0.81]) and DVT (14 trials, RR = 0.52; 95% CI [0.33-0.81]) but not PE (seven trials, RR = 0.73; 95% CI [0.32-1.68]). The quality of evidence was graded low, downgraded by risk of bias and inconsistency. Moderate and very low-quality evidence, respectively, suggests that adjunctive IPC is unlikely to change the risk of all-cause mortality or adverse events. Subgroup analyses indicate a more evident apparent benefit in industry-funded trials. CONCLUSIONS Results indicate low-quality evidence underpinning the additional use of IPC to pharmacological thromboprophylaxis for prevention of VTE and DVT. Further large high-quality randomized trials are warranted to support its use and to identify patient subgroups for whom it could be beneficial.
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Affiliation(s)
- Cécile Duval
- Department of Social and Preventative Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Quebec City, QC, Canada
- Centre of Excellence on Aging of Quebec, VITAM Research Centre on Sustainable Health, Quebec City, QC, Canada
| | - Félix H Savoie-White
- Department of Social and Preventative Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
- Faculty of Nursing, Université Laval, Quebec City, QC, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Deborah J Cook
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, QC, Canada
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Le Sage N, Chauny JM, Berthelot S, Archambault P, Neveu X, Moore L, Boucher V, Frenette J, De Guise É, Ouellet MC, Lee J, McRae AD, Lang E, Émond M, Mercier É, Tardif PA, Swaine B, Cameron P, Perry JJ. Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury. J Neurotrauma 2022; 39:1349-1362. [PMID: 35765917 PMCID: PMC9529302 DOI: 10.1089/neu.2022.0026] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.
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Affiliation(s)
- Natalie Le Sage
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
- VITAM-Centre de recherche en santé durable, Université Laval, Québec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Université de Montréal, Quebec, Canada
| | - Simon Berthelot
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Patrick Archambault
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Xavier Neveu
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Jérôme Frenette
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Élaine De Guise
- Department of Emergency Medicine, McGill University, Québec, Canada
| | | | - Jacques Lee
- Department of Emergency Medicine, University of Toronto, Ontario, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Alberta, Canada
| | - Marcel Émond
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Éric Mercier
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | | | - Bonnie Swaine
- Department of Emergency Medicine, Université de Montréal, Quebec, Canada
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Jeffrey J. Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ontario, Canada
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Moore L, Bérubé M, Tardif PA, Lauzier F, Turgeon A, Cameron P, Champion H, Yanchar N, Lecky F, Kortbeek J, Evans D, Mercier É, Archambault P, Lamontagne F, Gabbe B, Paquet J, Razek T, Belcaid A, Berthelot S, Malo C, Lang E, Stelfox HT. Validation of Quality Indicators Targeting Low-Value Trauma Care. JAMA Surg 2022; 157:2796291. [PMID: 36103195 PMCID: PMC9475433 DOI: 10.1001/jamasurg.2022.3912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/18/2022] [Indexed: 09/16/2023]
Abstract
Importance Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. Objective To assess the validity of quality indicators on low-value trauma care using trauma registry data. Design, Setting, and Participants Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. Main Outcomes and Measures Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). Results The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. Conclusions and Relevance This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Trauma Audit and Research Network, Salford, United Kingdom
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Transfert des Connaissances et Évaluation des Technologies et Modes d’Intervention en Santé, Centre de Recherche du CHU de Québec, Hôpital St François d’Assise, Université Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jérôme Paquet
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, Québec, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Québec, Canada
| | - Amina Belcaid
- Institut National d’Excellence en Santé et Services Sociaux, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Christian Malo
- Département de Médicine Familiale et de Médicine d’urgence, Faculté de Médecine, Université Laval, Québec City, Québec, Canada
| | - Eddy Lang
- University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Abiala G, Bérubé M, Mercier É, Yanchar N, Stelfox HT, Archambault P, Bourgeois G, Belcaid A, Neveu X, Isaac CJ, Clément J, Lamontagne F, Moore L. Pre- and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study. Acad Emerg Med 2022; 29:1084-1095. [PMID: 35612384 DOI: 10.1111/acem.14536] [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: 01/12/2022] [Revised: 05/03/2022] [Accepted: 05/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multiple clinical practice guidelines recommend minimizing radiation in trauma patients but there is a knowledge gap on the importance of this problem for trauma transfers. We aimed to estimate the incidence of pretransfer and repeat posttransfer computed tomography (CT) overall and in patients with an indication for immediate transfer, to assess interhospital practice variation, to identify predictors, and to quantify the influence of pretransfer CT on time to transfer. Methods We conducted a retrospective multicenter cohort study on patients transferred to major trauma centers from 2013 to 2019. Multilevel generalized linear regression was used to generate intraclass correlation coefficients (ICCs) to assess interhospital variation, multilevel logistic regression to generate odds ratios for each predictor, and geometric mean ratios to quantify the influence of CT on time to transfer. Results Of 18,244 patients included, 8501 (47%) had a pretransfer CT and one-quarter (26%) had a repeat posttransfer CT. Interhospital variation was moderate for pretransfer CT (5%-66%, ICC 12.5%) and for repeat posttransfer CT (7%-44%, ICC 14.7%). Pretransfer imaging was more frequent in elders and in males and repeat posttransfer imaging decreased over the study period but was more frequent in patients transferred in from Level III/IV centers than nondesignated hospitals. Time to transfer was doubled in patients who had a pretransfer CT. CONCLUSIONS Results suggest that pretransfer CT and repeat posttransfer CT are frequent and are subject to significant practice variation. In addition, pretransfer CT is associated with increased times to transfer though additional studies are needed to demonstrate causation. These results highlight potential opportunities to reduce low-value imaging for trauma transfers.
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Affiliation(s)
- Godwill Abiala
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada.,Department of Social and Preventive Medicine, Laval University, Québec, Québec, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada
| | - Éric Mercier
- Department of Family Medicine and Emergency Medicine, Laval University, Québec City, Québec, Canada
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - H Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences (HTS), Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Laval University, Québec City, Québec, Canada.,Centre de recherche intégré pour un système apprenant en santé et en services sociaux Lévis, Lévis, Québec, Canada.,VITAM-Centre de recherche en santé durable, Québec City, Québec, Canada
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Québec City, Québec, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et en Services Sociaux, Québec City, Québec, Canada
| | - Xavier Neveu
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada
| | - Chartelin J Isaac
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada.,Department of Social and Preventive Medicine, Laval University, Québec, Québec, Canada
| | - Julien Clément
- Department of Surgery, University Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, Centre de Recherche du CHU de Québec, Laval University (Hôpital de l'Enfant-Jésus), Laval University, Québec, Québec, Canada.,Department of Social and Preventive Medicine, Laval University, Québec, Québec, Canada
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Mansour T, Beck B, Gabbe B, Farhat I, Belcaid A, Neveu X, Moore L. International comparison of injury care structures, processes, and outcomes between integrated trauma systems in Québec, Canada, and Victoria, Australia. Injury 2022; 53:2907-2914. [PMID: 35688707 DOI: 10.1016/j.injury.2022.06.001] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Quality improvement activities in trauma systems are widely based on comparisons between trauma centers within the same system. Comparisons across different trauma systems may reveal further opportunities for quality improvement. OBJECTIVES This study aimed to compare the integrated trauma systems in Québec, Canada and in Victoria, Australia, regarding their structures, care processes and patient outcomes. METHODOLOGY The elements recommended by the American College of Surgeons were used to compare trauma systems structures. Comparisons of care processes and patient outcomes were based on data from major trauma admissions extracted from trauma registries (2013 and 2017). Care processes included time to reach a definitive care facility, time spent in the emergency department, and time lapsed before the first head computed tomography (CT) scan. These care processes were compared using a z-test of log-transformed times. Hospital mortality and hospital length of stay (LOS) were compared using indirect standardization based on multiple logistic and linear regression. RESULTS Major differences in trauma system structure were Advanced Trauma Life Support at the scene of injury (Victoria), the use of validated prehospital triage tools (Québec), and mandatory accreditation of all trauma centers (Québec). Patients in Québec arrived at their definitive care hospital earlier than their counterparts in Victoria (median: 1.93 vs. 2.13 h, p = 0.002), but spent longer in the emergency department (median: 8.23 vs. 5.15 h, p<0.0001) and waited longer before having their first head CT (median: 1.90 vs. 1.52 h, p<0.0001). In-hospital mortality and hospital LOS were higher in Québec than in Victoria (standardized mortality ratio: 1.15, 95% CI: 1.09 - 1.20; standardized LOS ratio: 1.10, 95% CI: 1.09 - 1.11). CONCLUSION We observed important differences in the structural components and care processes in Québec and Victoria's trauma systems, which might explain some of the observed differences in patient outcomes. This study shows the potential value of international comparisons in trauma care and identifies possible opportunities for quality improvement.
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Affiliation(s)
- Thowiba Mansour
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada; Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Imen Farhat
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Québec, QC, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et en Services Sociaux (INESSS), Québec, QC, Canada
| | - Xavier Neveu
- Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada; Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada.
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Duval C, Sirois C, Savoie-White F, Tardif P, Bérubé M, Turgeon-Fournier A, Cook D, Lauzier F, Moore L. 83 - Compression pneumatique intermittente adjuvante : revue systématique et méta-analyse. Rev Epidemiol Sante Publique 2022. [DOI: 10.1016/j.respe.2022.06.096] [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: 11/30/2022] Open
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Berthelot S, Mallet M, Blais S, Moore L, Guertin JR, Boulet J, Boilard C, Fortier C, Huard B, Mokhtari A, Lesage A, Lévesque É, Baril L, Olivier P, Vachon K, Yip O, Bouchard M, Simonyan D, Létourneau M, Pineault A, Vézo A, Stelfox HT. Adaptation of time‐driven activity‐based costing to the evaluation of the efficiency of ambulatory care provided in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12778. [PMID: 35865131 PMCID: PMC9292471 DOI: 10.1002/emp2.12778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/20/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives The aim of this study was: (1) to adapt the time‐driven activity‐based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time. Methods TDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015–2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field. Results Overall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals. Conclusions The greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated‐time‐based and measured‐time‐based costing. TDABC should be applied using objective measurement of the time per procedure.
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Affiliation(s)
- Simon Berthelot
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine familiale et de médecine d'urgence Faculté de médecine Québec Canada
| | | | | | - Lynne Moore
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine sociale et préventive Faculté de médecine Université Laval Québec Canada
| | - Jason R. Guertin
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine sociale et préventive Faculté de médecine Université Laval Québec Canada
| | | | | | | | | | | | | | | | - Laurence Baril
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine familiale et de médecine d'urgence Faculté de médecine Québec Canada
| | | | | | - Olivia Yip
- CHU de Québec‐Université Laval Québec Canada
| | | | | | | | | | - Adrien Vézo
- CHU de Québec‐Université Laval Québec Canada
| | - Henry T. Stelfox
- Department of Critical Care and the O'Brien Institute for Public Health McCaig Tower University of Calgary Calgary Alberta Canada
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Coulombe P, Tardif PA, Nadeau A, Beaumont-Boileau R, Malo C, Emond M, Blanchard PG, Moore L, Mercier E. Accuracy of Prehospital Trauma Triage to Select Older Adults Requiring Urgent and Specialized Trauma Care. J Surg Res 2022; 275:281-290. [DOI: 10.1016/j.jss.2022.02.037] [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] [Received: 07/26/2021] [Revised: 01/12/2022] [Accepted: 02/12/2022] [Indexed: 10/18/2022]
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Campbell A, Smith R, Petersen B, Moore L, Khan A, Barrie A. O-125 Application of artificial intelligence using big data to devise and train a machine learning model on over 63,000 human embryos to automate time-lapse embryo annotation. Hum Reprod 2022. [DOI: 10.1093/humrep/deac105.025] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
Can a machine learning (ML) model, developed using modern neural network architecture produce comparable annotation data; utilisable for algorithmic outcome prediction, to manual time-lapse annotations?
Summary answer
The model automatically annotated unseen embryos with comparable results to manual methods, generating morphokinetic data to enable comparably predictive outputs from an embryo selection algorithm.
What is known already
The application of artificial intelligence across healthcare industries, including fertility, is increasing. Several ML models are available that seek to generate or analyse embryo images and morphokinetic data, and to determine embryo viability potential. Along with photographic images, the use of time-lapse in IVF laboratories has amassed numeric data, resulting predominantly from annotated manual assessment of images over time. Embryo annotation practice is variable in quality, can be subjective and is time-consuming; commonly taking several minutes per embryo. The development of rapid, accurate automatic annotation would represent a significant time-saving as well as an increase in reproducibility and accuracy.
Study design, size, duration
Multicentre quality assured annotation data from 63,383 time-lapse monitored embryos (EmbryoScope®), comprising over 400 million individual images, were used to train a ML model to automatically generate morphokinetic annotations. Data was derived from 8 UK clinics within a cohesive group between 2012-2021. Accuracy was assessed using 900 unseen embryos (with live birth outcome) by comparing the output of an established in-house, prospectively validated embryo selection model when the input was either ML-automated, or manual annotations.
Participants/materials, setting, methods
Multi-focal plane images were processed on the Azure cloud (Microsoft) and resampled to 300x300 pixels. A Laplacian-based focal stacking algorithm merged frames into a single image. The model consisted of an EfficientNetB4 Convolutional Neural Network classifier to extract features and classify the stage of embryo images. A Temporal Convolutional Network interpreted a time-series of image features; producing annotations from pronuclear fading through to blastocyst. Soft localisation loss function used QA data to integrate annotation subjectivities.
Main results and the role of chance
The ML model rapidly and automatically generated annotations. Efficacy and comparability of the ML model to automate reliable, utilisable annotations was demonstrated by comparison with manual annotation data and the ML model’s ability to auto-generate annotations which could be used to predict live birth by providing annotation data to an established, validated in house embryo selection model. Live birth-predictive capability was measured, and benchmarked against manual annotation, using the area under the receiver operating characteristic curve (AUC).
When tested on time-lapse images, collected from pronuclear fading to full blastulation, representing 900 previously unseen, transferred blastocysts where live birth outcomes were blinded, the in-house developed auto-annotation ML model resulted in an AUC of 0.686 compared with 0.661 for manual annotations, for live birth prediction.
Auto annotation using the developed model took only milliseconds to complete per embryo. The developed auto-annotation model, built and tested on large data, is considered suitable for productionisation with the aim of being validated and integrated into an application to support IVF laboratory practice.
Limitations, reasons for caution
Whilst this model was trained to recognise key morphokinetic events, there are other morphokinetic variables that may be useful in the prediction of live birth and further improve embryo selection, or deselection, ability. Akin to manual interpretation, some embryos may fail to be annotated or need second opinion.
Wider implications of the findings
There is increasing evidence supporting the application of ML to utilise big data from time-lapse imaging and fertility care generally. Whilst promising benefits to IVF clinics and patients, responsible use of data is required alongside large high-quality datasets, and rigorous validation, to ensure safe and robust applications.
Trial registration number
N/A
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Affiliation(s)
- A Campbell
- CARE Fertility Group , Embryology, Nottingham, United Kingdom
| | - R Smith
- CARE Fertility Group , Embryology, Nottingham, United Kingdom
| | - B Petersen
- BMP Analytics, Mathematics , Aarhus, Denmark
| | - L Moore
- BJSS, Data Science , Leeds, United Kingdom
| | - A Khan
- BJSS, Data Science , Leeds, United Kingdom
| | - A Barrie
- CARE Fertility Group , Embryology, Nottingham, United Kingdom
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Donnez J, Taylor H, Gemzell-Danielsson K, Catherino W, Bestel E, Gotteland J, Humberstone A, Moore L, Garner E. O-306 LINZAGOLIX FOR ENDOMETRIOSIS-ASSOCIATED PAIN: SAFETY RESULTS FROM EDELWEISS 3, A PHASE 3, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL. Hum Reprod 2022. [DOI: 10.1093/humrep/deac105.103] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
Is once-daily linzagolix treatment for women with moderate to severe endometriosis-associated pain (EAP) safe for use for up to 6 months of treatment?
Summary answer
Both doses of linzagolix were well-tolerated with minimal BMD decrease and few TEAEs >5% in either linzagolix arm.
What is known already
Linzagolix (LGX) is an investigational once-daily oral GnRH receptor antagonist that reduces serum estradiol in a dose-dependent manner and is being developed in two dosages for the treatment of endometriosis-associated pain (EAP): 75 mg, and 200 mg dose with hormonal add-back therapy (ABT).
Study design, size, duration
EDELWEISS 3 is a randomized, double-blind, placebo-controlled, multicenter Phase 3 trial of linzagolix in women with moderate to severe EAP. The trial includes 3 treatment arms: 75 mg LGX, 200 mg LGX with ABT (E2 1 mg/ NETA 0.5 mg), or placebo. Here we present safety results up to 6 months (24 weeks) of treatment.
Participants/materials, setting, methods
Eligible reproductive-aged women with moderate-to-severe EAP were randomized and treated (n = 484) for 6 months with 75 mg LGX, 200 mg LGX with ABT (E2 1 mg/ NETA 0.5 mg), or placebo. Safety and tolerability objectives reported here include 6-month results for treatment emergent adverse events (TEAEs), assessment of mean percent change from baseline (CfB) in lumbar spine (LS) bone mineral density (BMD) and Z-scores.
The safety analysis set included 484 subjects across the 3 treatment groups.
Main results and the role of chance
The overall incidence of TEAEs was similar between the placebo and LGX 75 mg group (46.9%) and slightly higher (56.8%) in the LGX 200 mg + ABT group. There were few (3) serious TEAEs, and none were related to LGX. TEAEs that occurred in over 5% of patients in either active treatment arm included headache (10.5%, 8.1%, and 8.0%), hot flush (6.8%, 7.5%, and 2.5%), and fatigue (6.8%, 3.8%, and 2.5%) for the 200 mg LGX with ABT, 75 mg LGX, and placebo groups, respectively. Mean percent CfB (95% CI) in LS BMD was -0.79% (-1.15, -0.43%), -0.89% (-1.31, -0.47%), and +0.78% (0.41, 1.15%) for the 200 mg LGX with ABT, 75 mg LGX, and placebo groups, respectively. Z-scores at 6 months remained within the same range as baseline in all groups.
Limitations, reasons for caution
Additional efficacy and safety results from the trial's 24 weeks (6 mo) extension phase are pending. (Edelweiss 6 protocol: NCT04335591)
Wider implications of the findings
These results support further development of ABT and non-ABT doses of linzagolix that have potential to provide flexibility and choice for women seeking treatment for EAP. A non-ABT option is important for women who have a contraindication to, are at increased risk for complications, or prefer not to use ABT.
Trial registration number
ClinicalTrials.gov: NCT02778399
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Affiliation(s)
- J Donnez
- Catholic University of Louvain , Ob/Gyn, Brussels, Belgium
| | - H Taylor
- Yale University , Ob/Gyn, New Haven, U.S.A
| | | | - W Catherino
- Uniformed Services University of the Health Sciences , Ob/Gyn, Bethesda, U.S.A
| | - E Bestel
- ObsEva SA, Research & Development , Geneva, Switzerland
| | - J.P Gotteland
- ObsEva SA, Research & Development , Geneva, Switzerland
| | | | - L Moore
- ObsEva Inc., Medical Affairs , Boston, U.S.A
| | - E Garner
- ObsEva Inc., Medical Affairs , Boston, U.S.A
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Moore L, Guertin JR, Tardif PA, Ivers NM, Hoch J, Conombo B, Antony J, Stelfox HT, Berthelot S, Archambault P, Turgeon A, Gandhi R, Grimshaw JM. Economic evaluations of audit and feedback interventions: a systematic review. BMJ Qual Saf 2022; 31:754-767. [PMID: 35750494 DOI: 10.1136/bmjqs-2022-014727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/12/2022] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The effectiveness of audit and feedback (A&F) interventions to improve compliance to healthcare guidelines is supported by randomised controlled trials (RCTs) and meta-analyses of RCTs. However, there is currently a knowledge gap on their cost-effectiveness. OBJECTIVE We aimed to assess whether A&F interventions targeting improvements in compliance to recommended care are economically favourable. METHODS We conducted a systematic review including experimental, observational and simulation-based economic evaluation studies of A&F interventions targeting healthcare providers. Comparators were a 'do nothing' strategy, or any other intervention not involving A&F or involving a subset of A&F intervention components. We searched MEDLINE, CINAHL, CENTRAL, Econlit, EMBASE, Health Technology Assessment Database, MEDLINE, NHS Economic Evaluation Database, ABI/INFORM, Web of Science, ProQuest and websites of healthcare quality associations to December 2021. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios, incremental net benefit and incremental cost-benefit ratios. Pairs of reviewers independently selected eligible studies and extracted relevant data. Reporting quality was evaluated using CHEERS (Consolidated Health Economic Evaluation Reporting Standards). Results were synthesised using permutation matrices for all studies and predefined subgroups. RESULTS Of 13 221 unique citations, 35 studies met our inclusion criteria. The A&F intervention was dominant (ie, at least as effective with lower cost) in 7 studies, potentially cost-effective in 26 and was dominated (ie, the same or less effectiveness and higher costs) in 2 studies. A&F interventions were more likely to be economically favourable in studies based on health outcomes rather than compliance to recommended practice, considering medical costs in addition to intervention costs, published since 2010, and with high reporting quality. DISCUSSION Results suggest that A&F interventions may have a high potential to be cost-effective. However, as is common in systematic reviews of economic evaluations, publication bias could have led to an overestimation of their economic value.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Jason Robert Guertin
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Noah Michael Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Hoch
- Department of Public Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Blanchard Conombo
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Jesmin Antony
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | | | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Alexis Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Rohit Gandhi
- Department of Pediatric Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - J M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Gansaonré RJ, Moore L, Bleau LP, Kobiané JF, Haddad S. Stunting, age at school entry and academic performance in developing countries: A systematic review and meta-analysis. Acta Paediatr 2022; 111:1853-1861. [PMID: 35691004 DOI: 10.1111/apa.16449] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/12/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
Abstract
AIM To review evidence of the effects of stunting, or height-for-age, on schooling level and schooling trajectories, defined as the combination of school entry age, grade repetition, and dropouts. METHODS We conducted a systematic review of studies (last update March 20, 2021) that assessed the association between stunting, or height-for-age, and at least one component of school trajectory using five databases (PubMed, Embase, Education Resources Information Center (ERIC), Web of Science and PsycINFO). Two independent reviewers performed study selection and data extraction. Pooled effects were calculated using the generic inverse variance weighting random effect model. The risk of bias was assessed using the ROBINS-I tool. PROSPERO ID CRD42020198346. RESULTS We screened 3944 articles and 16 were eligible for the qualitative and quantitative synthesis. Meta-analysis showed that an increase in height-for-age leads to an increase in early enrollment [OR=1.34 (95% CI, 1.07-1.67)], a reduction in late enrollment [OR=0.63 (95% CI, 0.51-0.78)], an increase in schooling level [MD=0.24 (95% CI, 0.14-0.34)], and a reduction of school overage [OR=0.79 (95% CI, 0.70-0.90)]. Stunted children were more likely to repeat a grade than non-stunted [OR=1.59 (95% CI, 1.18-2.14). CONCLUSION This review suggests that stunting in childhood might negatively affect school trajectories. Future research should evaluate the effect of stunting on school trajectories and the modification effect of socioeconomic status.
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Affiliation(s)
- Rabi Joël Gansaonré
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Louis-Philippe Bleau
- VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, QC, Canada
| | - Jean-François Kobiané
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Slim Haddad
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada
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Esmail A, Kodali S, Graviss E, Nguyen D, Moore L, Saharia A, Uosef A, Victor D, Abdelrahim M. P-163 Tyrosine kinase inhibitors (TKIs) plus transarterial chemoembolization (TACE) compared to TACE alone as downstaging therapy in transplant recipients with hepatocellular carcinoma. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Conombo B, Guertin JR, Tardif PA, Gagnon MA, Duval C, Archambault P, Berthelot S, Lauzier F, Turgeon AF, Stelfox HT, Chassé M, Hoch JS, Gabbe B, Champion H, Lecky F, Cameron P, Moore L. Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review. Value Health 2022; 25:844-854. [PMID: 35500953 DOI: 10.1016/j.jval.2021.10.018] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/27/2021] [Accepted: 10/31/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population. METHODS Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494). RESULTS Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated. CONCLUSIONS This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Jason R Guertin
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Marc-Aurèle Gagnon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Cécile Duval
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada; VITAM-Centre de recherche en santé durable, Université Laval, Québec City, Québec, Canada; Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Québec City, Québec, Canada
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California, Davis, Davis, CA, USA
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine at Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Uniformed Services University of the Health Sciences Annapolis, Bethesda, MD, USA
| | - Fiona Lecky
- School of Health and Related Research, Sheffield, England, UK
| | - Peter Cameron
- School of Public Health and Preventive Medicine at Monash University, Melbourne, Victoria, Australia
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.
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Moore L, Freire G, Ben Abdeljelil A, Berube M, Tardif PA, Gnanvi E, Stelfox HT, Beaudin M, Carsen S, Stang A, Beno S, Weiss M, Labrosse M, Zemek R, Gagnon IJ, Beaulieu E, Berthelot S, Klassen T, Turgeon AF, Lauzier F, Pike I, Macpherson A, Gabbe BJ, Yanchar N. Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review. BMJ Open 2022; 12:e060054. [PMID: 35477878 PMCID: PMC9047816 DOI: 10.1136/bmjopen-2021-060054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER International Prospective Register of Systematic Reviews (CRD42021226934).
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Faculté de médecine, Université Laval, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Melanie Berube
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Quebec City, Quebec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Eunice Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Marianne Beaudin
- Sainte-Justine Hospital, Department of Paediatric Surgery, Université de Montréal, Montreal, Quebec, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Weiss
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Transplant Québec, Montréal, Québec, Canada
| | - Melanie Labrosse
- Department of Pediatrics, Division of Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Isabelle J Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Emilie Beaulieu
- Department of Pediatrics, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Terry Klassen
- George & Fay Yee Centre for Health Care Innovation, Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculté de médecine, Université Laval, Quebec City, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculté de médecine, Université Laval, Quebec City, Québec, Canada
| | - Ian Pike
- Department of Pediatrics, BC Injury Research and Prevention Unit, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Moore L, Bérubé M, Tardif PA, Lauzier F, Turgeon A, Cameron P, Champion H, Yanchar N, Lecky F, Kortbeek J, Evans D, Mercier É, Archambault P, Lamontagne F, Gabbe B, Paquet J, Razek T, Stelfox HT. Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care. JAMA Surg 2022; 157:507-514. [PMID: 35476055 PMCID: PMC9047751 DOI: 10.1001/jamasurg.2022.0812] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.,Trauma Audit and Research Network, Salford, United Kingdom
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec - Université Laval (Hôpital St François d'Assise), Université Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jérôme Paquet
- Division of Neurosurgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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