Canadian Health Region Research Articles

Frequency and Cost of Anti-neural Antibody Testing for Autoimmune Encephalitis in a Large Canadian Health Region (S4.010)

Frequency and Cost of Anti-neural Antibody Testing for Autoimmune Encephalitis in a Large Canadian Health Region (S4.010)

A cross-sectional study of breastfed infants referred for tongue tie assessment and frenotomy in one Canadian health region.

Tongue tie (TT) is a condition that can cause infant feeding difficulties due to restricted tongue movement. When TT presents as a significant barrier to breastfeeding, a frenotomy may be recommended. Universally accepted diagnostic criteria for TT are lacking and wide prevalence estimates are reported. New referral processes and a Frenotomy Assessment Tool were implemented in one Canadian health region to connect breastfeeding dyads with a provider for TT evaluation and frenotomy. To determine the proportion of babies with TT as well as the frequency of frenotomy. This cross-sectional study included infants who initiated breastfeeding at birth and were referred for TT evaluation over a 14-month period. Data were collected retrospectively by chart review and analyzed using SPSS. Factors associated with frenotomy were examined using logistic regression. Two hundred and forty-one babies were referred. Ninety-two percent (n = 222) were diagnosed with TT and 66.0% (n = 159) underwent frenotomy. In the multivariate model, nipple pain/trauma, inability to latch, inability to elevate tongue, and dimpling of tongue on extension were associated with frenotomy (P < 0.05). Most referrals in our region resulted in a diagnosis of TT; however, the number of referrals was lower than expected, and of these two-thirds underwent frenotomy. TT is a relatively common finding among breastfed infants. Future research should examine whether a simplified assessment tool containing the four items associated with frenotomy in our multivariate model can identify breastfed infants with TT who require frenotomy.

Population-based genomic surveillance of Pseudomonas aeruginosa causing bloodstream infections in a large Canadian health region.

Population-based surveillance was undertaken to determine clinical factors, susceptibility patterns, and incidence rates (IR) of Pseudomonas aeruginosa causing bloodstream infections (BSIs) in a Canadian region (2010-2018). We combined clinical data with genomics to characterize P. aeruginosa (BSIs) (n = 167) in a well-defined Canadian (Calgary) human population over a 9-year period (2010-2018). The annual population IR per 100,000 patient years increased from 3.4/100,000 in 2010 to 5.9/100,000 in 2018, with the highest IRs in elderly males from the hospital setting. Over a quarter of patients presented with febrile neutropenia, followed by urinary tract infections and pneumonia. Antimicrobial resistance (AMR) rates and determinants were rare. The P. aeruginosa population was polyclonal consisting of three dominant sequence types (STs), namely ST244, ST111, and ST17. Antimicrobial-susceptible ST244 was the most common clone and belonged to three clades (A, B, C). The ST244 IR/100,000 increased over time due to the expansion of clade C. Multidrug-resistant ST111 was the second most common clone and IR/100,000 decreased over time. ST111 belonged to three clades (A, B, C) with clade C containing blaVIM-2. Different serotypes were linked to various STs. The IR/100,000 of P. aeruginosa that belonged to serotypes O6 increased significantly over time. An effective multivalent vaccine consisting of five serotypes (O1, O3, O5, O6, O11) would confer protection to > 70% of Calgary residents with P. aeruginosa BSIs. This study has provided a unique perspective of the population dynamics over time of P. aeruginosa STs, clades, and serotypes responsible for BSIs.

Universal COVID-19 screening at hospitals in a large Canadian health region

Background: Hospitals were affected by COVID-19, with significant concern regarding transmission from unidentified cases. Fraser Health, a Canadian regional health authority, implemented universal testing along with screening questions for emergency department (ED) admissions. We sought to determine which factors were associated with SARS-CoV-2–positive test on admission as well as patient outcome, stratified by screening question responses. Methods: This retrospective analysis included patients aged ≥6 years admitted through 12 hospital EDs between November 1, 2020, and June 30, 2022. Admission, laboratory, and screening data were extracted from electronic health records. Patients who had a first SARS-CoV-2 PCR–positive test in the prior 60 days collected within 48 hours of admission were classified as positive. Covariates included age, geographical region, and SARS-CoV-2 variant era. All questions were modeled using multinomial logistic regression, with components informed through crude analysis in R Studio software. Results: There were 88,511 unique eligible admissions, with 7,642 positive tests (8.6%). The positivity rate over the study period ranged from 0.6% to 21.8%, with a mean of 6.5%. Patients meeting screening criteria were 4.7 times (95% CI, 4.43–4.92) as likely to test positive as those who did not. Patients in the SARS-CoV-2 omicron variant era were 3.2 times (95% CI, 2.98–3.47) as likely to test positive as those in the earlier era of the pandemic. Patients later in the pandemic were less likely to be identified by screening questions than those in earlier eras, with patients in the SARS-CoV-2 omicron variant era only 14% (95% CI, 12%–17%) as likely as in the earlier stages of the pandemic to be identified by screening questions. Patients who tested positive were 1.5 (95% CI, 1.37–1.64) times as likely to die as patients who tested negative, whereas patients in later stages of the pandemic were less likely to die overall. Discussion: Patients who tested positive on admission were more likely to meet screening criteria; however, screening missed half of all positive cases. It is not known whether patients who tested positive without meeting screening criteria would have resulted in transmission. Conclusions: Due to changes in COVID-19 epidemiology, Fraser Health has discontinued universal admission screening. Although universal testing increased resource needs, more than half of patients who tested positive during the study period would not have been identified based on screening criteria alone, allowing for implementation of precaution measures to prevent possible transmission. Ultimately, the decision to conduct universal testing must be a balance of the resources required, community prevalence, and patient population.Disclosures: None

Self-reported adherence to direct oral anticoagulants versus warfarin therapy in a specialized thrombosis service-a cross-sectional study of patients in a Canadian Health Region.

Direct oral anticoagulants (DOACs) havea better safety and efficacy profile than warfarin and are currently recommended for stroke prevention in non-valvular atrial fibrillation (AF) and treatment of venous thromboembolism (VTE). Given that DOACs do not require regular laboratory monitoring compared to warfarin, patients' interactions with the health care system is reduced. Adequate adherence to DOACs is important and reported adherence to anticoagulation is unclear in clinical practice. This study aims to assess self-reported adherence to oral anticoagulants in a specializedAdult Outpatient Thrombosis Service (TS).  METHODS: This cross-sectional study included patients aged ≥ 18years who were prescribed an oral anticoagulant and had attended at least one appointment withan Adult Outpatient Thrombosis Service (TS)between October 10, 2017, and May 31, 2019. Adherence to oral anticoagulant therapy was assessed using the 12-item validated Adherence to Refills and Medications Scale (ARMS) score. Logistic regression analyses were used to evaluate association between patient characteristics and medication adherence. Adherence rates in DOACs and warfarin were compared. Three hundredand ninety-nine patients completed and returned the survey. Of the 399 who completed the survey, 74% were prescribed DOACs and 26% received warfarin. Most of the patients (89.3%) were ≥ 50years of age and half (57.3%) were male. About two-thirds (67%) had at least post-secondary education. The duration of anticoagulation use differed between patients on DOAC and warfarin; a greater proportion of those who had used anticoagulants for less than 1year was on DOACs compared to warfarin (20.9% vs 4.9%, p = 0.001). For patients who had been on anticoagulation for > 5years, the proportion of warfarin patients was greater than DOAC (57.8% vs 20.5%, p = 0.001). Self-reported adherence to oral anticoagulant therapy using the 12-item ARMS scale for warfarin and DOACs were 87.3% and 90.9%, respectively. Among the warfarin users, patient satisfaction with TS was associated with medication adherence (OR = 0.22; 95% CI: 0.05-0.89). Self-reported medication adherence was similar between warfarin and DOACs. Since suboptimal adherence is associated with poor clinical outcomes and increased costs, various stakeholders should emphasize the importance of medication adherence to oral anticoagulants at each patient encounter.

Trends in Drug Treatment of Outpatients with Acute Pulmonary Embolism - a 5-Year Retrospective Cohort Study in One Canadian Health Region

INTRODUCTION Pulmonary Embolism (PE) is the third most common cardiovascular condition. The American Society of Hematology recommends the use of direct oral anticoagulants (DOACs) over parenteral anticoagulant therapy with low molecular weight heparin (LMWH (parenteral AC)) with or without a Vitamin K antagonist (VKA) for initial PE treatment. There is limited data within our Canadian health region on how these therapeutic options are being used, and the trends of use over time. METHODS We completed a retrospective cohort study of outpatients with acute PE from June 1, 2014 to May 31, 2019 in one Canadian health region servicing a population of over 300,000. We identified patients with acute PE utilizing a search strategy of the Picture Archiving and Communication System (PACS) diagnostic imaging database for positive PE, including computed tomography (CT) reports, as well as a review of ventilation-perfusion (V/Q) scanning. Imaging reports were then manually reviewed to determine the presence of acute PE. Patients were included if they were aged ≥18 years, and the PE was diagnosed as an outpatient. Patients were excluded if the PE was diagnosed during hospital admission for another condition. Data collected by chart review up to 90 days after the diagnosis of PE included drug and patient-specific characteristics, and components of the simplified Pulmonary Embolism Severity Index (sPESI). Medication treatment of patients with PE were categorized into DOACs alone, parenteral AC alone, parenteral AC transitioned to VKA, parenteral AC transitioned to DOACs, and transition between the three ACs (parenteral, VKA, DOACs). DOACs alone included initial treatment with therapeutic LMWH up to 10 days, and parenteral AC transitioned to DOACs comprised treatment with parenteral AC>10 days prior to switching to a DOAC. Data are reported as means and standard deviations for continuous variables or percentages for categorical variables. Patient characteristics and treatments are compared using chi-square and analysis of variance tests. Multinomial logistic regression was used to determine the predictors of acute PE treatment. RESULTS A total of 785 patients with PE were diagnosed as an outpatient, with mean age of 63.4 ± 15.9 years, 42.3% male, and mean weight of 92.0 ± 30.4 kg. There were 247 (31.5%) patients with a sPESI score = 0, and 521 (66.4%) were admitted to hospital for treatment of the acute PE. Treatments utilized included DOACs alone (n=281, 35.8%), parenteral anticoagulants alone (n=239, 30.4%) or combined with VKA (n=172, 21.9%), parenteral anticoagulants followed by DOACs (n=50, 6.4%) or parenteral anticoagulant combined with VKA switched to DOACs (n=43, 5.5%) (Table 1). Significant differences in patient characteristics between treatment groups included: mean age (p=0.001), mean weight (p<0.001), history of malignancy (p< 0.001), mean sPESI score (p<0.001) and low risk PE (sPESI=0) (p=<0.001), admission to hospital for PE treatment (p< 0.001) and length of stay for acute PE (p<0.001). Multinomial logistic regression showed that compared to parenteral anticoagulants alone, patients with a history of malignancy were less likely to be treated with DOACs (RR 0.06, 95% CI 0.03-0.11), parenteral anticoagulants transitioned to DOACs (RR 0.07, 95% CI 0.03-0.018), parenteral anticoagulants transitioned to VKA (RR 0.11, 95% CI 0.06 -0.20), or parenteral anticoagulants transitioned to VKA then DOACs (RR 0.05, 95% CI 0.02-0.13). Compared to parenteral anticoagulants alone, patients admitted to hospital for acute PE treatment were more likely to receive parenteral anticoagulants transitioned to VKA (RR 2.94, 95% CI 1.64 - 5.23), or parenteral anticoagulants transitioned to VKA then DOACs (RR 3.76, 95% CI 1.21 -11.65). Trends in anticoagulant use over the the period of study showed an increasing use of DOACs as initial treatment (Figure 1). CONCLUSION In our study, over a five year period, patients with acute PE and malignancy were more likely to be prescribed parenteral anticoagulation alone compared to other treatment options. Patients with acute PE admitted to hospital were more likely to be prescribed parenteral anticoagulants transitioned to VKA, or parenteral anticoagulants transitioned to VKA then switched to DOACs. The use of DOACs trended upwards for treatment of acute PE over the time period examined. Further analysis is ongoing to determine additional clinical and economic outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Comparative Analysis of 4 Risk Stratification Models to Identify Patients with Acute Pulmonary Embolism at Risk of Short Term Mortality in a Canadian Health Region

BACKGROUND Acute pulmonary embolism (PE) is a common, potentially life-threatening disease. It is estimated that 5-15% of patients with acute PE are at high risk of death or hemodynamic collapse. Multiple risk stratification models have been developed to identify patients at risk of complications. Common examples include, simplified Pulmonary Embolism Severity Index (sPESI) and Hestia criteria scores. The sPESI has demonstrated the ability to discriminate between high (score ≥ 1) and low risk (score =0) for 30-day mortality. Hestia criteria (score ≥ 1 = high risk, score = 0 low risk) has shown ability to identify low risk patients eligible for outpatient treatment. However, neither scoring model takes into account the presence of right ventricular dysfunction (RVD), a predictor of early mortality. Our objective was to compare the ability of 4 different risk stratification models to identify outpatients at risk of mortality up to 90 days after acute PE METHODS We conducted a retrospective cohort study of adult outpatients aged ≥18 years with objectively confirmed PE from 2014-2019. PE was identified by positive diagnostic imaging from radiology reports obtained via search of the Picture Archiving and Communication System (PACS) database in Eastern Health Region in Newfoundland and Labrador, Canada. Patient data was collected via manual chart review. We calculated sPESI and Hestia scores for each patient with confirmed PE using methods from original derivation studies. Patients were stratified into 4 categories according to sPESI or Hestia criteria alone, as well as a combination of sPESI or Hestia criteria with or without (w/wo) RVD. High risk PE included those with sPESI or Hestia = 0 with RVD. Categorical data are presented as percentages and continuous data are shown as mean±SD. Students t-test and X2 test were used to compare continuous and nominal variables, respectively. The Cox regression analysis was used to analyse all-cause mortality up to 90 days in each category. Area under the receiver operator curve was used to measure the discrimination of each of the 4 risk stratification models to estimate 7, 30 and 90-day mortality (AUC). AUC: 50%, 50-69%, ≥70-80%, >80-90% and >90-100% suggest no, modest, acceptable, excellent and outstanding discrimination respectively. RESULTS A total of 785 outpatients were included in this study and had a mean [SD] age of 64.9 [16.2] years; weight, 91.1 [29.4] kg; and 331 were male [42.2%]). About 17.6-31.5% were classified as low risk by the 4 risk stratification models. Death rate at 7, 30 and 90 days ranged from 2.4-11.3%, 2.0 - 9.6%, 2.3 - 11.0%, 4.9 - 9.4% for patients categorized by sPESI, Hestia criteria, sPESI w/wo RVD and Hestia w/wo RVD respectively in the high risk groups. No death occurred in low risk groups. Of the 4 models, sPESI and Hestia showed acceptable discrimination for 30-day mortality with AUC: 72.8 (95%CI; 66.6-78.9) and 71.0 (95%CI; 64.0-77.9) respectively. This suggests sPESI score and Hestia criteria have a 72.8% and 71.0% chance of properly identifying low-risk and high-risk individuals based on 30-day mortality risk, respectively. Use of sPESI alone demonstrated modest discrimination for risk of 7 [AUC; 69.1 (95%CI; 58.2-80.0)] and 90-day [AUC; 66.4 (95%CI; 49.3-83.6)] mortality while Hestia criteria alone showed modest discrimination for risk of 7-day mortality [AUC: 64.4 (95%CI: 47.0-81.7)] but poor discrimination for 90-day risk of mortality [AUC; 38.5 (95%CI: 17.6-59.3)]. Each risk stratification model discriminated modestly for 7-day mortality (AUC range, 58.9-69.1), with sPESI showing the highest and Hestia w/wo RVD the least. In each model, discrimination for 90-day was lowest (AUC range, 38.5-66.4) compared to 7 and 30-day mortality. Hestia w/wo RVD exhibited the least discrimination for risk of mortality (AUC; 50.0-59.2). CONCLUSION: Compared to other risk models, sPESI alone showed acceptable discrimination at identifying acute PE patients at risk of 30-day death and modest discrimination at 7 and 90 days and performed better across the three time trajectories. Use of Hestia criteria alone showed acceptable and modest discrimination at identifying patients at risk of 30 and 7-day death respectively but least discrimination for 90-day mortality compared to sPESI w/wo RVD and Hestia w/wo RVD. The Hestia w/wo RVD model had the least discrimination at identifying risk of 7 and 30-day mortality compared with other models. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Predictors of 90-Day Mortality in Patients with Acute Pulmonary Embolism- a 5-Year Retrospective Cohort Study of Patients in One Canadian Health Region

BACKGROUND Acute pulmonary embolism (PE) can be fatal if not treated. PE is linked to major co-morbidities such as cancer and ischemic heart disease. Recurrence of PE may occur and is linked to high morbidity and death. Although acute PE is a common diagnosis, the incidence is still unknown in our health region. Published studies from other countries indicate an annual incidence between 0.2 and 0.8 /1000 persons, where the variation may be related to different inclusion criteria. Our knowledge about the association between concomitant diseases and PE and its outcomes is mostly based on data from clinical trials, and these patients may not fully represent real-life PE patients. This potentially limits our understanding of concomitant disorders that are associated to PE. We sought to determine 90-day survival and predictors of mortality for patients with acute PE in a real world setting. METHODS We retrospectively analyzed a cohort of adult outpatients aged ≥18 years with objectively confirmed acute PE between 2014 and 2019. PE was identified by positive diagnostic imaging from radiology reports obtained via search of the Picture Archiving and Communication System (PACS) database in the Eastern Health Region of Newfoundland and Labrador, Canada. We defined the clinical end-point as all-cause death within 90 days of PE diagnosis at a health facility in the health region. Cox-regression analysis was used to study the impact of patient characteristics and comorbidities on 90-day survival after the episode of acute PE. RESULTS A total of 1184 patients were identified as having acute PE between 2014 and 2019 within the Eastern Health Region. The annual incidence of PE among adults was estimated at 0.95/1000 persons. Of the total, 785 patients were diagnosed with acute PE as outpatients and were included in our study. Mean age was [SD] 63.4 ± 15.9 years, weight [SD] 92.0 ± 30.4 kilograms, and 42.3% were men. Patients were followed for 67274 person-days and 61 (7.8%) of outpatients died. Surgery ≤ 2 weeks prior to acute PE (44.6%), cancer (44.2%) and previous venous thromboembolism (15.2%) were most prevalent comorbid conditions among the patients [Table 1]. Male patients had a multivariate-adjusted hazard ratio (HR) of 5.63 (95% CI: 1.49 - 21.32); p = 0.011; 3.24 (95%CI: 1.47 - 7.14); p=0.004 and 2.48 (95% CI: 1.39-4.42); p=0.002 for 7, 30 and 90-day mortality respectively compared to females. Patients who had surgery ≤ 2 weeks prior to acute PE were associated with HR: 6.29 (95%CI: 1.31 - 30.29) p=0.0218; HR: 4.34 (95%CI: 1.79 - 10.48) p=0.001 and HR: 2.00 (95%CI: 1.18 - 3.52); p=0.010 higher risk of 7, 30 and 90 day-mortality, respectively. Having cancer was associated with increased risk of 30-day (HR: 6.13[95%CI: 1.81 - 20.72]; p=0.004) and 90-day (HR; 4.27 [95%CI: 1.87 - 9.72]; p<0.001) mortality. An increase in weight is associated with lower risk of 30 (HR; 0.95 [95%CI: 0.94 - 0.99]; p=0.007) and 90-day mortality (HR: 0.97[95%CI: 0.95 - 0.99]; p<0.001) respectively [Figure 1]. CONCLUSIONS Male sex, surgery ≤ 2 weeks prior to PE, cancer and weight are factors that predicted 90-mortality among patients with acute PE. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

COVID-19 Variants of Concern: An Analysis of Critical Care Admission in Hospitalized Patients in a Canadian Health Region

PurposeTo examine outcomes in COVID-19 positive acute care patients and the differential impact of the presence of COVID-19 Variants of Concern (VOCs).Methods & MaterialsThis study was a cross-sectional analysis using patient data from the patient's electronic medical records. Inclusion criteria were COVID-19-positive patients hospitalized within acute care sites in Fraser Health (British Columbia) between January 1 and April 30, 2021. Data analysis was conducted using SAS Studio 3.8 and STATA 17.0.ResultsOf the patients included in the study, 934 (33%) were classified as having a VOC. The proportion of VOC-related COVID-19 cases steadily increased from 0.6% of all COVID-19 admissions in January 2021 to 67.2% in April 2021. Males were more likely to have VOCs than females (36% vs. 30%). The age groups with the highest proportion of VOCs were 40-49 (51%), 50-59 (44%), and 60-69 (40%). After controlling for sex and age, it was shown that patients with VOCs were more than twice as likely to require critical care admission than those without VOCs (OR=2.04, 95%CI:1.67, 2.48; p<0.001). There was no statistically significant difference in overall length of stay (p=0.502) or length of stay in critical care (p=0.237) for those with VOCs after controlling for age and sex. While patients with VOCs were more than twice as likely to require critical care, there was no difference in mortality (OR=1.03, 95%CI:0.75,1.41), p=0.877).ConclusionVOCs were more likely to be present in middle-aged hospitalized patients than in older patients, and were more prevalent in males. Patients with VOCs were more likely to require critical care; however, there was no difference in length of stay in critical care, or in overall mortality. This is important to understand, as VOCs make up a larger proportion of COVID-19 cases, and will likely place significant burden on critical care resources. Limitations of this study are that other factors such as co-morbidities and socioeconomic status have not been controlled for, and the findings may not be generalizable to other health regions with different populations and health care systems. This study provides groundwork for future research on this evolving topic.

224. Evaluating the Epidemiology of Bloodstream Infections: A Population-Based Study

BackgroundBloodstream infections (BSI) are a major cause of morbidity, mortality, and health care costs worldwide. Population-based studies are key to assess BSI epidemiology over time while minimizing selection bias but remain limited. Therefore, we aimed to assess the incidence of BSI in a large Canadian health region in a contemporary period. We hypothesized that there would be significant age and sex-based differences including over time.MethodsWe conducted a retrospective cohort study from 2011 through 2018 using a population-based microbiology database to determine the annual age- and sex-specific BSI testing and case rates with the census as the population reference. BSI was defined as a positive blood culture for a pathogen. Episodes > 30 days apart were included for analysis. Incidence rate ratios (IRR) for testing and case rates including by sex were calculated to assess changes over time. All analyses were run at a two-sided α of 0.05 and were conducted with R 4.0.4.ResultsA total of 154,147 distinct individuals (49.9% male) were analyzed and 22,869 (14.8%) had a BSI at the first encounter in the study period. Overall BSI testing incidence ranged from 1529 to 1707 per 100,000 person-years and case incidence ranged from 180 to 292 per 100,000 person-years. Testing and case incidence for BSI was greatest in the 0-4 and 75+ years age groups (p < 0.01). Males compared to females had greater testing and case incidence rates in young and old age groups, but females had greater rates in the 15-44 years groups (p < 0.01). Overall IRR for cases comparing 2018 to 2011 was 0.62 (95% CI 0.59-0.65) reflecting a significant decrease over time. Testing also decreased over the study period with an IRR of 0.90 (95% CI 0.88-0.91). Testing and case IRRs were not significantly different stratified by sex.Incidence rates (per 100,000 person-years) of BSI testing and cases by sex from 2011 through 2018 in a Canadian health region ConclusionIn our large population-based study of BSI, we identified that BSI remain frequent and the youngest and oldest age groups as well as males in these age groups have the greatest BSI incidence rates which may reflect both biological sex and gender-based differences. Encouragingly, BSI incidence rates have decreased over time at a greater increment relative to testing rates. Future studies of BSI should focus on pathogen and outcome-based evaluations.Disclosures All Authors: No reported disclosures

Forgoing transesophageal echocardiogram in selected patients with complicated Staphylococcus aureus bacteremia.

Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7days, IQR 23.4-48.6 vs. 43.8days, IQR 33.3-49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.

Public health nurse perceptions of evolving work and how work is managed: A qualitative study.

To explore public health nurse (PHN) perspectives of their evolving work and how public health nurse work is managed in a Canadian health region. Professional and public health organisations describe public health nurse practice roles as population-focused work. Health care management directs public health nurse work to achieve specific goals. In this qualitative study, data were collected during focus groups with 42 public health nurse participants in one health region. Focus group data were analysed for meanings and themes. Public health nurses perceived increasing immunizations and limited resources for public health nurse work meant that population-focused care for the public was rationed or missing. Participants perceived the health care organisation directed, managed and assigned public health nurse specialist work; however, public health nurses managed their client-focused practice with knowledge, reasoning and support from colleagues. Evolving visible public health nurse work was managed by health organisational management directives to increase immunizations and disease control. Public health nurses managed their evolving visible and invisible work supported by their knowledge, practice values and public health nurse colleagues. Nursing management must lead and communicate the vision supporting better health, better population-focused care and health outcomes to public health nurse and stakeholders, while reviewing resources needed to optimize public health nursing and improve population health.

Access to radiotherapy and its association with cancer outcomes in a high-income country: Addressing the inequity in Canada

Background and purposeCanada is a high-income country with universal healthcare. In international comparisons, its overall level of access to radiotherapy appears sufficient. However, challenges exist due to Canada’s large geographic area and small population density. The association between access and cancer outcomes nationally has not yet been described. Materials and methodsWe quantified geographic accessibility for 2012 using the linear distance from each Canadian health region centroid to the nearest radiotherapy center. We used geospatial analytic techniques to detect clusters of age-standardized all-cancer mortality-to-incidence ratios (MIRs) across health regions, from 2010–2012. Global ordinary least squares (OLS) and geographically-weighted regression (GWR) were conducted to examine relationships between distance and MIR, adjusting for sociodemographic factors. ResultsMedian distance from health region centroid to nearest radiotherapy center was 101.73 km (range 1.14–2095.12). One cluster of worse outcomes (MIR range 0.45–0.88) involved most of northern Canada, with a second cluster of better outcomes (MIR range 0.40–0.41) in southern British Columbia. In both regression models, regions with longer distance to radiotherapy center (ß = 0.0001), increased smoking (ß = 0.002), and poorer food security (ß = –0.003) were significantly associated with worse outcomes (OLS R2 = 0.70, GWR R2 = 0.74). Distance remained independently associated with MIR for lung and colorectal cancer subgroups, but not breast and prostate. ConclusionsA clear north–south discordance in cancer outcomes exists in Canada, with poorer outcomes in the north, while radiotherapy centers are concentrated along the south. Increased distance to radiotherapy, along with other sociodemographic and health-system factors, are associated with poorer cancer outcomes. Our study could be replicated, particularly in other high-income countries, to help identify national patterns and regional disparities in access and outcomes.

Epidemiology and Outcome Determinants of Staphylococcus aureus Bacteremia Revisited: A Population-Based Study.

Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to re-define the burden, epidemiology and mortality-associated risk factors of SAB in a large Canadian health region. Residents (> 18years) experiencing SAB from 2012 to 2014 were assessed. Incidence rates were calculated using civic census results. Factors associated with 30-day mortality were determined through multivariate logistic regression. Incidence and risk factors for SAB were compared to 2000-2006 data. 780 residents experienced 840 episodes of SAB (MRSA; 20%). Incidence rates increased from 23.5 to 32.0 cases/100,000 from 2012 to 2014; [IRR 1.15 (95% CI 1.07-1.23); p < 0.001]. Compared to a decade ago, incidence of SAB has increased [IRR 1.28 (95% CI 1.21-1.36); p < 0.001] despite minimal change in nosocomial SAB. MRSA proportion did not change through the study (p = 0.3), but did increase relative to a decade ago (20.0% vs 11.0%, p < 0.001). Thirty-day mortality rates were 30.6% and 21.3% for MRSA and MSSA, respectively (p = 0.01), similar to rates from 2000 to 2006. Several clinical, demographic, and biochemical factors were independently associated with SAB mortality. SAB is common within our population resulting in significant mortality. Incidence rates of SAB are increasing in our health region; however, 30-day mortality rates remain stable.

PIN88 INTERRUPTED TIME SERIES ANALYSIS OF UVGI TECHNOLOGY TO REDUCE INFECTION RATES IN A CANADIAN HEALTH REGION - AN ECONOMIC ANALYSIS

An estimated 200,000 Canadians experience a hospital acquired infection (HAI) annually, with approximately 8,000 to 12,000 persons dying as a result of their infection. Ultra-violet germicidal irradiation (UVGI) is an emerging disinfection technology that has biocidal activity against a wide range of pathogens. Including: Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CDI). Given the nascent stage of this technology’s development, there is limited research on its clinical effectiveness and cost-effectiveness – and there are no published studies in a Canadian context according to a literature review by ‘Health Quality Ontario’ in February, 2018. UVGI devices were implemented within three of twelve hospitals in a Canadian health region over a six-month period in November 2016. Patient data from intervention and control sites was extracted between September 2014 and May 2018 including rates of CDI and MRSA infection. A preliminary cost analysis was conducted using aggregate data, and followed by a more sophisticated Interrupted time Series (ITS) analysis to determine the level and trend changes in infection rates related to introduction and removal of the UVGI devices in intervention sites relative to control sites. The initial cost analysis determined that over the 6 month trial period, the UVGI technology delivered between $165,194 and $415,905 in costs avoided based on reductions of CDI and MRSA cases. The results of the ITS analysis are currently being compiled, and will provide a robust picture of the economic impact of the introduction and removal of the technology in intervention sites relative to control sites. Initial results point towards the implementation of UVGI technology delivering of cost-savings via reduced infection rates. Given the paucity of evidence in general and in Canadian contexts in particular, dissemination of the latest evidence is crucial to informing investment decisions by health care leaders.

The Cost of Use of the Emergency Department by Persons With Inflammatory Bowel Disease Living in a Canadian Health Region: A Retrospective Population-Based Study.

BackgroundWe aimed to determine the costs of emergency department (ED) attendance by persons with inflammatory bowel disease (IBD) not admitted to hospital from the ED.MethodsThis was a population-based administrative database study linking the University of Manitoba IBD Epidemiology Database with the Winnipeg Regional Health Authority (WRHA) ED Information Service database. We identified persons with IBD who presented to the ED and were not admitted between January 1, 2009 and March 31, 2012. We then applied costs in Canadian dollars for these visits including an average ED visit cost plus 26% for overhead (total = $508), an average estimated cost of laboratory investigations ($50), and costs for each of radiographic imaging, lower endoscopy and consultation with an internist/gastroenterologist or a surgeon. We tallied the costs of each unique ED presentation. We determined average costs for visits associated with specific consultations or investigations.ResultsOne thousand six hundred and eighty-two persons with IBD (4,853 individual visits) attended the ED and did not get hospitalized. The average cost per ED visit by a person with IBD who did not get hospitalized was $650. This resulted in a total expenditure of $3,152,227 on these persons for their ED attendance or $969,916 per year. The visits with the highest mean costs were those associated with an abdominal computerized tomography scan ($979), those associated with surgical consultation ($1019), and those associated with an internist/gastroenterologist consultation ($942).ConclusionBetter strategies for management of acute issues for persons with IBD that can reduce the use of an ED are needed and can be considerably cost saving.

Timing of onset of persistent critical illness: a multi-centre retrospective cohort study.

Persistent critical illness has been described as a subtype of chronic critical illness, characterized as a transition after ICU admission where primary diagnosis and illness acuity are no better at predicting outcome than pre-hospital characteristics. Herein we describe the occurrence and outcomes associated with persistent critical illness in a large Canadian health region. In this multi-center observational cohort study, all patients aged older than 14years admitted to 12 ICUs in Alberta, Canada, between June 2012 and December 2014 were included. Primary outcome was in-hospital mortality. Predictors at ICU admission were separated into: (1) antecedent characteristics component (e.g., demographics, chronic health component of the APACHE II score, comorbid conditions); and (2) acute illness component (e.g., APACHE II score at admission, SOFA score, primary diagnostic category, surgical status, acute organ support). Using multiple statistical methods and randomly splitting the cohort into development and validation samples for risk scoring using logistic regression, we examined mortality prediction of each of these components to characterize the timing of transition to persistent critical illness. We included 17,783 patients with a median (IQR) age 61years (49-71), 62% were male, and mean APACHE II score was 19.0 (7.9). In-hospital mortality was 16.8%. Among patients alive and in ICU, the acute illness component, which accurately predicted outcome at the time of admission [area under the receiver operating characteristics curve (AUC) 0.861; 95% CI 0.860-0.862], progressively lost predictive ability and was no longer more predictive than antecedent characteristics after 9days. This transition defined the onset of persistent critical illness and comprised 16.1% (n = 2856) of the cohort. Transition ranged between 5 and 21days across subgroups. In-hospital mortality was greater for those with persistent critical illness [23.9% vs. 15.5%, odds ratio (OR) 1.54; 95% CI 1.43-1.67, p < 0.001]. Persistently critically ill patients accounted for 54.5% of 97844 ICU bed-days and 36.3% of 420119 hospital bed-days, respectively. Persistent critical illness occurred in one in six patients admitted to Alberta ICUs and portended greater risk of death, prolonged ICU and hospital stay, and disproportionate use of health resources compared to patients without persistent critical illness.

PMD49 - Cost Effectiveness of Ultra-Violet Germicidal Irradiation in Canadian Health Region

PMD49 - Cost Effectiveness of Ultra-Violet Germicidal Irradiation in Canadian Health Region

Association between afterhours admission to the intensive care unit, strained capacity, and mortality: a retrospective cohort study

BackgroundAdmission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00–06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity.MethodsThis is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00–06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ≥ 90% or clustering of admissions (≥ 0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity.ResultsOf 12,265 admissions, 34.7% (n = 4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7–37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44–70) vs 60 (47–70) years, p < 0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p < 0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p < 0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p = 0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923–1.135, p = 0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p = 0.90) or hospital length of stay (LOS) (p = 0.27), although ICU LOS was shorter (p = 0.049). Early-morning admission (00:00–06:59 h) with ICU occupancy ≥ 90% was associated with short-term (≤ 7 days) and all-cause ICU mortality.ConclusionsOne-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity.

Examining sociodemographic risk factors for Chlamydia trachomatis infection: a population-based cohort study.

Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infectionin developed nations and is an important public health concern. We aimed to assess the factors associated with testing and positivity of C. trachomatis in a large population. A retrospective study of a large Canadian health region was undertaken using 2011 census and laboratory data. Demographic and socioeconomic data from the national household survey were linked to microbiologic data for C. trachomatis. Multivariable generalized estimating equation models were constructed to examine relative risk for C. trachomatis testing and positivity. For testing and positivity, female sex and younger age groups were associated with increased risk. University education and South Asian ethnicity were associated with lower risk of positivity. Incorporatingsocio-demographic factors will be critical to the success of future sexually transmitted infection public health programs.