Provincial Health Care System Research Articles

Acute Care Use by Breast Cancer Patients on Adjuvant Chemotherapy in Alberta: Demonstrating the Importance of Measurement to Improving Quality.

Breast cancer patients receiving adjuvant chemotherapy are at increased risk of acute care use. The incidence of emergency department (ED) visits and hospitalizations (H) have been characterized in other provinces but never in Alberta. We conducted a retrospective population-based cohort study using administrative data of women with stage I-III breast cancer receiving adjuvant chemotherapy. Rates of ED and H use in the 180 days following chemotherapy initiation were determined, and logistic regression was performed to identify risk factors. We found that 47% of women receiving adjuvant chemotherapy experienced ED or H, which compared favourably to other provinces. However, Alberta had the highest rate of febrile neutropenia-related ED visits, and among the highest chemotherapy-related ED visits. The incidence of acute care use increased over time, and there were significant institutional differences despite operating under a single provincial healthcare system. Our study demonstrates the need for systematic measurement and the importance of quality improvement programs to address this gap.

Analysis of Patient Reported Outcomes for Stage IV Non-Small Cell Lung Cancer Patients in Ontario

Stage IV non-small cell lung cancer (NSCLC) is associated with substantial disease and treatment-related morbidity. In Ontario, Canada, patient reported outcomes (PRO) evaluation through Edmonton Symptom Assessment System (ESAS) has been integrated into clinical workflow since 2007. ESAS elicits patients' self-reported severity of common cancer-associated symptoms at clinical encounters. ESAS domains are anxiety, depression, drowsiness, appetite, nausea, pain, shortness of breath, tiredness, and well-being. This province-wide study investigated moderate-to-severe symptom burden in this population.ESAS collected from stage IV NSCLC patients diagnosed between 2007-2018 linked to Ontario provincial healthcare system database were studied. ESAS acquired within 12 months following diagnosis were analyzed and the proportion reporting moderate-to-severe scores (ESAS ≥4) in each domain was calculated and plotted over time. Potential covariates of moderate-to-severe scores: lung cancer treatments, age, sex, Elixhauser comorbidity index, immigration status, income quintiles, and time since diagnosis were analyzed using multivariable Poisson regression models with robust error variance.Of 22,799 patients, 13,289 (58.3%) completed ESAS (84,373 assessments) in the year following diagnosis. Patients with older age, high comorbidity, and not receiving active cancer therapy had lower ESAS completion. Almost all patients (94.4%) reported at least 1 moderate-to-severe symptoms. Most prevalent were tiredness (84.1%), low wellbeing (80.7%), low appetite (71.7%), and shortness of breath (67.8%). Monthly peaks and nadirs of these symptoms were: 67.6% (month 1) and 47.0% (month 12) for tiredness; 64.6% (month 1) and 43.3% (month 10) for lack of wellbeing; 50.5% (month 1) and 33.1%. All symptoms severity peaked at 1 or 2 months after diagnosis and demonstrated downwards trajectories in the subsequent months. On multivariable analyses, moderate-to-severe scores in all ESAS domains were associated with radiotherapy within 2 weeks prior, while drowsiness, low appetite and wellbeing, nausea, and tiredness were associated with systemic therapy within 2 weeks prior. Comorbidity, low income, non-immigrants, and urban residency were also associated with moderate-to-severe symptoms.This province-wide PRO analysis showed moderate-to-severe symptoms were highly prevalent and persistent among metastatic NSCLC patients, underscoring the need to address supportive measures in this population especially around treatments. In-person PRO completions were lower among patients who are older, highly comorbid, and not receiving active treatment, arguably more vulnerable patients. Implementation of virtual PRO may lower barrier to care, allowing timely identification of symptoms that may be amenable to intervention in these patients.

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada

Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.

Province-Wide Analysis of Patient-Reported Outcomes for Stage IV Non-Small Cell Lung Cancer.

In Ontario, Canada, patient-reported outcome (PRO) evaluation through the Edmonton Symptom Assessment System (ESAS) has been integrated into clinical workflow since 2007. As stage IV non-small cell lung cancer (NSCLC) is associated with substantial disease and treatment-related morbidity, this province-wide study investigated moderate to severe symptom burden in this population. ESAS collected from patients with stage IV NSCLC diagnosed between 2007 and 2018 linked to the Ontario provincial health care system database were studied. ESAS acquired within 12 months following diagnosis were analyzed and the proportion reporting moderate to severe scores (ESAS ≥4) in each domain was calculated. Predictors of moderate to severe scores were identified using multivariable Poisson regression models with robust error variance. Of 22,799 patients, 13,289 (58.3%) completed ESAS (84,373 assessments) in the year following diagnosis. Patients with older age, with high comorbidity, and not receiving active cancer therapy had lower ESAS completion. The majority (94.4%) reported at least one moderate to severe symptom. The most prevalent were tiredness (84.1%), low well-being (80.7%), low appetite (71.7%), and shortness of breath (67.8%). Most symptoms peaked at diagnosis and, while declining, remained high in the following year. On multivariable analyses, comorbidity, low income, nonimmigrants, and urban residency were associated with moderate to severe symptoms. Moderate to severe scores in all ESAS domains aside from anxiety were associated with radiotherapy within 2 weeks prior, whereas drowsiness, low appetite and well-being, nausea, and tiredness were associated with systemic therapy within 2 weeks prior. This province-wide PRO analysis showed moderate to severe symptoms were prevalent and persistent among patients with metastatic NSCLC, underscoring the need to address supportive measures in this population especially around treatments. In this largest study of lung cancer patient-reported outcomes (PROs), stage IV non-small cell lung cancer patients had worse moderate-to-severe symptoms than other metastatic malignancies such as breast or gastrointestinal cancers when assessed with similar methodology. Prevalence of moderate-to-severe symptoms peaked early and remained high during the first year of follow-up. Symptom burden was associated with recent radiation and systemic treatments. Early and sustained PRO collection is important to detect actionable symptom progression, especially around treatments. Vulnerable patients (e.g., older, high comorbidity) who face barriers in attending in-person clinic visits had lower PRO completion. Virtual PRO collection may improve completion.

Improving Primary Health Care for Residents Living in Assisted Living: Evidence for Practice and Policy.

The fact that there is a large and growing number of older Canadians has generated a sense of urgency in improving seniors' access to health and long-term care services. Many provincial health care systems have engaged in a range of reforms to help older adults remain healthy and independent. Although many transformational changes have taken place across Canada to improve primary care, variations exist across provinces and territories in terms of older adults' access to primary health care. Opportunities exist for provinces to learn from successful reforms implemented in other Canadian jurisdictions. Residents of assisted living (AL) facilities are an ideal group to whom to target primary health care reforms, given the important role these facilities play in the care continuum and the complex needs of their residents. Allowing practitioners to practice to their full scope and assume greater responsibility within the health care system is a strategy adopted in some jurisdictions with success. This article reports on reforms that have been made to expand the scopes of practice of nurse practitioners and paramedics in some provinces, but also have the potential to improve access to primary health care for those living in AL across the entire country, including those living in smaller provinces such as New Brunswick.

Wearable Health Technology for the Diagnosis and Management of Atrial Fibrillation: A Systematic Review

Introduction: Atrial Fibrillation (AF), the most commonly sustained arrhythmia, affects approximately 200,000 Canadians and costs an annual $815 million to the Ontario provincial healthcare system. The current model for chronic AF management (favouring infrequent hospital visits) in combination with the challenge of detecting cardiac arrythmias provides opportunity for wearable devices to improve quality of care. Physicians must be aware of available wearable devices, their accuracy, validity, and potential to improve patient care. Methods: PubMed and Google Scholar databases were searched for primary studies involving AF and wearable devices published from database inception to 2020. Due to the heterogeneity of the findings, quantitative synthesis of the information could not be conducted. A narrative synthesis was performed for the obtained results, including a discussion of apparent trends and common study outcome measures: sensitivity, specificity, positive-, and negative-predictive-values. The narrative included comparisons to similar reviews and a discussion on both the current and future research directions. Results: The systematic search produced 214 studies, of which, 7 met the pre-determined eligibility criteria. The studies were published between 2018-2020 in 5 countries. Each eligible study was described and summarized; devices investigated include the Apple Watch with Kardia Band (Atrial fibrillation-sensing watch; AFSW), Huawei wearable devices (Honor 4 wristband, Honor Watch or Watch GT), CardioTracker (CART) + a pulse oximeter, and the RITMA system. Discussion: This systematic review comprehensively examined wearable devices used to deliver care for patients with AF. It was found that currently available wearable technologies for AF detection and management varied greatly in their accuracy, application settings, and accessibility. With technological advancements and further exploration into AF devices’ usability, widespread implementation of wearable technology in AF care is plausible. Successful application of these technologies can improve AF care and contribute to a significant reduction in AF-related healthcare costs. Conclusion: There are many devices available for AF care that show promise for certain applications. Additionally, there remains a demand for large-scale, high-quality research in this field to investigate the advantages and shortcomings of various devices that have shown promise in preliminary research. Future research should focus on randomized controlled trials to generate conclusive findings for wearable technologies in AF.

Identification and operationalisation of indicators to monitor successful uptake of advance care planning policies: a modified Delphi study

BackgroundIn 2014, the province of Alberta, Canada implemented a province-wide policy and procedures for advance care planning (ACP) and goals of care designation (GCD) across its complex, integrated public healthcare...

Impact of a Province-wide Endometrial Cancer Guideline on Daily Practice

Most women are managed by a general gynaecologist rather than being centralized in an oncogynaecology unit, resulting in different clinical management. In 2006, a hub & spoke model was introduced in the Provincial Healthcare System of Reggio Emilia, and shared guidelines were written. We aimed to verify the adherence to guidelines and the consequent improvements in quality care. All patients who underwent a hysterectomy for endometrial cancer in the Reggio Emilia Province hospitals from 2000 to 2016 were included in the study. Clinical and pathological data were carefully recorded for each patient included. This study included 132 and 277 patients in the periods before and after the implementation of the guideline, respectively. In the post-guideline period, the use of hysteroscopy, magnetic resonance, laparoscopy and adjuvant treatment significantly increased. Common shared guidelines and a clinical audit can help in improving centralization, resulting in an increased quality of care.

Opioid Prescribing Practices for Women Undergoing Elective Gynecologic Surgery

To describe the opioid prescribing practices in opioid-naive women undergoing elective gynecologic surgery for benign indications and identify risk factors associated with increased perioperative opioid use. We also explored factors associated with new persistent opioid use in women with perioperative opioid use. Retrospective, population-based cohort study. We used linked administrative data from a government-administered single-payer provincial healthcare system in Canada. This study was undertaken at ICES, a not-for-profit research institute in Ontario, Canada. We followed opioid-naive adult women who underwent benign elective gynecologic surgery between 2013 and 2018. None. The primary outcome was perioperative opioid use defined as ≥1 opioid prescription from 30 days before to 14 days after surgery. New persistent opioid use after gynecologic surgery was defined as having filled 1 or more opioid prescriptions between 91 days and 180 days postoperatively. Multivariable log-linear regression analyses were employed to adjust for clinical and demographic data. Of the 132506 patients included in our cohort, most (74.3%) underwent minor gynecologic procedures. Perioperative opioid use was documented in 27 763 (21.0%) patients, and there was a significant decreasing trend (p <.001) in the proportion of patients with perioperative opioid use from 21.8% in 2013 to 18.5% in 2018. Factors associated with increased perioperative opioid use included younger age; higher income quintile; urban dwellers; and diagnosis of infertility, endometriosis, or adnexal mass. Perioperative opioid use was an independent risk factor for persistent use (adjusted relative risk 1.40; 95% confidence interval, 1.13-1.72) and for every 65 patients prescribed opioids associated with gynecologic surgery, one developed new persistent opioid use. The highest risk factor for developing persistent use was filling a high-dose opioid prescription (adjusted relative risk5th quintileOME 2.33; 95% confidence interval, 1.83-2.96). One in 5 women who undergo a gynecologic procedure has a new exposure to opioids. For every 65 patients who fill an opioid prescription after their gynecologic surgery, one will experience prolonged opioid use.

Geographical Distance from Quaternary Treatment Center Does Not Impact Choice of Upfront Therapy, Clinical Trial Participation and Outcomes in Patients with Newly Diagnosed AML

Upfront therapy for newly diagnosed patients with acute myeloid leukemia (AML) includes intensive induction chemotherapy with curative intent, low dose chemotherapy, best supportive care, and clinical trials. The choice between these therapies is influenced by multiple factors including age, cytogenetic and molecular mutations, and performance status. In our single payer provincial health care system, induction chemotherapy and clinical trials are only offered at a small number of specialized quaternary care centers with geographically large catchment areas. As a result, some patients are required to travel long distances for their appointments, which may constitute a barrier to care, especially among elderly patients. We therefore asked whether distance from the quaternary center influences the choice of care for AML. We reviewed the records of patients ≥18 years of age diagnosed with AML from 2015-2017 and assessed at our quaternary care center in Toronto, Canada. We compared upfront therapy choice and survival between patients living close versus distant from the cancer center (empirically defined as &amp;lt;50 km versus &amp;gt;50km) and stratified by age. A total of 675 patients were assessed by our quaternary center for a new diagnosis of AML during the timeframe studied. Of those patients, 477 (71%) patients lived ≤50km, and 198 (29%) patients lived &amp;gt;50km from the quaternary center. The overall median distance from patient residence to the quaternary center was 33.2km (range: 1-1791km), and the median distance of patients in the &amp;gt;50km group was 93km (range: 50.2-1791km). Age, sex, baseline Eastern Cooperative Oncology Group Performance Status (ECOG), and cytogenetic risk were not significantly different between the two groups. There were no differences in the proportion of patients receiving induction chemotherapy or clinical trial as upfront therapy between patients living close versus distant from the quaternary center, even when stratified for age ≥70 years. There was no difference in overall survival between patients living ≤50km versus &amp;gt;50km from the quaternary center either overall, or when stratified by age. In conclusion, geographic distance from treatment center does not appear to impact choice of upfront therapy, access to clinical trials, or clinical outcomes in this study of newly diagnosed patients with AML treated in a single payer environment. Disclosures Gupta: Bristol MyersSquibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Incyte: Honoraria, Research Funding; Pfizer: Consultancy; Sierra Oncology: Consultancy, Membership on an entity's Board of Directors or advisory committees. Maze:Novartis: Honoraria; Pfizer: Consultancy; Takeda: Research Funding. McNamara:Novartis: Honoraria. Schimmer:Takeda: Honoraria, Research Funding; Novartis: Honoraria; Jazz: Honoraria; Otsuka: Honoraria; Medivir AB: Research Funding; AbbVie Pharmaceuticals: Other: owns stock .

Charting a course to support military families navigating service systems for children with Autism Spectrum Disorder: A qualitative study

Introduction: Most military families experience mandatory relocation, or posting, several times during their military career. For Canadian military families, who must access provincial or territorial health care systems, maintaining reasonable continuity of care is a persistent issue. Such challenges may be amplified when a child in a military family has special needs within the health and educational systems. The purpose of this qualitative study was to gain a better understanding of Canadian Armed Forces (CAF) families’ experiences in navigating health care systems on behalf of a child with Autism Spectrum Disorder (ASD), in the context of mandatory relocation, and to determine their recommendations for improved system navigation. Methods: Parents of children with ASD, where at least one parent serves in the CAF and had faced military-related relocation, were recruited. Semi-structured interviews were recorded, transcribed verbatim, and analyzed thematically. Results: A total of 13 participants represented 12 families and 15 children with ASD. Participants discussed two primary ways to support military families: (1) Improve communication between military-connected families with children with ASD, and (2) Improve transition coordination. Discussion: The recommendations made by military families echo those made in clinical professional association reports and recent Canadian research. International policy initiatives to offset the impacts of military family relocation may serve as examples to adapt to the provincial and territorial jurisdictions for both health and education in Canada.

Advanced Radiation Therapy Technology Use in the Treatment of Bone Metastases in a Public, Salary-Funded, Non-Incentivized Health Care System.

There is limited evidence to support the routine use of conformal radiotherapy (RT) techniques in the treatment of bone metastases. This study evaluated trends in advanced technique use within the province of British Columbia. Data on patients who received RT for bone metastases between 2009 and 2016 (with the exception of 2012) at 6 regional cancer centers were reviewed. Descriptive statistics summarized radiation technique patterns. Logistic regression assessed the influence of patient, treatment, and provider variables on receipt of RT technique. A total of 24,215 RT courses were identified; 97% were planned by simple RT and 3% by advanced techniques (3-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and stereotactic body radiotherapy). The use of advanced techniques was significantly higher in recent years compared with in 2009 (odds ratios [ORs], 2.2, 4.2, 4.2, and 6.3, respectively, for the years 2013 to 2016; P < .001). Patients with thyroid, sarcoma, and neuroendocrine malignancies (ORs, 10.3, 5.5, and 5.2, respectively; P < .005) were more likely to be treated with advanced techniques, as were skull, sternum, rib, and pelvic metastases (ORs, 8.0, 5.2, 2.2, and 2.2, respectively; P < .001). Advanced techniques were most commonly used in the setting of re-irradiation (38%). They were associated with slightly higher incompletion rates (3.0% v 1.5%, P < .005) and less use within 30 days of death (6% v 15%, P < .001). Within our publicly funded, salary-based provincial health care system, we found that the majority of bone metastases are still being treated by simple RT; however, the use of advanced techniques is increasing, and we identified select patterns in which they are being prescribed. Additional study into clinical benefit is required.

Health Sector responses to the COVID-19 pandemic in Ontario, Canada – January to May 2020

The first positive case of COVID-19 in Canada was reported on January 25, 2020, in the city of Toronto, Ontario. Over the following four months, the number of individuals diagnosed with COVID-19 in Ontario grew to 28,263 cases. A state of emergency was announced by the Premier of Ontario on March 17, 2020, and the provincial health care system prepared for a predicted surge of COVID-19 patients requiring hospitalization. The Chief Medical Officer of Health and the Minister of Health guided the changes in the system in response to the evolving needs and science related to COVID-19. The pandemic required a rapid, concerted, and coordinated effort from all sectors of the system to optimize and maximize the capacity of the health system. The response to the pandemic in Ontario was complex with some sectors experiencing multiple outbreaks of COVID-19 (i.e. long-term care homes and hospitals). Notably, numerous sectors shifted to virtual delivery of care. By the end of May 2020, it was announced that hospitals would gradually resume postponed or cancelled services. This paper explores the impact of the COVID-19 pandemic on multiple health system sectors (i.e., public health, primary care, long-term care, emergency medical services, and hospitals) in Ontario from January to May 2020. Given the scope of the sectors contributing to the health system in Ontario, this analysis of a regional response to COVID-19 provides insight on how to improve responses and better prepare for future health emergencies.

The Quest for Value in Canadian Healthcare: The Applied Value in Healthcare Framework

The exponential rise in healthcare costs in developed nations has sharpened the need for greater "value" in healthcare. Porter's (2010) seminal work is one of the most cited definitions and equation for value-based care. The pursuit of greater value in our healthcare system is of paramount importance, yet translating value-based healthcare (VBHC) into a framework that can be effectively utilized in the Canadian system remains a challenge. To address this challenge, we propose that VBHC can be adapted to fit the Canadian healthcare system through (1) visionary leadership for and conceptualization of VBHC at the federal government level and (2) thoughtful application of VBHC at the provincial government level. Our applied value in healthcare framework serves as a platform from which VBHC initiatives, programs and outcome measures can be systematically organized and executed within provincial healthcare systems. This methodical approach could support both provincial ministries and their health systems in pursuit of VBHC and provide the basis for explicit measurement of VBHC success, thereby helping to address the pressing issue of sustainability of the Canadian healthcare system while optimizing patient-centred outcomes of care.

OCTANE (Ontario-wide Cancer Targeted Nucleic Acid Evaluation): a platform for intraprovincial, national, and international clinical data-sharing.

Cancer is a genetic disease resulting from germline or somatic genetic aberrations. Rapid progress in the field of genomics in recent years is allowing for increased characterization and understanding of the various forms of the disease. The Ontario-wide Cancer Targeted Nucleic Acid Evaluation (octane) clinical trial, open at cancer centres across Ontario, aims to increase access to genomic sequencing of tumours and to facilitate the collection of clinical data related to enrolled patients and their clinical outcomes. The study is designed to assess the clinical utility of next-generation sequencing (ngs) in cancer patient care, including enhancement of treatment options available to patients. A core aim of the study is to encourage collaboration between cancer hospitals within Ontario while also increasing international collaboration in terms of sharing the newly generated data. The single-payer provincial health care system in Ontario provides a unique opportunity to develop a province-wide registry of ngs testing and a repository of genomically characterized, clinically annotated samples. It also provides an important opportunity to use province-wide real-world data to evaluate outcomes and the cost of ngs for patients with advanced cancer. The octane study is attempting to translate knowledge to help deliver precision oncology in a Canadian environment. In this article, we discuss the background to the study and its implementation, current status, and future directions.

Comprehensive Economic Evaluation of Automatic Optimization in Cardiac Resynchronization Defibrillators (CRT-Ds): Cost-Effectiveness Analysis - A Canadian Perspective

Introduction Innovative algorithms allowing automated optimization of cardiac resynchronization therapy defibrillators (CRT-Ds), have been introduced in Canada. These automatically adjust the A-V interval and appropriately withhold right ventricular (RV) pacing during times it may not be needed. These “adaptive” algorithms may increase response to therapy, as network meta-analyses have demonstrated, reduce hospitalizations, and drastically reduce the need of periodic ultrasound-driven device optimization. We wanted to investigate the cost-effectiveness of these algorithms from a Canadian provincial Healthcare system. Methods Markov Modelling informed by the AdaptivCRT Clinical Trial and propensity score matching with earlier CRT-D trials. Costs of device implantations were achieved from Ontario Case Costing Initiative. Other costs were obtained through Canadian literature reviews. 3% discounting of costs and outcomes was applied. Results The predicted patient survival was 10.97 years with adaptive algorithms and 10.50 years with traditional CRT, a 4.5% increase over lifetime. Deterministic results suggested adaptive algorithms produce 0.31 quality-adjusted life years (QALYs) more than traditional CRT (7.41 vs. 7.10). The cost saving per life-year gained with adaptive algorithms was CAD 2,118.47. The cost saving per QALY was CAD 3,133.83. Conclusions The use of adaptive algorithms was projected to improve average patient survival, quality of life, while avoiding costs. Avoidance of AF-related admissions and cardiac ultrasounds will make the benefits more pronounced.

Risks of preoperative anemia in women undergoing elective hysterectomy and myomectomy

Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications. The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality. In this retrospective, population-based cohort study, we followed up adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) between the years 2013 and 2015 for benign indications in Ontario, Canada. We used linked administrative data from a government-administered, single-payer provincial health care system using Canadian Classification of Health Interventions intervention codes, International Classification of Diseases, 10th revision, diagnostic codes, physician billing codes, and laboratory data from both community and hospital laboratories across the province. Our exposure of interest was preoperative anemia, defined as a hemoglobin value <12 g/dL on the complete blood count measured closest to the date of surgery. Our primary outcome was the composite of 30 day postoperative morbidity and mortality. Secondary outcomes were 5 individual components of the primary outcome: death, transfusion, surgical site infection, venothromboembolism, and return to the hospital within 30 days. To adjust for confounding, we generated a propensity score using a multiple logistic regression model in which the presence of anemia was regressed on all baseline characteristics. We matched anemic to nonanemic patients on the logit of the propensity score. Using an unadjusted log-binomial model estimated using generalized estimating equations to account for the matched pairs, we calculated the relative risk, 95% confidence intervals, and P values to evaluate the effect of anemia on outcomes. Of the 16,218 women in the cohort, 3664 (22.6%) had anemia. After propensity matching, standardized differences in all baseline characteristics (n= 3261 per group) were <0.10. In the matched cohort, the primary outcome (death, complications, or readmission) occurred in 41.2% of anemic patients and 36.2% of nonanemic patients (relative risk, 1.14, 95% confidence interval, 1.07-1.21, P < .0001; absolute risk reduction, 5.03%, 95% confidence interval, 2.70-7.36; (number needed to harm= 20). The risk of transfusion was significantly higher in anemic patients (relative risk, 3.25, 95% confidence interval, 2.67-3.95, P < .0001; absolute risk reduction, 8.34%, 95% confidence interval, 7.06-9.63; number needed to harm= 12). There was no difference in other secondary outcomes. In a subgroup analysis (women >55 years vs ≤55, n= 736), older women were at increased risk of the primary outcome (relative risk, 1.40, 95% confidence interval, 1.12-1.76, P= .004), transfusion (relative risk, 4.20, 95% confidence interval, 1.65-10.72, P= .003), surgical site infection (relative risk, 1.35, 95% confidence interval, 1.01-1.81, P= .04), and return to the hospital (relative risk, 2.36, 95% confidence interval, 1.54-3.62, P < .0001). Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.

Navigating health care systems for military-connected children with autism spectrum disorder: A qualitative study of military families experiencing mandatory relocation.

Most military families experience mandatory relocation, or posting, several times during the military career. For Canadian military families who must access provincial or territorial health care systems, maintaining reasonable continuity of care is a persistent issue. Such challenges may be amplified when a child in a military family has special needs within the health and educational systems. The purpose of this qualitative study was to gain a better understanding of Canadian Armed Forces families' experiences in navigating health care systems on behalf of a child with autism spectrum disorder (ASD) in the context of mandatory relocation. Parents of children with ASD, where at least one parent serves in the Canadian Armed Forces and had faced military-related relocation, were recruited. Semi-structured interviews were recorded, transcribed verbatim, and analyzed thematically. Twelve participants represented 12 families and 15 children with ASD. Participants discussed two primary themes. (1) High mobility inherent in the military lifestyle can create disruptions and discontinuities to service, including delays in diagnosis or intervention, losses and gains in available services determined by the direction of posting, and the need to start health care access processes over again when relocating. (2) Navigating health systems for children with ASD creates personal stress and frustration related to relocating, and has career implications for both parents. Military-related relocation can create significant disruption in access to health and educational services for Canadian military families who have a child with ASD, and take a personal toll on these families.

Lessons Learned: It Takes a Village to Understand Inter-Sectoral Care Using Administrative Data across Jurisdictions.

Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group’s (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia.This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on ‘lessons learned’.The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved.Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ.Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and, for future use, we include a list of ‘lessons learned’ and a list of recommended steps for conducting this kind of work.Key FindingsThe conduct of inter-sectoral research using linked administrative health data requires a committed team that is adequately resourced and has a set of clear, feasible objectives at the start.Guiding principles include: maximization of sectoral participation by including single-jurisdiction expertise and making the most inclusive data decisions; use of living documents that track all data decisions and careful consideration about data quality and availability differences.Inter-sectoral research requires a good understanding of the local healthcare system and other contextual issues for appropriate interpretation of observed differences.

Multi-province epidemiological research using linked administrative data: a case study from Canada.

BackgroundCanada has a publicly-funded universal healthcare system with information systems managed by 13 different provinces and territories. This context creates inconsistencies in data collection and challenges for research or surveillance conducted at the national or multi-jurisdictional level.ObjectiveUsing a recent Canadian research project as a case study, we document the strengths and challenges of using administrative health data in a multi-jurisdictional context. We discuss the implications of using different health information systems and the solutions we adopted to deal with variations. Our goal is to contribute to better understanding of these challenges and the development of a more integrated and harmonized approach to conducting multi-jurisdictional research using administrative data.Context and modelUsing data from five separate provincial healthcare data systems, we sought to create and report on a set of provincially-comparable mental health and addiction services performance indicators. In this paper, we document the research process, challenges, and solutions. Finally, we conclude by making recommendations for investment in national infrastructure that could help cut costs, broaden scope, and increase use of administrative health data that exists in Canada.ConclusionsCanada has an incredible wealth of administrative data that resides in 13 territorial and provincial government systems. Navigating access and improving comparability across these systems has been an ongoing challenge for the past 20 years, but progress is being made. We believe that with some investment, a more harmonized and integrated information network could be developed that supports a broad range of surveillance and research activities with strong policy and program implications.