Vancouver Coastal Health Research Articles

Louis Brier Home and Hospital Rapid Improvement Events: Kaizen and 5S

A public long-term care facility serving Vancouver’s Jewish community, funded by the Vancouver Coastal Health Authority, and supported by the Jewish Foundation. The Louis Brier Home and Hospital offers resident and family centered care.

Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

BackgroundEnd-stage ankle arthritis is often debilitating, associated with diminished mobility, pain, and reduced health related quality of life. Direct hospital costs of AA and TAA differ, with hospital length of stay being a major contributor. The objective of this study is to test the association between four patient-reported outcome measures with hospital length of stay, potentially important for preoperative planning and care. MethodsThis study is based on a prospective cohort of patients scheduled for AA or TAA for end-stage ankle arthritis in the Vancouver Coastal Health authority, Canada. Participants completed a condition-specific instrument, the AOS, and three generic instruments, the PHQ-9, PEG and EQ-5D(3L) shortly after being scheduled for surgery. Multivariate mixed-effects Poisson regression models were used to measure the association between preoperative patient-reported outcome measures and length of stay. ResultsAmong the 183 patients eligible to participate, the participation rate was 48.5%. There were 89 participants. Participants reported a high level of preoperative ankle impairment and pain. The adjusted results found no relationship between the AOS, EQ-5D(3L) VAS or PHQ-9 values and participants’ LOS. Participants with at least one chronic health condition and lowest SES category had longer LOS. ConclusionsThis study found no evidence of an association between four PROs collected prior to AA or TAA with hospital LOS. This finding suggests collecting these PROs preoperatively may not help with discharge planning.

Using scent detection dogs to identify environmental reservoirs of Clostridium difficile: Lessons from the field

Environmental reservoirs have been implicated in transmission of Clostridium difficile infections. Scent detection by canines has demonstrated promising ability to rapidly triage hospital surfaces and equipment. 18 months of data collected post-implementation of the canine scent detection project at Vancouver Coastal Health were used to identify key environmental reservoirs for C. difficile and possible mitigation strategies.

Association of Anemia With Outcomes Among ST-Segment-Elevation Myocardial Infarction Patients Receiving Primary Percutaneous Coronary Intervention.

Anemia may confer a poor prognosis among patients with the acute coronary syndrome. However, few data exist on the association of anemia with in-hospital outcomes, including bleeding, among ST-segment-elevation myocardial infarction patients receiving primary percutaneous coronary intervention. We identified 1919 ST-segment-elevation myocardial infarction patients who had undergone primary percutaneous coronary intervention within the Vancouver Coastal Health Authority (2007-2016) of whom 322 (16.8%) had anemia on admission. Between-group differences in (unadjusted) in-hospital outcomes, including heart failure, cardiogenic shock, major bleeding, and death were examined. Spearman correlation ( rs) and multivariate logistic regression were used to evaluate the relationship of anemia on admission with clinical outcomes. Compared with nonanemic patients, anemic patients were more likely to have preexisting hypertension, diabetes mellitus, and prior myocardial infarction. Anemic patients had higher unadjusted rates of in-hospital death (8.1% versus 3.7%; P<0.001), bleeding (18.2% versus 9.4%; P<0.001), and were more likely to develop heart failure (odds ratio [OR], 1.62; 95% CI, 1.19-2.22), shock (OR, 2.35; 95% CI, 1.62-3.40), or cardiac arrest (OR, 1.94; 95% CI, 1.10-3.40) during their hospital stay. Baseline anemia was independently associated with major bleeding (OR, 1.78; 95% CI, 1.25-2.56) but not all-cause mortality (OR, 0.99; 95% CI, 0.57-1.73). There was no significant correlation between anemia and overall reperfusion times (OR, 0.95; 95% CI, 0.74-1.22). In a contemporary ST-segment-elevation myocardial infarction cohort receiving primary percutaneous coronary intervention, nearly 1 in 5 patients were anemic. Anemia was associated with increased comorbidities and higher-risk features on presentation and was independently associated with subsequent major in-hospital bleeding but not all-cause mortality. These results suggest that anemic ST-segment-elevation myocardial infarction patients may safely receive timely primary percutaneous coronary intervention but with particular consideration for bleeding avoidance strategies.

Protocol for a phase II, open-label exploratory study investigating the efficacy of fesoterodine for treatment of adult patients with spinal cord injury suffering from neurogenic detrusor overactivity for amelioration of autonomic dysreflexia

IntroductionManaging and preventing risk factors associated with cardiovascular and cerebrovascular impairment is well studied in able-bodied individuals. However, individuals with spinal cord injury (SCI) at or above the spinal segment...

Endometrial Cancer Presentation and Outcomes Based on Mismatch Repair Protein Expression From a Population-Based Study.

There is uncertainty about the prognostic significance of mismatch repair (MMR) deficiency in endometrial cancer. The objective was to evaluate clinical characteristics and outcomes of endometrial cancers based on MMR status within a population-based study. This was a retrospective population-based cohort study of all endometrial cancer cases from the Vancouver Coastal Health Authority region, evaluated for 4 MMR proteins using immunohistochemistry from 2012 to 2015. Patients were classified as MMR deficient (dMMR, any MMR protein absent) or MMR proficient (pMMR), Demographics, tumor characteristics, recurrences, and survival rates were compared according to MMR status. There were 892 patients, with 650 pMMR (72.5%) and 242 dMMR tumors. The dMMR group had more endometrioid tumors (87.6% vs 74.0%, P < 0.001), lymphovascular space invasion (43.8% vs 30.8%, P = 0.001), and dedifferentiation (5.9% vs 1.5%, P < 0.001), but fewer grade 1 tumors compared with the pMMR group (31.8% vs 40.8%, P < 0.001). Median progression-free survival and overall survival have not been reached. After a median follow-up of 31 months (1-99 months), there was no difference in progression or recurrence rates between pMMR and dMMR tumors (19.5% vs 16.5%; P = 0.31). However, among those with nonendometrioid tumors, recurrence and mortality rates were significantly higher for pMMR than dMMR tumors (42.0% vs 10.0%, P = 0.001, and 36.1% vs 13.1%, P = 0.01, respectively), despite similar stage and lymphovascular space invasion distributions. In this population-based study, there were no significant differences in recurrence or survival outcomes according to MMR status in endometrial cancer. However, among those with nonendometrioid tumors, there were lower recurrence and mortality rates associated with MMR-deficient compared with MMR-proficient tumors.

Does MMR status in endometrial cancer influence response to adjuvant therapy?

ObjectiveMismatch repair (MMR) deficiency occurs in 20–40% of endometrial cancers but its therapeutic implication remains uncertain. Our objective was to compare clinical outcomes after adjuvant therapy between MMR deficient and proficient endometrial cancers from a population-based study. MethodsThis was a retrospective population-based cohort study of all endometrial cancers from the Vancouver Coastal Health authority region from 2011 to 2016, for which adjuvant therapy (radiotherapy and/or chemotherapy) was administered. Primary outcome measure was recurrence rates, expressed per 100 person-years (p100 py). Progression free survival (PFS) and overall survival (OS) rates were compared using Kaplan-Meier method and log-rank tests, and covariates were evaluated using Cox proportional hazards regression. ResultsThere were 535 patients who received adjuvant therapy (radiotherapy and/or chemotherapy), including 162 (30.3%) and 373 (69.7%) with MMR-deficient and proficient tumors, respectively. Demographic variables were similar except MMR-deficient patients were younger (62.0 vs. 64.8, p = 0.01). Patients with MMR-deficient tumors were more likely to have endometrioid histotype (85.8% vs. 61.4%), more likely to have Stage I disease (62.3% vs 54.7%), and LVSI (65.4% vs. 53.4%) compared to those with MMR-proficient tumors. There was a trend for MMR-proficient group to have higher recurrence rates (10.7 p100 py vs 5.9 p100 py) and MMR deficiency was associated with better OS and PFS, but on multivariable analysis, MMR status was no longer significant. ConclusionWomen with MMR-deficient endometrial cancers who receive adjuvant therapy have a lower rate of recurrence compared to those with MMR-proficient cancers. However, on multivariable analysis, MMR status does not remain associated with differences in PFS or OS.

Enhanced surveillance to monitor response to a provincial overdose emergency, Canada

ObjectiveTo describe the use of multiple data sources to monitor overdoses in near real-time in order to evaluate response to the provincial overdose emergencyIntroductionOn April 14, 2016, British Columbia (BC)’s Provincial Health Officer declared a public health emergency due to a significant increase in drug-related overdoses and deaths in the Province. Despite the declaration, 161 suspected drug overdose deaths were reported across the Province in December 2016, a 137% increase over the number of deaths occurring in the same month of 2015 [1]. In response to the surge overdoses, Vancouver Coastal Health Authority (VCH), one of 5 health regions within BC, rapidly implemented a number of novel harm reduction initiatives. Overdose Prevention Sites (OPS) were opened on December 8, 2016. At these sites, people using illicit drugs are supervised by peers who can provide rapid intervention if an overdose occurs. The Mobile Medical Unit (MMU), a temporary state-of-art medical facility, was deployed on December 13, 2016 to reduce the congestion for the BC Ambulance Service (BCAS) and a major urban emergency department (ED) [2]. Following deployment of the MMU, services were transitioned to a permanent program at the Downtown Eastside Connections Clinic (DTES Connections) in the spring of 2017. DTES Connections was created to provide rapid access to addiction treatment [3]. In order to keep pace with the rapidly increasing number of novel harm reduction initiatives, enhanced surveillance programs were implemented at VCH to monitor and evaluate these innovative harm reduction activities, including development of new surveillance programs for the MMU, OPS and DTES Connections, along with existing routine surveillance system from EDs and a Supervised Injection Site (Insite).MethodsSince 2011, after a spike of heroin-related deaths was reported in the Vancouver region, VCH started weekly monitoring of overdoses at nine EDs and Insite. Daily data extracts from EDs are automatically transferred to a secure driver by secure file transfer protocols. Groups of ICD 9/10 codes and keywords were refined to identify overdoses from EDs. A formal epidemiological evaluation was conducted to measure the algorithm’s accuracy in 2013. A live connection with Insite database was set up in 2011. Overdose events at Insite are clinically determined by clinical staff. Substance injected, characteristics of overdose event and emergency interventions are entered in the database.With the implementation of MMU, OPS and DTES Connections, a series of protocols were developed to monitor visitors' information and overdose events from each site. Demographic information, visit information, clinical presentations and substance used are collected from MMU and DTES Connections. A subset of data fields, including client handle, visit information, substance involved, overdose occurrence, naloxone intervention and ED transfer, are collected from OPS to minimize impact on peers and community partners who run the sites.ResultsBetween November 2016 and January 2017, a sharp increase in overdoses was identified from EDs and Insite. Opioids, especially fentanyl and analogs, most likely contributed to the sudden increase. Weeks with government income assistance payment showed an even greater increase in overdoses.Since December 2016, six OPS opened in Vancouver. Four of them are still operating and one received federal approval to become a supervised consumption site. By September 2017, there were 184,760 visits to the OPS. 1,017 overdoses were reversed.A total of 2,798 patients visited the MMU during the whole operation period. 589 (21%) presented from treatment of overdose. The highest number of overdose visits occurred on December 21, 2016 after that month’s income assistance payment. Since then, the number of visits fluctuated with most visits driven by non-overdose related reasons. 89% of overdose visits arrived by BCAS and 79% of overdoses needed emergent and urgent care.108 patients were transferred to DTES Connections by BCAS for treatment of overdoses by September 2017. All patients presented with opioid addiction issues.As of the end of September 2017, no deaths were reported from OPS, MMU and DTES Connections since operations.ConclusionsAs VCH continues responding to the drug overdose emergency in face of increasing drug overdoses, enhanced surveillance data have been widely used by the VCH Emergency Overdose Response Committee for decision making on harm reduction activities, such as expanding operation hours at OPS and Insite on income assistance payment days; examining the impact on EDs of opening the MMU; encouraging users to avoid using alone; opening new supervised injection service and women’s only OPS; and referring ED patients with non-fatal overdose to rapid access opioid agonist treatment and outreach follow-up.

MP23: A collaborative quality improvement initiative to improve the time to electrocardiogram in patients with chest pain presenting to the emergency department

Introduction: For patients with chest pain, the target time from first medical contact to obtaining an electrocardiogram (ECG) is 10 minutes, as reperfusion within 120 minutes can reduce the risk of death and adverse outcomes in patients with ST elevation myocardial infarction (STEMI). In 2007, Vancouver Coastal Health (VCH) began tracking key indicators including time to first ECG. The Vancouver General Hospital (VGH) Emergency Department (ED) has been troubled with the longest door to ECG times in the region since 2014. In 2016, the VGH ED Quality Council developed a strategy to address this issue, with an aim of obtaining ECGs on 95% of patients presenting to the VGH ED with active chest pain within 10 minutes of presentation within a 6 month period. Methods: The VGH ED Quality Council brought together frontline clinicians, ECG technicians, and other stakeholders and completed a process map. We obtained baseline data regarding the median time to ECG in both patients with STEMI and all patients presenting with chest pain. Root cause analysis determined two main barriers: access to designated space to obtain ECGs, and the need for patients to be registered in the computer system before an ECG could be ordered. The team identified strategies to eliminate these barriers, identifying a dedicated space and undergoing multiple PDSA cycles to change the workflow to stream patients to this space before registration. Results: Our median times in patients with STEMI have gone from 33 minutes to 8 minutes as of June 2017. In all patients presenting with chest pain, we improved from a median of 36 to 17 minutes. As of April 2017 we are obtaining an ECG within 10 minutes in 27% of our patients, compared to 3% in 2016. Given the limitations in our data extraction process, we were not able to differentiate between patients with active chest pain versus those whose chest pain had resolved. Conclusion: By involving frontline staff, and having frontline champions providing real time support, we were able to make significant changes to the culture at triage. We cultivated sustainability by changing the workflow and physical space, and not relying on education only. While we have improved the times for our walk-in patients, we have not perfected the process when a patient moves immediately to a bed or presents via ambulance. Implementing small changes and incorporating feedback has allowed us to identify these new challenges early.

Bullous Pemphigoid: A 10-Year Study of Discordant Results on Direct Immunofluorescence.

Bullous pemphigoid (BP) is the most common subepidermal autoimmune disorder characterized by tense bullae. It is associated with circulating autoantibodies against BP antigen-1 and BP antigen-2. Diagnosis is based upon clinical, histopathologic, and immunopathologic examination. Direct immunofluorescence (DIF) of perilesional skin highlights C3 with or without IgG in a linear pattern along the basement membrane. We hypothesized that repeat biopsies may be required for a definitive DIF diagnosis of BP, as initial DIF evaluation may result in a false-negative result. A retrospective chart review was conducted on 1143 specimens collected for evaluation for BP. Cases from 2 Vancouver Coastal Health Authority laboratories from 2006 to 2016 were reviewed. Results were interpreted as positive, negative, or indeterminate based on pathologic description and specimen quality. After meeting the inclusion criteria, 739 specimens were further evaluated. There were 289 cases of BP in the 10-year period. Five patients (1.73%; 95% confidence interval [CI], 1.50-1.96) required a second biopsy to support a BP diagnosis, and within this group, 1.04% of the 289 (95% CI, 0.811-1.27) were true successive negative-to-positive DIF results. DIF is the most reliable test used to diagnose BP; however, a small percentage of patients will initially have a negative result. False-negative or indeterminate results may be due to specimen sampling from lesional skin or due to a subthreshold quantity of immune complexes in the skin. Repeat biopsy is warranted despite an initial negative DIF if BP is clinically suspected.

Evaluation of the Fecal Incontinence Quality of Life Scale (FIQL) using item response theory reveals limitations and suggests revisions.

The Fecal Incontinence Quality of Life Scale (FIQL) is a commonly used patient-reported outcome measure for fecal incontinence, often used in clinical trials, yet has not been validated in English since its initial development. This study uses modern methods to thoroughly evaluate the psychometric characteristics of the FIQL and its potential for differential functioning by gender. This study analyzed prospectively collected patient-reported outcome data from a sample of patients prior to colorectal surgery. Patients were recruited from 14 general and colorectal surgeons in Vancouver Coastal Health hospitals in Vancouver, Canada. Confirmatory factor analysis was used to assess construct validity. Item response theory was used to evaluate test reliability, describe item-level characteristics, identify local item dependence, and test for differential functioning by gender. 236 patients were included for analysis, with mean age 58 and approximately half female. Factor analysis failed to identify the lifestyle, coping, depression, and embarrassment domains, suggesting lack of construct validity. Items demonstrated low difficulty, indicating that the test has the highest reliability among individuals who have low quality of life. Five items are suggested for removal or replacement. Differential test functioning was minimal. This study has identified specific improvements that can be made to each domain of the Fecal Incontinence Quality of Life Scale and to the instrument overall. Formatting, scoring, and instructions may be simplified, and items with higher difficulty developed. The lifestyle domain can be used as is. The embarrassment domain should be significantly revised before use.

ASSOCIATION OF LEFT ANTERIOR CORONARY ARTERY INVOLVEMENT ON CLINICAL OUTCOMES AMONG STEMI PATIENTS PRESENTING WITH AND WITHOUT OUT-OF-HOSPITAL CARDIAC ARREST

Acute ST elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA) is associated with greater in-hospital mortality compared to STEMI patients without cardiac arrest. However, there has been no prior attempt to discern if there is an independent association of culprit coronary artery involvement with outcomes of STEMI patients with and without OHCA. This study aimed to describe such an independent association. We identified all 1020 patients within the Vancouver Coastal Health Authority (VHCA) who presented with an acute STEMI and who underwent primary percutaneous coronary intervention (pPCI) between June 26, 2007 and March 31, 2016. Among these, there were 91 patients with and 929 without a preceding OHCA. Logistic regression was used to examine the impact of ischemic territory and OHCA on mortality and other outcomes. STEMI patients with OHCA had more in-hospital-cardiac arrest (43.3% vs 8.3% p < 0.001), heart failure (50.5% vs 11.3% p < 0.001), cardiogenic shock (49.5% vs 5.7% p < 0.001) and mortality (35.2% vs 3.3% p < 0.001) compared to STEMI patients without OHCA. Left anterior coronary artery (LACA) involvement was identified in 57.1% of STEMI patients with OHCA and in 47.7% of STEMI patients without OHCA (p=0.085). Among non-OHCA patients, LACA involvement was associated with increased heart failure (18.1% vs 5.2% p < 0.001), in-hospital cardiac arrest (10.7% vs 6.2% p < 0.014), cardiogenic shock (8.4% vs 3.3% p < 0.001) and mortality (5.2% vs 1.3% p=0.003) compared to no LACA involvement, but not in OHCA patients. Logistic regression demonstrated that LACA involvement and OHCA were both independently associated with increased in-hospital mortality, but there was no significant association between the presence of OHCA and LACA involvement (Figure 1). Compared to STEMI patients without OHCA, those with OHCA experienced worse in-hospital outcomes. Similarly, compared to non-ACA involvement, ACA involvement was also associated with worse in-hospital outcomes, but only among STEMI patients without OHCA. This data suggests that ACA involvement in STEMI confers a worse prognosis among STEMI patients without OHCA, and suggests that OHCA patients have other high risk features that drive their poor outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Improving the quality of healthcare data through information design

Improving the quality of patient care, generally referred to as Quality Improvement (QI), is a constant mission of healthcare. Although QI initiatives take many forms, these typically involve collecting data to measure whether changes to procedures have been made as planned, and whether those changes have achieved the expected outcomes. In principle, such data are used to measure the success of a QI initiative and make further changes if needed. In practice, however, many QI data reports provide only limited insight into changes that could improve patient care. Redesigning standard approaches to QI data can help close the gap between current norms and the potential of QI data to improve patient care. This paper describes our study of QI data needs among healthcare providers and managers at Vancouver Coastal Health, a regional health system in Canada. We present an overview of challenges faced by healthcare providers around QI data collection and visualization, and illustrate the advantages and disadvantages of different visualizations. At present, user– centred and evidence–based design is practically unknown in healthcare QI, and thus offers an important new contribution.

Vested outsourcing in corporate real estate and facilities management

In 2003 the University of Tennessee began a research project tasked to answer a simple question: ‘Is there a better way to outsource?’ Researchers studied some of the world’s most successful outsourcing relationships, including Procter &amp; Gamble, Microsoft and McDonald’s. Researchers immediately saw trends in these successful relationships where organisations were shifting away from transaction-based agreements to collaborative outcome-based outsourcing relationships that the researchers described as a ‘vested’ mind-set. Researchers codified their learning into a methodology they coined ‘Vested Outsourcing®’, or Vested for short. Today, Vested is referred to as a mind-set, methodology and business model that enables highly collaborative relationships in which buying organisations and their service providers are committed equally to each other’s success. Organisations that have applied the concept often refer to it as a movement because of its power to transform the way organisations outsource. This article addresses the fundamentals of Vested Outsourcing as well as its applicability to corporate real estate and facilities management, including under what circumstances it can be most beneficial. Case studies from within Corporate Real Estate and Facilities Management (CREFM) are shared, including TD Bank, Vancouver Coastal Health and Novartis.

Cancer mortality in Yukon 1999–2013: elevated mortality rates and a unique cancer profile

ABSTRACTBackground: Although cancer is the leading cause of death in Canada, cancer in the North has been incompletely described.Objective: To determine cancer mortality rates in the Yukon Territory, compare them with Canadian rates, and identify major causes of cancer mortality.Design: The Yukon Vital Statistics Registry provided all cancer deaths for Yukon residents between 1999-2013. Age-standardised mortality rates (ASMRs) were calculated using direct standardisation and compared with Canadian rates. Standardised mortality ratios (SMRs) were calculated using indirect standardisation relative to age-specific rates from Canada, British Columbia (BC), and three sub-provincial BC administrative health regions : Interior Health (IH), Northern Health (NH) and Vancouver Coastal Health (VCH). Trends in smoothed ASMRs were examined with graphical methods.Results: Yukon’s all-cancer ASMRs were elevated compared with national and provincial rates for the entire period. Disparities were greatest compared with the urban VCH: prostate (SMRVCH=246.3, 95% CI 140.9–351.6), female lung (SMRVCH=221.2, 95% CI 154.3–288.1), female breast (SMRVCH=169.0 95% CI, 101.4–236.7), and total colorectal (SMRVCH=149.3, 95% CI 101.8–196.8) cancers were significantly elevated. Total stomach cancer mortality was significantly elevated compared with all comparators.Conclusions: Yukon cancer mortality rates were elevated compared with national, provincial, urban, and southern-rural jurisdictions. More research is required to elucidate these differences.

Abstract B86: Novel assessment of SPARC expression by hierarchical clustering in pancreatic ductal adenocarcinoma shows distinct prognostic and predictive groups

Abstract Background: Secreted Protein, Acid, Cysteine-Rich (SPARC) has been classified as a marker of poor prognosis and has been postulated as a therapeutic target in pancreatic ductal adenocarcinoma (PDAC). The clinical trial findings have been discordant with Phase I/II trials declaring that patients treated with nab-paclitaxel and gemcitabine whose tumors express SPARC in the stromal component have a significantly improved response. Unfortunately, these results were not validated in a subsequent Phase III trial. The focus of examining SPARC expression in a particular component and using nab-paclitaxel, which binds to SPARC, sets the stage for partial clinical efficacy due to component expression heterogeneity. The goal of this study is to develop an integrated component based approach to the quantification of SPARC in PDAC to reveal discrete prognostic and predictive groups in a cohort of resected patients treated with an adjuvant pyrimidine analog or subjected to post-surgical observation. Methods: Tissue-microarray based immunohistochemical quantification of SPARC expression was performed in the epithelial and stromal histological components of 246 resected PDACs from the Vancouver Coastal Health Region collected between 1989-2013. The semi-quantitative H-Score methodology was used where the percent of cells staining for SPARC is multiplied by the subjective assessment of its intensity (1-3) resulting in a range of scores between 0 - 300. These scores were subjected to unsupervised hierarchical clustering using Ward’s algorithm. The number of clusters was determined through an a priori decision that no cluster could have a resultant N &amp;lt; 30. Comparisons of component specific H-Scores across the resultant clusters were performed with the non-parametric Steel-Dwass test for multiple comparisons. Univariable disease specific survival (DSS) analysis was performed with the Kaplan-Meier method to examine the cluster specific survival profiles with regard to prognostic and predictive effects. The proportional hazards model was used to perform multivariable DSS to determine if the resultant prognostic groups were statistically independent when other known prognostic variables were considered. Results: The distribution of H-Scores spanned the entire range of possible values for both the epithelial and stromal components with medians [IQRs] of 120 [120] and 270 [120] respectively. The two-variable hierarchical clustering procedure yielded six clusters ranging in size from 31 to 51 cases. Kaplan-Meier curves showed no statistically significant differences between any of the clusters. However, the cluster exhibiting the best prognosis (N=36) also had significantly lower H-Scores for the stromal component compared to the remaining 5 clusters (p&amp;lt;0.0001). Similar differences were observed for the epithelial component with statistically significant differences observed in 4 (p&amp;lt;=0.0008) of the 5 comparisons. Based on these data, the five clusters with higher expression and one with low were respectively categorized as SPARCHigh (N =243) and SPARCLow (N=36). Kaplan-Meier analysis showed that the SPARCLow cohort had a 7.4-month survival advantage (p=0.03). Multivariable analysis was performed including: age at surgery, adjuvant chemotherapy, lymphovascular invasion, perineural invasion, pN Stage, and tumor budding which showed that the SPARCLow/High categorization is of independent prognostic significance (p=0.03). Assessment of the predictive ability of the six SPARC clusters showed that three of the six clusters representing 117 (47%) patients in this cohort would benefit from adjuvant pyrimidine analog based therapy. The three predictive clusters had concordant high or low expression in both components. Conclusion: This study illustrates that there is enhanced value in a combinatorial approach to the examination of SPARC in the stromal and epithelial components of PDAC where we have confirmed its status as a negative prognostic marker. While this cohort cannot address the issue of nab-paclitaxel in PDAC, we have noted that heterogeneity of SPARC expression at the component level can yield discrete predictive groups with regard to response to adjuvant pyrimidine analogs. Citation Format: Steve E. Kalloger, Joanna M. Karasinska, HuiLi Wong, Daniel J. Renouf, David F. Schaeffer.{Authors}. Novel assessment of SPARC expression by hierarchical clustering in pancreatic ductal adenocarcinoma shows distinct prognostic and predictive groups. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr B86.

Vancouver Coastal Health's Second Generation Health Strategy: A need for a reboot?

In this commentary, we consider the motivations and implications of Vancouver Coastal Health's place-based population health strategy called the Downtown Eastside Second Generation Health Strategy (2GHS) in light of a broader historical view of shifting values in population and public health and structural health reforms in Canada over the past three decades. We argue that the tone and content of the 2GHS signals a shift towards a neoliberal clientelist model of health that treats people as patients and the DTES as a site of clinical encounter rather than as a community in its own right. In its clinical emphasis, the 2GHS fails to recognize the political dimension of health and well-being in the DTES, a community that faces compounding health risks associated with colonialism, gentrification, human displacement, the criminalization of poverty, sex work, and the street economy. Furthermore, we suggest that in its emphasis on allocating funding based on a rationalist model of health system access, the 2GHS undermines well-established insights and best practices from community-driven health initiatives. Our aim is to provide a provocation that will encourage public health policy-makers to embrace community-based leadership as well as the broader structural health determinants that are at the root of the current circumstances of people in the DTES and other marginalized communities in Canada.

Do neighbourhoods in Vancouver and surrounding areas demonstrate different rates of bystander CPR and survival for out-of-hospital cardiac arrest?

No prior work exists examining the relation between the geographic distribution of out-of-hospital cardiac arrest (OHCA) in the city of Vancouver and surrounding areas that may exhibit a clustering of cases. The primary objective of this study was to describe the distribution of OHCA within the Vancouver Coastal Health region using a geographic information system (GIS) analysis and appropriate statistical analyses. This study was a post-hoc GIS-based analysis of OHCA patients in the city of Vancouver and surrounding areas, using data collected by the Resuscitation Outcomes Consortium between September 2007 and December 2011. The kernel density techniques and regression tree analysis using binary recursive partitioning were used. We examined 1617 cases of OHCA with a mortality rate of 86.5% (95% CI 84.8-88.2). The mean age of OHCA cases was 66.6 years (95% CI 65.7-67.5), and 33.6% (95% CI 31.3-35.9) were female. The proportion with an initial shockable rhythm (VF or pulseless VT) was 22.2% (95% CI 20.2-24.2); 42.3% (95% CI 39.9-44.7) of all cases received bystander CPR, and 49.7% (95% CI 47.3-52.1) were transported to the hospital by paramedics. The rate of survival to hospital discharge with favourable neurological status (FNS) Cerebral Performance Category (CPC) 1 or 2 was 10.4% (8.9-11.9). Distance of transport to the hospital (less than 2.7 km) was a significant predictor of survival with FNS, but income did not predict survival with FNS. Areas with higher proportions of commuters by car demonstrated lower rates of survival with FNS. This is the first GIS-based study to examine OHCA in a single large Canadian centre. Clustering of OHCA consistent with areas of high population density was observed. Distance of transport was a significant predictor of survival with FNS for patients with OHCA. This may have important implications for future emergency medical services deployment and dispatch decision-making, and public policy initiatives.

Expanding patient engagement in quality improvement and health system redesign: Three Canadian case studies.

Healthcare organizations face growing pressures to increase patient-centred care and to involve patients more in organizational decisions. Yet many providers worry that such involvement requires additional time and resources and do not see patients as capable of contributing meaningfully to decisions. This article discusses three efforts in four organizations to engage patients in quality improvement efforts. McGill University Health Centre, Saskatoon Health Region, and Vancouver Coastal and Fraser Health Regions all engaged patients in quality improvement and system redesign initiatives that were successful in improving care processes, outcomes, and patient experience measures. Patient involvement in redesigning care may provide a way to demonstrate the value of patients' experiences and inputs into problem-solving, building support for their involvement in other areas. Further study of these cases and a broader survey of organizational experiences with patient involvement may help elucidate the factors that support greater patient engagement.

Clinical Recognition of Melanoma in Dermatologists and Nondermatologists.

The incidence of melanoma is increasing annually in Canada. This retrospective study was designed to assess the ability of physicians of different specialties to accurately recognize melanoma. Pathology reports of biopsies submitted to Vancouver Coastal Health with clinical diagnoses of melanoma were reviewed (January to July 2013). The clinical diagnoses made by dermatologists, general practitioners and family physicians, and all other specialists were correlated with the final histopathologic diagnoses. The dermatologists, general practitioners and family physicians, and all other specialists achieved diagnostic accuracies of 24.75%, 3.52%, and 12.75%, respectively. Although the diagnostic accuracy of dermatologists was significantly better than that the other practitioners, the majority of patients with suspicious skin lesions present to family physicians or general practitioners first. Thus, there is considerable value in providing more training and education to nondermatologists, because it can have a meaningful impact on patient care.