CMAJ open最新文献

{"title":"Hospital discharges for substance-related injuries before and during the COVID-19 pandemic: a descriptive surveillance study using administrative data.","authors":"Stephanie Toigo, Steven R McFaull, Wendy Thompson","doi":"10.9778/cmajo.20220164","DOIUrl":"10.9778/cmajo.20220164","url":null,"abstract":"<p><strong>Background: </strong>The COVID-19 pandemic and associated behavioural changes have contributed to an increase in substance-related hospital discharges, and has altered the injury epidemiology landscape in Canada. We sought to evaluate hospital discharges for substance-related injuries during the pandemic compared with prepandemic and to identify subpopulations that have been greatly affected by substance-related injuries during the first year of the pandemic.</p><p><strong>Methods: </strong>We compared data on hospital discharges in Canada from before the pandemic (March 2019-February 2020) with discharges during the first year of the pandemic (March 2020-February 2021) using the Discharge Abstract Database. We identified discharges for substance-related injuries using codes from the <i>International Statistical Classification of Diseases and Related Health Problems, 10th Revision</i>. We calculated percent changes, age-standardized rates and age-specific rates of discharges for substance-related injuries.</p><p><strong>Results: </strong>Hospital discharges for substance-related injuries increased by 7.1% during the first year of the pandemic. Discharges for intentional injuries decreased by 6.3%, whereas unintentional substance-related injuries increased by 15.1% during this period. Male patients accounted for 95.6% of the increase in hospital discharges for substance-related injuries during the first year of the pandemic. We observed a percent increase among discharges for injuries related to alcohol, opioid, cannabinoid, hallucinogen, tobacco, volatile solvents, other psychoactive substances and polysubstance use.</p><p><strong>Interpretation: </strong>We observed an increase in hospital discharges for substance-related injuries during the first year of the COVID-19 pandemic, compared with the same time period before the pandemic. This work will provide useful insight into the ongoing management of the COVID-19 pandemic, as well as future policy and health care planning related to substance use in Canada.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E54-E61"},"PeriodicalIF":0.0,"publicationDate":"2023-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/1d/e9/cmajo.20220164.PMC9876582.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9619480","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Universal ophthalmia neonatorum prophylaxis in Ontario: a cost-effectiveness analysis.","authors":"Ellen C Rowlands Snyder,&nbsp;Elspeth McGregor,&nbsp;Doug Coyle","doi":"10.9778/cmajo.20210226","DOIUrl":"https://doi.org/10.9778/cmajo.20210226","url":null,"abstract":"<p><strong>Background: </strong>Although prophylaxis for ophthalmia neonatorum at birth is required by law in Ontario, declining prevalence of disease and efficacy of prophylaxis have called this practice into question. The objective of this modelling study was to assess the cost-effectiveness of universal prophylaxis for ophthalmia neonatorum to inform decision-makers on the potential impact of a change in this policy.</p><p><strong>Methods: </strong>We compared the cost-effectiveness of prophylaxis for ophthalmia neonatorum with no prophylaxis through cost-utility analysis with a lifetime time horizon, considering a provincial government payer, for a hypothetical population of newborns in Ontario. We assessed both the mean incremental costs of prophylaxis and its mean incremental effectiveness using a hybrid (part decision tree, part Markov) model. We used a scenario analysis to evaluate alternative time horizons and discount rates. We conducted a threshold analysis to evaluate the impact of variations in the cost of prophylaxis and in the prevalence of sexually transmitted infections (gonorrhea and chlamydia).</p><p><strong>Results: </strong>In our model, prophylaxis for ophthalmia neonatorum did not meet a willingness-to-pay threshold of Can$50 000 per quality-adjusted life-year (QALY). Although prophylaxis was effective in reducing morbidity associated with ophthalmia neonatorum, the number needed to treat to prevent 1 case of ophthalmia neonatorum blindness was 500 000, with an associated cost of more than Can$4 000 000. When compared with no prophylaxis, prophylaxis had an incremental cost of Can$355 798 per long-term QALY gained (incremental cost-effectiveness ratio).</p><p><strong>Interpretation: </strong>We found that prophylaxis for ophthalmia neonatorum, although individually inexpensive, leads to very high costs on a population level. These findings contribute to the discussion on mandatory prophylaxis currently underway in several jurisdictions.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E33-E39"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d4/8f/cmajo.20210226.PMC9851624.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9243139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-effectiveness modelling of birth and infant dose vaccination against hepatitis B virus in Ontario from 2020 to 2050.","authors":"Mia J Biondi,&nbsp;Chris Estes,&nbsp;Devin Razavi-Shearer,&nbsp;Kanwar Sahdra,&nbsp;Nechama Lipton,&nbsp;Hemant Shah,&nbsp;Camelia Capraru,&nbsp;Harry L A Janssen,&nbsp;Homie Razavi,&nbsp;Jordan J Feld","doi":"10.9778/cmajo.20210284","DOIUrl":"https://doi.org/10.9778/cmajo.20210284","url":null,"abstract":"Background: The World Health Organization recommends universal birth dose vaccination for hepatitis B virus (HBV), yet only 3 provinces and territories in Canada provide birth dose vaccination, and Canadian-born children in Ontario are acquiring HBV before adolescent vaccination. We sought to determine whether birth and/or infant HBV vaccination is cost-effective. Methods: We used a dynamic HBV model that incorporates population by year, disease stage, sex and the influence of immigration to quantify the disease and economic burden of chronic HBV infection in Ontario from 2020 to 2050. We compared 4 vaccination scenarios, which included a birth dose vaccine and variations of the 2 subsequent doses (either alone or as a part of the hexavalent vaccine) and a hexavalent-only strategy in infancy with the current adolescent vaccination strategy. Our costing estimates were based on values from 2020. Results: All 4 infant vaccination approaches prevented an additional 550–560 acute and 160 chronic pediatric HBV infections from 2020 to 2050 compared with adolescent vaccination. Whereas birth dose could be cost-effective, incorporating vaccination into a hexavalent vaccine was cost saving. By 2050, the hexavalent approach led to $428 000 in cost savings per disability-adjusted life years averted. Interpretation: At the current prevalence in Ontario, a switch to birth dose or infant dose will be cost-effective or even cost saving. Introducing any form of infant HBV immunization in Ontario will prevent acute and chronic pediatric HBV infections.","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E24-E32"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/91/1c/cmajo.20210284.PMC9842099.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9250470","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses.","authors":"Bridget L Ryan,&nbsp;Luke Mondor,&nbsp;Walter P Wodchis,&nbsp;Richard H Glazier,&nbsp;Leslie Meredith,&nbsp;Martin Fortin,&nbsp;Moira Stewart","doi":"10.9778/cmajo.20220006","DOIUrl":"https://doi.org/10.9778/cmajo.20220006","url":null,"abstract":"<p><strong>Background: </strong>Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched).</p><p><strong>Methods: </strong>Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls.</p><p><strong>Results: </strong>There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]).</p><p><strong>Interpretation: </strong>Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods.</p><p><strong>Ontario: </strong>ClinicalTrials.gov : 104191.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E45-E53"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/72/55/cmajo.20220006.PMC9851625.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9250483","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prescribing, deprescribing and potential adverse effects of proton pump inhibitors in older patients with multimorbidity: an observational study.","authors":"Carole E Aubert,&nbsp;Manuel R Blum,&nbsp;Viktoria Gastens,&nbsp;Olivia Dalleur,&nbsp;Fanny Vaillant,&nbsp;Emma Jennings,&nbsp;Drahomir Aujesky,&nbsp;Wade Thompson,&nbsp;Tijn Kool,&nbsp;Cornelius Kramers,&nbsp;Wilma Knol,&nbsp;Denis O'Mahony,&nbsp;Nicolas Rodondi","doi":"10.9778/cmajo.20210240","DOIUrl":"https://doi.org/10.9778/cmajo.20210240","url":null,"abstract":"Background: Proton pump inhibitors (PPIs) contribute to polypharmacy and are associated with adverse effects. As prospective data on longitudinal patterns of PPI prescribing in older patients with multimorbidity are lacking, we sought to assess patterns of PPI prescribing and deprescribing, as well as the association of PPI use with hospital admissions over 1 year in this population. Methods: We conducted a prospective, longitudinal cohort study using data from the Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM) trial, a randomized controlled trial testing an intervention to reduce inappropriate prescribing (2016–2018). This trial included adults aged 70 years and older with at least 3 chronic conditions and prescribed at least 5 chronic medications. We assessed prevalence of PPI use at time of hospital admission, and new prescriptions and deprescribing at discharge, and at 2 months and 1 year after discharge, by intervention group. We used a regression with competing risk for death to assess the association of PPI use with readmissions related to their potential adverse effects, and all-cause readmission. Results: Overall, 1080 (57.4%) of 1879 patients (mean age 79 yr) had PPI prescriptions at admission, including 496 (45.9%) patients with a potentially inappropriate indication. At discharge, 133 (24.9%) of 534 patients in the intervention group and 92 (16.8%) of 546 patients in the control group who were using PPIs at admission had deprescribing. Among 680 patients who were not using PPIs at discharge, 47 (14.6%) of 321 patients in the intervention group and 40 (11.1%) of 359 patients in the control group had a PPI started within 2 months. Use of PPIs was associated with all-cause readmission (n = 770, subdistribution hazard ratio 1.31, 95% confidence interval 1.12–1.53). Interpretation: Potentially inappropriate use of PPI, new PPI prescriptions and PPI deprescribing were frequent among older adults with multimorbidity and polypharmacy. These data suggest that persistent PPI use may be associated with clinically important adverse effects in this population.","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E170-E178"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/34/cd/cmajo.20210240.PMC9981164.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9251655","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparative effectiveness of metformin versus sulfonylureas on kidney function decline or death among patients with reduced kidney function: a retrospective cohort study.","authors":"Adriana M Hung,&nbsp;Amber J Hackstadt,&nbsp;Marie R Griffin,&nbsp;Carlos G Grijalva,&nbsp;Robert A Greevy,&nbsp;Christianne L Roumie","doi":"10.9778/cmajo.20210207","DOIUrl":"https://doi.org/10.9778/cmajo.20210207","url":null,"abstract":"<p><strong>Background: </strong>Diabetes often causes kidney disease. In this study, we sought to evaluate if metformin use was associated with death or kidney events in patients with diabetes and concurrent reduced kidney function.</p><p><strong>Methods: </strong>We used data from the Veterans Health Administration, Medicare and National Death Index databases to assemble a national retrospective cohort of veterans who were using metformin or sulfonylureas from 2001 through 2016 and who began follow-up at an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m². The primary composite outcome was a kidney event (i.e., 40% decline in eGFR or end-stage renal disease) or death. The secondary outcome was a kidney event (eGFR decline or end-stage renal disease). We weighted the cohort using propensity scores and used Cox proportional models to estimate the cause-specific hazard of outcomes and of treatment nonpersistence as a competing risk. We stratified follow-up into 2 periods, namely the first 360 days from the start of follow-up, and 361 days and beyond.</p><p><strong>Results: </strong>In the first 360 days, the propensity score-weighted cohort included 24 883 patients who used metformin and 24 998 who used sulfonylureas. There were 33.5 (95% confidence interval [CI] 30.9-36.3) and 43.0 (95% CI 40.1-46.0) deaths or kidney events per 1000 person-years for patients who used metformin or sulfonylureas, respectively (hazard ratio [HR] 0.78, 95% CI 0.71-0.85). For the secondary outcome of kidney events, the HR was 0.94 (95% CI 0.67-1.33). In the second period from 361 days onward, the primary outcome event rate was 26.5 (95% CI 24.7-28.5) per 1000 person-years for those who used metformin, compared with 36.3 (95% CI 34.2-38.6) per 1000 person-years for those who used sulfonylureas (HR 0.73, 95% CI 0.67-0.79). Results were consistent for kidney events alone (HR 0.73, 95% CI 0.59-0.91).</p><p><strong>Interpretation: </strong>Metformin use for 361 days or longer after reaching an eGFR of less than 60 mL/min/1.73 m² was associated with decreased likelihood of kidney events or death in patients with diabetes, compared with use of sulfonylureas. Metformin provided end-organ protection, in addition to glucose control.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E77-E89"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/39/04/cmajo.20210207.PMC9894655.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9243630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Estimating the test-adjusted incidence of <i>Chlamydia trachomatis</i> infections identified through Public Health Ontario Laboratories in Peel region, Ontario, 2010-2018: a population-based study.","authors":"Lindsay Obress,&nbsp;Olaf Berke,&nbsp;David N Fisman,&nbsp;Shilpa Raju,&nbsp;Ashleigh R Tuite,&nbsp;Monali Varia,&nbsp;Amy L Greer","doi":"10.9778/cmajo.20210236","DOIUrl":"https://doi.org/10.9778/cmajo.20210236","url":null,"abstract":"<p><strong>Background: </strong>Public health guidelines for chlamydia testing are not sex specific, but young females test at a disproportionally higher rate than males and other age groups. This study aims to describe testing trends across age and sex subgroups, then estimate a test-adjusted incidence of chlamydia in these subgroups to identify gaps in current testing practices.</p><p><strong>Methods: </strong>We used a population-based study to examine observed chlamydia rates by age and sex subgroups: 15-19 years, 20-29 years, 30-39 years and older than 40 years. The study included diagnostic test results recorded by Public Health Ontario Laboratories between Jan. 1, 2010, and Dec. 31, 2018, for individuals living in Peel region, Ontario. We then employed meta-regression models as a method of standardization to estimate the effect of sex and age on standardized morbidity ratio, testing ratio and test positivity, then calculate a test-adjusted incidence of chlamydia for each subgroup.</p><p><strong>Results: </strong>Over the study period, infection, testing and test positivity varied across age and sex subgroups. Observed incidence and testing were highest in females aged 20-29 years, whereas males had the highest standardized test positivity across all age groups. After estimating test-adjusted incidence for each age-sex subgroup, males in the 15-19-year and 30-39-year age groups had an increase in incidence of 60.2% and 9.7%, respectively, compared with the observed incidence.</p><p><strong>Interpretation: </strong>We found that estimated test-adjusted incidence was higher than observed incidence in males aged 15-19 years and 30-39 years. This suggests that infections in males are likely being missed owing to differential testing, and this may be contributing to the persistent increase in reported cases in Canada. Public health programming that targets males, especially in high-risk settings and communities, and use of innovative partner notification methods could be critical to curbing overall rates of chlamydia.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E62-E69"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/c0/2b/cmajo.20210236.PMC9876583.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9619481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Physician perceptions of restrictive visitor policies during the COVID-19 pandemic: a qualitative study.","authors":"Kirsten Wentlandt,&nbsp;Kayla T Wolofsky,&nbsp;Andrea Weiss,&nbsp;Lindsay Hurlburt,&nbsp;Eddy Fan,&nbsp;Camilla Zimmermann,&nbsp;Sarina R Isenberg","doi":"10.9778/cmajo.20220048","DOIUrl":"https://doi.org/10.9778/cmajo.20220048","url":null,"abstract":"<p><strong>Background: </strong>Little is understood of the consequences of restrictive visitor policies that were implemented in hospitals to minimize risk of infection during the COVID-19 pandemic. The objective of this study was to describe physician experiences with these policies and reflections of their effects.</p><p><strong>Methods: </strong>We conducted semistructured phone interviews from September 2020 to March 2021 with physicians practising in Ontario hospitals, recruited via professional networks and snowball sampling. We audio-recorded, transcribed and analyzed interviews to describe and interpret overarching themes by thematic analysis.</p><p><strong>Results: </strong>We interviewed 21 physicians (5 intensivists, 5 internists, 11 specialists in palliative care). Four main thematic categories emerged, including provider, system, patient and caregiver effects. Provider-related factors included increased time and effort on communication with a need to establish limits; increased effort to develop rapport with caregivers; lack of caregiver input on patient care; the need to act as a caregiver surrogate; and the emotional toll of being a gatekeeper or advocate for visitors, exacerbated by lack of evidence for restrictions and inconsistent enforcement. System effects included the avoidance of hospital admission and decreased length of stay, leading to readmissions, increased deaths at home and avoidance of transfer to other facilities with similar policies. Patient-related factors included isolation and dying alone; lack of caregiver advocacy; and prioritization of visitor presence that, at times, resulted in a delay or withdrawal of aspects of care. Caregiver-related factors included inability to personally assess patient health, leading to poor understanding of patient status and challenging decision-making; perceived inadequate communication; difficulty accessing caregiver supports; and increased risk of complicated grief. Participants highlighted a disproportionate effect on older adults and people who did not speak English.</p><p><strong>Interpretation: </strong>Our study highlights substantial negative consequences of restrictive visitor policies, with heightened effects on older adults and people who did not speak English. Research is required to identify whether the benefits of visitor restrictions on infection control outweigh the numerous deleterious consequences to patients, families and care providers.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E110-E117"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/51/5f/cmajo.20220048.PMC9911125.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9251141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study.","authors":"Alex M Cressman,&nbsp;Ushma Purohit,&nbsp;Ellen Shadowitz,&nbsp;Edward Etchells,&nbsp;Adina Weinerman,&nbsp;Darren Gerson,&nbsp;Kaveh G Shojania,&nbsp;Lynfa Stroud,&nbsp;Brian M Wong,&nbsp;Steve Shadowitz","doi":"10.9778/cmajo.20220020","DOIUrl":"https://doi.org/10.9778/cmajo.20220020","url":null,"abstract":"<p><strong>Background: </strong>Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.</p><p><strong>Methods: </strong>We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.</p><p><strong>Results: </strong>We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (<i>p</i> < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.</p><p><strong>Interpretation: </strong>Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E201-E207"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/77/5a/cmajo.20220020.PMC9981162.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9251652","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perceived workplace support and mental health, well-being and burnout among health care professionals during the COVID-19 pandemic: a cohort analysis.","authors":"Imrana Siddiqui,&nbsp;Jaya Gupta,&nbsp;George Collett,&nbsp;Iris McIntosh,&nbsp;Christina Komodromos,&nbsp;Thomas Godec,&nbsp;Sher Ng,&nbsp;Carmela Maniero,&nbsp;Sotiris Antoniou,&nbsp;Rehan Khan,&nbsp;Vikas Kapil,&nbsp;Mohammed Y Khanji,&nbsp;Ajay K Gupta","doi":"10.9778/cmajo.20220191","DOIUrl":"https://doi.org/10.9778/cmajo.20220191","url":null,"abstract":"<p><strong>Background: </strong>Little is known about the relationship between workplace support and mental health and burnout among health care professionals (HCPs) during the COVID-19 pandemic. In this cohort study, we sought to evaluate the association between perceived level of (and changes to) workplace support and mental health and burnout among HCPs, and to identify what constitutes perceived effective workplace support.</p><p><strong>Methods: </strong>Online surveys at baseline (July-September 2020) and follow-up 4 months later assessed the presence of generalized anxiety disorder (using the 7-item Generalized Anxiety Disorder scale [GAD-7]), clinical insomnia, major depressive disorder (using the 9-item Patient Health Questionnaire), burnout (emotional exhaustion and depersonalization) and mental well-being (using the Short Warwick-Edinburgh Mental Wellbeing Score). Both surveys assessed self-reported level of workplace support (single-item Likert scale). For baseline and follow-up, independently, we developed separate logistic regression models to evaluate the association of the level of workplace support (tricohotomized as unsupported, neither supported nor unsupported and supported) with mental health and burnout. We also developed linear regression models to evaluate the association between the change in perceived level of workplace support and the change in mental health scores from baseline and follow-up. We used thematic analyses on free-text entries of the baseline survey to evaluate what constitutes effective support.</p><p><strong>Results: </strong>At baseline (<i>n</i> = 1422) and follow-up (<i>n</i> = 681), HCPs who felt supported had reduced risk of anxiety, depression, clinical insomnia, emotional exhaustion and depersonalization, compared with those who felt unsupported. Among those who responded to both surveys (<i>n</i> = 681), improved perceived level of workplace support over time was associated with significantly improved scores on measures of anxiety (adjusted β -0.13, 95% confidence interval [CI] -0.25 to -0.01), depression (adjusted β -0.17, 95% CI -0.29 to -0.04) and mental well-being (adjusted β 0.19, 95% CI 0.10 to 0.29), independent of baseline level of support. We identified 5 themes constituting effective workplace support, namely concern or understanding for welfare, information, tangible qualities of the workplace, leadership and peer support.</p><p><strong>Interpretation: </strong>We found a significant association between perceived level of (and changes in) workplace support and mental health and burnout of HCPs, and identified potential themes that constitute perceived workplace support. Collectively, these findings can inform changes in guidance and national policies to improve mental health and burnout among HCPs. <b>Trial registration:</b> ClinicalTrials.gov, no. NCT04433260.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E191-E200"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d7/13/cmajo.20220191.PMC9981163.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9251657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}