65 research outputs found
Development and validation of a hospital indicator of resource use intensity for injury admissions
Introduction : Les blessures reprĂ©sentent la 5Ăšme cause dâhospitalisation au Canada. En 2010, leur soins ont coutĂ© 16 milliards de dollars. Selon des Ă©tudes AmĂ©ricaines, lâutilisation des ressources en traumatologie nâest pas strictement dictĂ©e par lâĂ©tat des patients. Toutefois, le manque dâoutil de mesure et de surveillance de lâintensitĂ© dâutilisation des ressources a jusque lĂ empĂȘchĂ© le dĂ©veloppement dâinterventions visant Ă amĂ©liorer lâefficience des soins en traumatologie. Objectifs : Notre objectif gĂ©nĂ©ral Ă©tait de dĂ©velopper et valider un indicateur de lâintensitĂ© dâutilisation des ressources pour les soins aigus en traumatologie. Nos objectifs spĂ©cifiques Ă©taient de (1) faire une synthĂšse des mĂ©thodes dâĂ©valuation des coĂ»ts des soins aigus en traumatologie ; (2) estimer lâutilisation des ressources pour les soins aigus en traumatologie, identifier les dĂ©terminants de cette utilisation et en Ă©valuer la variation inter-hospitaliĂšre et (3) dĂ©velopper un indicateur de lâintensitĂ© dâutilisation des ressources pour les soins aigus en traumatologie et en Ă©valuer les validitĂ©s interne et temporelle. MĂ©thodes : Pour le premier objectif, nous avons effectuĂ© une revue systĂ©matique de la littĂ©rature. Pour les second et troisiĂšme objectifs, nous avons menĂ© des Ă©tudes de cohortes ur les personnes de â„ 16 ans hospitalisĂ©es dans les centres de traumatologie pour adultes au QuĂ©bec, de 2014 Ă 2016. Nous avons extrait les donnĂ©es du registre des traumatismes et des rapports financiers des hĂŽpitaux et estimĂ© lâutilisation des ressources avec des coĂ»ts par centre dâactivitĂ© hospitaliĂšre. Pour le second objectif, nous avons identifiĂ© les dĂ©terminants avec un modĂšle linĂ©aire multi-niveau, dĂ©terminĂ© leur importance relative avec le coefficient fÂČ de Cohen et Ă©valuĂ© la variation avec le coefficient de corrĂ©lation intra-classe (CCI) et son intervalle de confiance Ă 95%. Pour le troisiĂšme objectif, nous avons effectuĂ© les analyses par niveau de dĂ©signation des centres de traumatologie (I/II et III/IV). Nous avons dĂ©veloppĂ© des modĂšles dâajustement pour tous les patients et pour des groupes diagnostics spĂ©cifiques puis Ă©valuĂ© les validitĂ©s interne et temporelle avec respectivement le coefficient de dĂ©termination (rÂČ) et le rÂČ) annuel. RĂ©sultats : Pour la revue systĂ©matique, 10 Ă©tudes Ă©taient Ă©ligibles. LâĂ©valuation des hĂŽpitaux Ă©tait ajustĂ©e selon lâĂ©tat des patients Ă lâarrivĂ©e dans seulement cinq Ă©tudes (50%). Dans la seconde Ă©tude (n = 32,411), les plus importantes composantes de lâutilisation des ressources Ă©taient les soins rĂ©guliers (57%), le bloc opĂ©ratoire (23%) et les soins intensifs(13%). Le plus important dĂ©terminant Ă©tait la destination Ă la sortie de lâhĂŽpital (fÂČ = 7%). La plus grande utilisation des ressources Ă©tait observĂ©e pour les blessures mĂ©dullaires :11193 (Quartiles 1 et 3 : 3045-8762). Nous avons identifiĂ© des centres oĂč lâutilisation des ressources Ă©tait plus grande ou plus petite que la moyenne gĂ©omĂ©trique provinciale, globalement et pour les blessures cranio-cĂ©rĂ©brales, orthopĂ©diques isolĂ©es et thoraco-abdominales isolĂ©es. Conclusions : Nos donnĂ©es suggĂšrent que 70% Ă 90% de lâutilisation des ressources en traumatologie au QuĂ©bec est dictĂ©e par des facteurs autres que le statut clinique des patients. Nous avons dĂ©veloppĂ© un indicateur pour identifier les variations de lâutilisation des ressources dans un mĂȘme centre/systĂšme de traumatologie, au fil du temps, ou entre centres/systĂšmes de traumatologie dans un(e) mĂȘme province/pays. Cet indicateur ainsi que les dĂ©terminants de lâutilisation des ressources que nous avons identifiĂ©s peuvent servir de donnĂ©es probantes pour lâallocation des ressources et lâĂ©laboration dâinterventions visant Ă amĂ©liorer lâefficience des soins en traumatologie. PrĂ©sentement, des Ă©tudes examinent lâassociation entre lâintensitĂ© dâutilisation des ressources et les rĂ©sultats cliniques des patients Ă partir des mĂ©thodes dĂ©veloppĂ©es dans ce projet. Les Ă©tudes futures devraient identifier les dĂ©terminants des variations inter-hospitaliĂšres de lâutilisation des ressources.Background: Injuries are the 5th leading cause of hospitalization in Canada and their care cost 16 billion dollars in 2010. Studies in the United States suggest that resource use fo racute injury care may be driven by factors other than the clinical status of patients. However, the lack of tools to measure and monitor resource use intensity has hampered the development of interventions aiming to improve the efficiency of injury care. Objectives: Our goal was to develop and validate a hospital indicator of resource use intensity for injury admissions. Our objectives were to (1) review how data on costs have been used to evaluate injury care; (2) estimate patient-level resource use for injury admissions, identify determinants of resource use intensity, and evaluate inter-hospital variations in resource use; and (3) develop a hospital indicator of resource use intensity fo rinjury admissions, and evaluate its internal and temporal validity. Methods: For the first objective, we conducted a systematic review of the literature. For the second and third objectives, we conducted retrospective, multicenter cohort studies based on â„ 16-year-olds admitted to adult trauma centers in Quebec from 2014 to 2016. We extracted data from the Quebec trauma registry and hospital financial reports and estimated resource use with activity-based costs. For the second objective, we identified determinants using a multilevel linear model and assessed their relative importance with Cohenâs fÂČ , and evaluated variations with intraclass correlation coefficients (ICC) and 95% confidence intervals. For the third objective, we conducted analyses by trauma center designation level (I/II and III/IV). We developed risk-adjustment models using a competing risks framework for the whole sample and for specific diagnostic groups. We assessed model internal validity with the optimism-corrected coefficient of determination (rÂČ ), and temporal validity with yearly rÂČ . We performed benchmarking by comparing the adjusted geometric mean cost of each center, obtained using shrinkage estimates, to the provincial geometric mean. Results: In our systematic review, we identified 10 eligible studies, of which nine were conducted in the United States. Hospital comparisons were adjusted according to patient case mix in only five studies (50%). In our second study (n = 32,411), activity centers associated with the greatest resource use were the regular ward (57%), followed by the operating room (23%) and the intensive care unit (13%). The strongest determinant of resource use was discharge destination (fÂČ = 7%). Among injury types, the highest resource use was observed for spinal cord injuries: 5014 (Quartiles 1 and 3: 3045-8762). In the whole sample and among patients with traumatic brain, isolated orthopedic and isolated thoracoabdominal injuries, we identified centers with higher or lower than expected resource use. Conclusions: Our review highlighted the need for more data on trauma center resource use, particularly in single-payer healthcare systems. Results from our second and third studies suggest that between 70% and 90% of the variation in resource use for injury care in Quebec is dictated by factors other than the clinical status of patients on arrival. We developed an indicator to identify variations in resource use intensity within a single trauma center or system over time, or across provinces or countries. This indicator and the determinants of resource use intensity we identified can be used to establish evidence-based resource allocations and design high-impact interventions to improve the efficiency of acute injury care. Research is underway to examine the association between hospital resource use intensity and clinical outcomes for trauma patients based on the methods we developed. Future research should identify determinants of inter-hospital variations inresource use intensity and aspects of resource use that drive optimal patient outcomes
Editorial Preface: TeMA Journal of Land Use Mobility and Environment 2 (2017)
The 10th volume of TeMA Journal, given the relevance of the topics, dedicates the three issues of 2017 to
promotes the scientific debate on the definition and the implementation of methods, tools and best practices
aimed at improving, in the forthcoming decades, the capacity of the urban areas to cope a range of climate,
technological and socio-economic challenges that will require the development of integrated and adaptive
strategies. The articles published in this second issue address some themes, such as the resilience capacity
of urban system, the energy consumption, the geographical information system, the community spaces, the
urban green network design, the urban regeneration processes and the territorial cohesion
Presenting the Organisation APN-Sahell
Practices of the association for the protection of nature in the Sahel (APN-Sahel)
Projet de vigie rehaussée de l'hépatite B au Québec
En 2005, le comitĂ© sur lâimmunisation du QuĂ©bec recommandait de passer du programme de vaccination contre lâhĂ©patite B (HB) des prĂ©adolescents Ă celui des nourrissons lorsquâun vaccin hexavalent serait disponible. Pour dĂ©terminer lâimpact dâun tel changement, un bilan Ă©pidĂ©miologique de lâHB a Ă©tĂ© rĂ©alisĂ© Ă partir des cas dĂ©clarĂ©s au fichier des maladies Ă dĂ©clarations obligatoires. De 2005 Ă 2009, une vaccination des nourrissons aurait potentiellement pu prĂ©venir 0,0335 (IC 95%: 0.0334-0.0336) cas aigus par 100 000 personnes-annĂ©es chez les moins de 20 ans. De 2010 Ă 2013, aucun cas aigu nâa Ă©tĂ© rapportĂ© dans ce groupe dâĂąge. Le programme de vaccination actuel des prĂ©adolescents est hautement efficace. En 2014, changer ce programme pour une vaccination des nourrissons avec un vaccin hexavalent nâapporterait pas de bĂ©nĂ©fice Ă©pidĂ©miologique mais permettrait dâaugmenter la couverture vaccinale de 8-12%.In 2005, the Quebec immunization committee recommended to replace the hepatitis B (HB) school-based immunization program by an infant program when an hexavalent vaccine would become available. To estimate the potential impact of such a program change, we summarized the HB epidemiology based on reported cases retrieved from the provincial registry of notifiable diseases. Between 2005 and 2009, 0.0335 (95% CI: 0.0334-0.0336) acute case per 100,000 person-years reported in 0-19 year-olds could have potentially been prevented by an infant immunization program. Between 2010 and 2013, no acute cases were reported in this age group. The current vaccination program is highly effective. In 2014, changing for an infant vaccination program using the hexavalent vaccine can hardly bring additional epidemiological benefit but may increase the vaccine coverage rate by 8-12%
Impact of Trauma System Structure on Injury Outcomes : A Systematic Review and Meta-Analysis
The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.Peer reviewe
Impact of Trauma System Structure on Injury Outcomes : A Systematic Review and Meta-Analysis
The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.Peer reviewe
Zika Virus Infection as a Cause of Congenital Brain Abnormalities and Guillain-Barré Syndrome: Systematic Review.
BACKGROUND
The World Health Organization (WHO) stated in March 2016 that there was scientific consensus that the mosquito-borne Zika virus was a cause of the neurological disorder Guillain-Barré syndrome (GBS) and of microcephaly and other congenital brain abnormalities based on rapid evidence assessments. Decisions about causality require systematic assessment to guide public health actions. The objectives of this study were to update and reassess the evidence for causality through a rapid and systematic review about links between Zika virus infection and (a) congenital brain abnormalities, including microcephaly, in the foetuses and offspring of pregnant women and (b) GBS in any population, and to describe the process and outcomes of an expert assessment of the evidence about causality.
METHODS AND FINDINGS
The study had three linked components. First, in February 2016, we developed a causality framework that defined questions about the relationship between Zika virus infection and each of the two clinical outcomes in ten dimensions: temporality, biological plausibility, strength of association, alternative explanations, cessation, dose-response relationship, animal experiments, analogy, specificity, and consistency. Second, we did a systematic review (protocol number CRD42016036693). We searched multiple online sources up to May 30, 2016 to find studies that directly addressed either outcome and any causality dimension, used methods to expedite study selection, data extraction, and quality assessment, and summarised evidence descriptively. Third, WHO convened a multidisciplinary panel of experts who assessed the review findings and reached consensus statements to update the WHO position on causality. We found 1,091 unique items up to May 30, 2016. For congenital brain abnormalities, including microcephaly, we included 72 items; for eight of ten causality dimensions (all except dose-response relationship and specificity), we found that more than half the relevant studies supported a causal association with Zika virus infection. For GBS, we included 36 items, of which more than half the relevant studies supported a causal association in seven of ten dimensions (all except dose-response relationship, specificity, and animal experimental evidence). Articles identified nonsystematically from May 30 to July 29, 2016 strengthened the review findings. The expert panel concluded that (a) the most likely explanation of available evidence from outbreaks of Zika virus infection and clusters of microcephaly is that Zika virus infection during pregnancy is a cause of congenital brain abnormalities including microcephaly, and (b) the most likely explanation of available evidence from outbreaks of Zika virus infection and GBS is that Zika virus infection is a trigger of GBS. The expert panel recognised that Zika virus alone may not be sufficient to cause either congenital brain abnormalities or GBS but agreed that the evidence was sufficient to recommend increased public health measures. Weaknesses are the limited assessment of the role of dengue virus and other possible cofactors, the small number of comparative epidemiological studies, and the difficulty in keeping the review up to date with the pace of publication of new research.
CONCLUSIONS
Rapid and systematic reviews with frequent updating and open dissemination are now needed both for appraisal of the evidence about Zika virus infection and for the next public health threats that will emerge. This systematic review found sufficient evidence to say that Zika virus is a cause of congenital abnormalities and is a trigger of GBS
Progress in vaccination towards hepatitis B control and elimination in the Region of the Americas
Causes des déperditions d'effectifs dans les centres de formation des jeunes agriculteurs
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