Attending Nurse Practitioners in Long-Term Care Homes Evaluation

Introduction In 2014, the Ontario Ministry of Health and Long-Term Care (MOHLTC) announced funding for 75 nurse practitioners (NPs) over three years in long-term care (LTC) homes. This evaluation was approved by ICES’ Applied Health Research Question (AHRQ) team, a portfolio which answers questions from stakeholders having impact on healthcare policy. Objectives and Approach The purpose of this project is to evaluate the impact of the first thirty NPs hired. Changes will be evaluated using key outcome measures of resident care (e.g., early hospital discharge, emergency room bed days) identified through a literature review conducted by the MOHLTC. LTC home residents were identified using all individuals with claims in OHIP during the 2016-17 fiscal year with a location of a LTC home. LTC homes with a hired NP were considered to be cases and all other LTC homes were considered to be controls. Results For part one of this evaluation, case and control LTC homes were stratified by bed size, Case Mix Index, rurality and Local Health Integration Network. Hospitalization records and emergency visits (from Discharge Abstract Database and National Ambulatory Care Reporting System) were determined for LTCH residents 6 months before and after the NP hire date of October 1, 2016. Overall, the rate of hospital admissions (per 100 residents) increased by 3.44% (8.51% to 11.94%) following the NP hire date; whereas, the rate of hospital admissions increased by 2.29% (6.55% to 8.83%) among controls. Following the NP hire date, the rate of emergency department visits also increased by 3.15% among cases (16.62% to 19.77%) in comparison to a 2.31% increase among controls (12.55% to 14.86%). Conclusion/Implications The findings from this evaluation will inform further implementation strategies of the NP program and guide decision-making of future funding opportunities. In summary, the results will inform policies to strengthen care of LTC homes and improve the quality of care of residents

Examination of High-Cost Patients in Ontario

Introduction In Ontario, the top 5% of high-cost users account for 66% of health care costs. The heavy use of resources combined with perceived inefficiencies offer an imperative to target strategies to redesign care to better meet patient needs and increase value. Objectives and Approach As part of a request submitted to the Applied Health Research Question (AHRQ) review team, the main objective of this study was to identify drivers of high health care use in Ontario in order to find better ways to improve the efficiency in healthcare delivery. Using data in fiscal year 2012/13, characteristics of the top 5% of high costs users were described, and further stratified by mental health status. Total spending by sector of care were also described. Data were linked including physician, hospital, medication and long term care databases for each patient. Results In the top 5% of high-cost users, there were 729,870 patients who accounted for $20,179,208,348 of total healthcare spending in 2012/13, with the highest percentage of spending observed among older adults aged 61-80 years old. Mental health high-cost patients accounted for 6.1% of these patients, of which 51.5% were female, had a low socio-economic status and an average age of 44 years. These patients had an average of 4.9 (SD=2.3) ICD chapters and used an average of 8.7 (SD=3.8) drugs. Using the health accounts methodology (ICHA), as described by the OECD and WHO, over 90% of healthcare costs among the top 5% of high-cost patients were from inpatient care, day surgery and clinic care, physician care, outpatients drugs and inpatient rehabilitation and complex/continuing care. Conclusion/Implications This study provides a systematic description of the needs in a high cost patient group, and serves as a platform for international comparisons across healthcare systems to better understand gaps and identify targets for intervention. These cross-comparisons offer a tool to evaluate performance of healthcare systems and to prioritize policies

Surgery Versus Radiotherapy for Clinically-localized Prostate Cancer: A Systematic Review and Meta-analysis

AbstractContextTo date, there is no Level 1 evidence comparing the efficacy of radical prostatectomy and radiotherapy for patients with clinically-localized prostate cancer.ObjectiveTo conduct a meta-analysis assessing the overall and prostate cancer-specific mortality among patients treated with radical prostatectomy or radiotherapy for clinically-localized prostate cancer.Evidence acquisitionWe searched Medline, EMBASE, and the Cochrane Library through June 2015 without year or language restriction, supplemented with hand search, using Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. We used multivariable adjusted hazard ratios (aHRs) to assess each endpoint. Risk of bias was assessed using the Newcastle-Ottawa scale.Evidence synthesisNineteen studies of low to moderate risk of bias were selected and up to 118 830 patients were pooled. Inclusion criteria and follow-up length varied between studies. Most studies assessed patients treated with external beam radiotherapy, although some included those treated with brachytherapy separately or with the external beam radiation therapy group. The risk of overall (10 studies, aHR 1.63, 95% confidence interval 1.54–1.73, p<0.00001; I2=0%) and prostate cancer-specific (15 studies, aHR 2.08, 95% confidence interval 1.76–2.47, p < 0.00001; I2=48%) mortality were higher for patients treated with radiotherapy compared with those treated with surgery. Subgroup analyses by risk group, radiation regimen, time period, and follow-up length did not alter the direction of results.ConclusionsRadiotherapy for prostate cancer is associated with an increased risk of overall and prostate cancer-specific mortality compared with surgery based on observational data with low to moderate risk of bias. These data, combined with the forthcoming randomized data, may aid clinical decision making.Patient summaryWe reviewed available studies assessing mortality after prostate cancer treatment with surgery or radiotherapy. While the studies used have a potential for bias due to their observational design, we demonstrated consistently higher mortality for patients treated with radiotherapy rather than surgery

Case-control studies with misclassified exposure : a Bayesian approach

When dealing with the case-control data, it is often the case that the exposure to a risk factor of interest is subject to miclassification. Methods for correcting the odds-ratio are available when the misclassification probabilities are known. In practice, however, good guesses rather than the exact values are available for these probabilities. We show that when these guesses are treated as exact even the smallest differencies between the true and guessed values can lead to very erroneous odds-ratio estimates. This problem is alleviated by a Bayesian analysis which incorporates the uncertainty about the misclassification probabilities as prior information. In practice, data on the exposure variable are quite often available from more than one source. We review three methods for improving the odds-ratio estimates that combine information from two sources. We then develop a Bayesian approach which is based on latent class analysis, and apply it to the sudden infant death syndrome data. The inference required the use of the Metropolis-Hastings algorithm and/or the Gibbs sampler.Science, Faculty ofStatistics, Department ofGraduat

Noninvasive Ventilation Initiation in Clinical Practice: A Six-Year Prospective, Observational Study

BACKGROUND: Despite evidence supporting the role of noninvasive ventilation (NIV) in diverse populations, few publications describe how NIV is used in clinical practice

Increasing research capacity with ICES Data & Analytic Services (DAS)

ABSTRACT Background The Institute for Clinical Evaluative Sciences (ICES) is a not-for-profit organization that conducts research to evaluate health care delivery and outcomes. Established in 1992, ICES houses a vast and secure array of linkable, coded health-related data on more than 13 million Ontarians, including health services data, health care provider data, registries and population-based health surveys. ICES has a reputation for generating strong evidence-based knowledge to inform policy and practice, however the use of the data was restricted to ICES’ purposes. In March 2014, ICES launched the Data & Analytic Services (DAS) platform with the primary objective of increasing access to its data to publicly-funded researchers, health care providers and administrators, policymakers and students. Method DAS provides access to highly de-identified, risk-reduced datasets created from ICES’ data holdings; analytic support; and complete data analysis and report writing services. DAS also enables the importation of external data for linkage to ICES’ data holdings. Research objectives and methodology are led by the requestor and ICES analysts rely on their subject matter expertise to direct the deliverables. Results Since launch, over 200 requests from Canada, United States and United Kingdom have been adjudicated, of which 187 have been deemed feasible and eligible. Over the same period of time, ICES as an organization had over 700 active projects of which 348 were initiated, an increase in capacity of 26%. Though Toronto-based researchers represent the majority of the requests (62%), there have been requests from outside Ontario interested in comparing aspects of Ontario’s healthcare to their home province. Research topics have varied and include assessments of health care provision by sector, disease prevalence and treatment, and statistical methods. An unexpected outcome of increasing access has been the large interest from small physician groups and knowledge users who are not typically involved in research for academic purposes. Access to ICES’ data holdings provides an opportunity to examine a larger cohort of patients who share the same characteristics as their clinic patients or group. Furthermore, by enabling remote access to the data, DAS is able to leverage the capabilities of ICES’ data holdings and increase research capacity in a short period of time. Conclusion In making one of the most comprehensively linked health administrative data repositories in the world widely available to the broader research and healthcare community, DAS engages investigators involved in front-line care, stimulates new avenues of research and fosters collaboration that was previously unachievable

Institute for Clinical Evaluative Sciences (ICES) Exploratory Data & Analytic Services Private Sector Pilot Project

ABSTRACT Objectives Prior to the launch of ICES Data & Analytic Services (DAS) in March 2014, only ICES scientists and analysts could access ICES data, and data could only be accessed at physical ICES locations. The DAS infrastructure, which allows public sector researchers to work with coded record level data remotely through a secure virtual environment, together with broader trends including high profile reports that call for increased access to data and the Ontario government’s Open Data initiative, prompted ICES to launch a pilot project to explore potential DAS work with the private sector. Approach Three mandatory principles were established for all work with the private sector: (i) alignment with ICES’ mission, vision and values; (ii) transparency; (iii) private sector work must not detract from ICES’ research institute work. The pilot included: a jurisdictional scan; informal conversations with private sector organizations to determine potential services/studies of interest; extensive discussions with data partners; the selection and conduct of two pilot studies; focus groups with members of the general public and scientists; external advice on business model options; and an external evaluation of the pilot. No changes to data sharing agreements or ICES processes were required as work with the private sector and public sector are equally allowed under Ontario law. Results The two pilot studies were successfully completed. The first study “The disease burden of gout in Ontario: A real world data retrospective study” was performed by researchers at IMS Brogan (a healthcare analytic services provider) who were provided with access to coded record-level data using the DAS iDAVE environment and performed their own analyses. In the second pilot study, “The impact of adherence to biologics on healthcare resource utilization in rheumatoid arthritis”, Janssen researchers established the research question and study design, and DAS staff and scientists provided advice about data holdings, performed the analyses, and provided Janssen and three government-funded decision making bodies with results tables. Research Ethics Board approval was required for both studies, and both private sector organizations are in the process of publishing findings. Conclusions ICES was able to work with private sector organizations without compromising the three principles. Based on the evaluation of the private sector pilot, and the findings from the focus groups, ICES will begin offering limited analytic services to private sector researchers beginning June 2016 under ICES’ existing corporate structure, and bring recommendations regarding ongoing operations to the ICES Board in June 2017