Genome screening, reporting, and genetic counseling for healthy populations.

Rapid advancements of genome sequencing (GS) technologies have enhanced our understanding of the relationship between genes and human disease. To incorporate genomic information into the practice of medicine, new processes for the analysis, reporting, and communication of GS data are needed. Blood samples were collected from adults with a PCR-confirmed SARS-CoV-2 (COVID-19) diagnosis (target N = 1500). GS was performed. Data were filtered and analyzed using custom pipelines and gene panels. We developed unique patient-facing materials, including an online intake survey, group counseling presentation, and consultation letters in addition to a comprehensive GS report. The final report includes results generated from GS data: (1) monogenic disease risks; (2) carrier status; (3) pharmacogenomic variants; (4) polygenic risk scores for common conditions; (5) HLA genotype; (6) genetic ancestry; (7) blood group; and, (8) COVID-19 viral lineage. Participants complete pre-test genetic counseling and confirm preferences for secondary findings before receiving results. Counseling and referrals are initiated for clinically significant findings. We developed a genetic counseling, reporting, and return of results framework that integrates GS information across multiple areas of human health, presenting possibilities for the clinical application of comprehensive GS data in healthy individuals.

Unhelmeted Injured Cyclists in a Canadian Emergency Department: Cycling Behavior and Attitudes Towards Helmet Use.

INTRODUCTION: We seek to characterize unhelmeted injured cyclists presenting to the emergency department: demographics, cycling behavior, and attitudes towards cycling safety and helmet use. METHODS: This was a prospective case series in a downtown teaching hospital. Injured cyclists presenting to the emergency department were recruited for a standardized survey if not wearing a helmet at time of injury and over age 18. Exclusion criteria included inability to consent (language barrier, cognitive impairment) or admission to hospital. RESULTS: We surveyed 72 UICs (unhelmeted injured cyclists) with mean age of 34.3 years (range 18-68, median 30, IQR 15.8 years). Most UICs cycled daily or most days per week in non-winter months (88.9%, n = 64). Most regarded cycling in Toronto as somewhat dangerous (44.4%, n = 32) or very dangerous (5.9%, n = 4). Almost all (98.6%, n = 71) had planned to cycle when departing home that day. UICs reported rarely (11.1%, n = 8) or never (65.3%, n = 47) wearing a helmet. Reported factors discouraging helmet use included inconvenience (31.9%, n = 23) and lack of ownership (33.3%, n = 24), but few characterized helmets as unnecessary (11.1%, n = 7) or ineffective (1.4%, n = 1). CONCLUSIONS: Unhelmeted injured cyclists were frequent commuter cyclists who generally do not regard cycling as safe yet choose not to wear helmets for reasons largely related to convenience and comfort. Initiatives to increase helmet use should address these perceived barriers, and further explore cyclist perception regarding risk of injury and death.

A blueprint for building an emergency department quality improvement and patient safety committee.

The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, "Leading Change." Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a "burning platform," select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.

RéSUMé: Le domaine de l'amélioration de la qualité de la pratique clinique et de la sécurité des patients (AQSP) s'est considérablement développé en médecine d'urgence au cours de la dernière décennie. Alors qu'il y a quelques années, les projets d'AQSP étaient autonomes, mal alignés sur le plan stratégique et conçus de manière incohérente, les responsables des services d'urgence (SU) reconnaissent aujourd'hui que la mise en place d'une infrastructure d'AQSP plus solide permet de hiérarchiser et d'organiser les projets pour qu'ils aient plus de chances de réussir et d'avoir un impact sur les patients et le système. Ce processus comprend le développement d'un comité d'AQSP départemental bien défini, responsable et soutenu. On peut y parvenir efficacement en utilisant une approche délibérée et structurée, comme celle décrite par le professeur John Kotter de la Harvard Business School dans son ouvrage phare intitulé « Leading Change ¼. Dans le présent document, nous présentons un plan à l'aide de ce cadre et incluons des exemples pratiques tirés de notre expérience de l'élaboration d'un comité et d'une infrastructure d'AQSP de SU solides et réussis. Les étapes comprennent la façon d'élaborer une « plateforme brûlante ¼, de sélectionner une coalition de dirigeants, d'élaborer une vision et des initiatives stratégiques, de recruter une armée de membres bénévoles, de permettre des actions pour le comité, de générer des succès à court terme, de maintenir le rythme du changement et enfin, permettre à l'infrastructure de soutenir les améliorations en cours. Cette feuille de route peut être reproduite par des équipes d'urgence de tailles et de contextes différents pour structurer, hiérarchiser et rendre opérationnelles leurs activités d'AQSP et, en fin de compte, améliorer les résultats de leurs patients.

Implementation of serological and molecular tools to inform COVID-19 patient management: protocol for the GENCOV prospective cohort study.

INTRODUCTION: There is considerable variability in symptoms and severity of COVID-19 among patients infected by the SARS-CoV-2 virus. Linking host and virus genome sequence information to antibody response and biological information may identify patient or viral characteristics associated with poor and favourable outcomes. This study aims to (1) identify characteristics of the antibody response that result in maintained immune response and better outcomes, (2) determine the impact of genetic differences on infection severity and immune response, (3) determine the impact of viral lineage on antibody response and patient outcomes and (4) evaluate patient-reported outcomes of receiving host genome, antibody and viral lineage results. METHODS AND ANALYSIS: A prospective, observational cohort study is being conducted among adult patients with COVID-19 in the Greater Toronto Area. Blood samples are collected at baseline (during infection) and 1, 6 and 12 months after diagnosis. Serial antibody titres, isotype, antigen target and viral neutralisation will be assessed. Clinical data will be collected from chart reviews and patient surveys. Host genomes and T-cell and B-cell receptors will be sequenced. Viral genomes will be sequenced to identify viral lineage. Regression models will be used to test associations between antibody response, physiological response, genetic markers and patient outcomes. Pathogenic genomic variants related to disease severity, or negative outcomes will be identified and genome wide association will be conducted. Immune repertoire diversity during infection will be correlated with severity of COVID-19 symptoms and human leucocyte antigen-type associated with SARS-CoV-2 infection. Participants can learn their genome sequencing, antibody and viral sequencing results; patient-reported outcomes of receiving this information will be assessed through surveys and qualitative interviews. ETHICS AND DISSEMINATION: This study was approved by Clinical Trials Ontario Streamlined Ethics Review System (CTO Project ID: 3302) and the research ethics boards at participating hospitals. Study findings will be disseminated through peer-reviewed publications, conference presentations and end-users.

Mask shortage during epidemics and pandemics: a scoping review of interventions to overcome limited supply.

OBJECTIVE: To characterise published evidence regarding preclinical and clinical interventions to overcome mask shortages during epidemics and pandemics. DESIGN: Systematic scoping review. SETTINGS: All healthcare settings relevant to epidemics and pandemics. SEARCH STRATEGY: English peer-reviewed studies published from January 1995 to June 2020 were included. Literature was identified using four databases (Medline-OVID, EMBASE, CINAHL, Cochrane Library), forwards-and-backwards searching through Scopus and an extensive grey literature search. Assessment of study eligibility, data extraction and evidence appraisal were performed in duplicate by two independent reviewers. RESULTS: Of the 11 220 database citations, a total of 47 articles were included. These studies encompassed six broad categories of conservation strategies: decontamination, reusability of disposable masks and/or extended wear, layering, reusable respirators, non-traditional replacements or modifications and stockpiled masks. Promising strategies for mask conservation in the context of pandemics and epidemics include use of stockpiled masks, extended wear of disposable masks and decontamination. CONCLUSION: There are promising strategies for overcoming face mask shortages during epidemics and pandemics. Further research specific to practical considerations is required before implementation during the COVID-19 pandemic.

Regional anesthesia in Canadian emergency departments: Emergency physician practices, perspectives, and barriers to use.

OBJECTIVES: Regional anesthesia has many applications in the emergency department (ED). It has been shown to reduce general anesthetic dose, requirement for post-procedural opioids, and recovery time. We sought to characterize the use of regional anesthesia by Canadian emergency physicians, including practices, perspectives and barriers to use in the ED. METHODS: A cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables. RESULTS: The survey was completed by 149/1144 staff emergency physicians, with a response rate of 13%. Respondents used regional anesthesia a median of 2 (IQR 0-4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of respondents, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). Respondents agreed that regional anesthesia is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had point of care ultrasound available, however less than half (49.0%) felt comfortable using it for RA. Respondents indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use of RA. CONCLUSION: Canadian emergency physicians use regional anesthesia infrequently but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake.

Evaluating the impact of implementing public bicycle share programs on cycling: the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS).

BACKGROUND: Despite rapid expansion of public bicycle share programs (PBSP), there are limited evaluations of the population-level impacts of these programs on cycling, leaving uncertainty as to whether these programs lead to net health gains at a population level or attract those that already cycle and are sufficiently physically active. Our objective was to determine whether the implementation of PBSPs increased population-level cycling in cities across the US and Canada. METHODS: We conducted repeat cross-sectional surveys with 23,901 residents in cities with newly implemented PBSPs (Chicago, New York), existing PBSPs (Boston, Montreal, Toronto) and no PBSPs (Detroit, Philadelphia, Vancouver) at three time points (Fall 2012, 2013, 2014). We used a triple difference in differences analysis to assess whether there were increases in cycling over time amongst those living in closer proximity (< 500 m) to bicycle share docking stations in cities with newly implemented and existing PBSPs, relative to those in cities with no PBSPs. RESULTS: Living in closer proximity to bicycle share predicted increases in cycling over time for those living in cities with newly implemented PBSPs at 2-year follow-up. No change was seen over time for those living in closer proximity to bicycle share in cities with existing PBSPs relative to those in cities with no PBSP. CONCLUSION: These findings indicate that PBSPs are associated with increases in population-level cycling for those who live near to a docking station in the second year of program implementation.

Helmet-Wearing Practices and Barriers in Toronto Bike-Share Users: a Case-Control Study.

BACKGROUND: Helmet use among bike-share users is low. We sought to characterize helmet-use patterns, barriers to helmet use, and cycling safety practices among bike-share users in Toronto. METHODS: A standardized survey of public bike-share program (PBSP) users at semi-random distribution of PBSP stations was undertaken. By maintaining a ratio of one helmet-wearer (HW): two non-helmet-wearers (NHW) per survey period, we controlled for location, day, time, and weather. RESULTS: Surveys were completed on 545 (180 HW, 365 NHW) unique users at 48/80 PBSP locations, from November 2012 to August 2013. More females wore helmets (F: 41.1%, M: 30.9%, p=0.0423). NHWs were slightly younger than HWs (NHW mean age 34.4 years vs HW 37.3, p=0.0018). The groups did not differ by employment status, education, or income. Helmet ownership was lower among NHWs (NHW: 62.4% vs HW: 99.4%, p<0.0001), as was personal bike ownership (NHW: 65.8%, vs HW: 78.3%, p=0.0026). NHWs were less likely to always wear a helmet on personal bikes (NHW: 22.2% vs HW: 66.7%, p<0.0001), and less likely to wear a helmet always or most of the time on PBSP (NHW: 5.8% vs HW: 92.3%, p<0.0001). Both groups, but more HWs, had planned to use PBSP when leaving their houses (HW: 97.2% vs NHW: 85.2%, p<0.0001), primarily to get to work (HW: 88.3% vs NHW: 84.1%, p=0.19). NHWs were more likely to report that they would wear a helmet more (NHW: 61.4% vs HW: 13.9%, p<0.0001), and/or cycle less (NHW: 22.5% vs HW: 4.4%) if helmet use was mandatory. CONCLUSIONS: PBSP users surveyed appear to make deliberate decisions regarding helmet use. NHWs tended to be male, slightly younger, and less likely to use helmets on their personal bikes. As Toronto cyclists who do not wear helmets on PBSP generally do not wear helmets on their personal bikes, interventions to increase helmet use should target both personal and bike-share users. Legislating helmet use and provision of rental helmets could improve helmet use among bike-share users, but our results suggest some risk of reduced cycling with legislation.

Evaluating the impact of environmental interventions across 2 countries: the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS) Study protocol.

BACKGROUND: Few international studies examine public bicycle share programs (PBSP) health impacts. We describe the protocol for the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS). METHODS: A quasi-experimental non-equivalent groups design was used. Intervention cities (Montreal, Toronto, Boston, New York and Vancouver) were matched to control cities (Chicago, Detroit, and Philadelphia) on total population, population density, cycling rates, and average yearly temperature. The study used three repeated, cross-sectional surveys in intervention and control cities in Fall 2012 (baseline), 2013 (year 1), and 2014 (year 2). A non-probabilistic online panel survey with a sampling frame of individuals residing in and around areas where PBSP are/would be implemented was used. A total of 12,000 respondents will be sampled. In each of the 8 cities 1000 respondents will be sampled with an additional 4000 respondents sampled based on the total population of the city. Survey questions include measures of self-rated health, and self-reported height and weight, knowledge and experience using PBSP, physical activity, bicycle helmet use and history of collisions and injuries while cycling, socio-demographic questions, and home/workplace locations. Respondents could complete questionnaires in English, French, and Spanish. Two weights will be applied to the data: inverse probability of selection and post-stratification on age and sex.A triple difference analysis will be used. This approach includes in the models, time, exposure, and treatment group, and interaction terms between these variables to estimate changes across time, between exposure groups and between cities. DISCUSSION: There are scientific and practical challenges in evaluating PBSP. Methodological challenges included: appropriate sample recruitment, exchangeability of treatment and control groups, controlling unmeasured confounding, and specifying exposure. Practical challenges arise in the evaluation of environmental interventions such as a PBSP: one of the companies involved filed for bankruptcy, a Hurricane devastated New York City, and one PBSP was not implemented. Overall, this protocol provides methodological and practical guidance for researchers wanting to study PBSP impacts on health.

Incidental findings of elevated random plasma glucose in the ED as a prompt for outpatient diabetes screening: a retrospective study.

OBJECTIVE: To determine whether random plasma glucose (RPG) collected from patients without known impaired glucose metabolism (IGM) in the emergency department (ED) is a useful screen for diabetes or prediabetes. DESIGN: Retrospective cohort study. SETTING: ED of a Canadian teaching hospital over 1 month. PARTICIPANTS: Adult patients in ED with RPG over 7 mmol/L were recruited for participation. Exclusion criteria included known diabetes, hospital admission and inability to consent. Participants were contacted by mail, encouraged to follow-up with their family physician (FP) for further testing and subsequently interviewed. OUTCOME MEASURES: The primary outcome measure was the proportion of patients in the ED with RPG over 7 mmol/L and no previous diagnosis of IGM who were diagnosed with diabetes or prediabetes after secondary testing by FP with oral glucose tolerance test or fasting plasma glucose (FPG). Secondary outcomes included patient characteristics (age, gender, body mass index and language) and (2) compliance with advice to seek an appropriate follow-up care. RESULTS: RPG was drawn on approximately one-third (33%, n=1149) of the 3470 patients in the ED in March 2010. RPG over 7 mmol/L was detected in 24% (n=278) of patients, and after first telephone follow-up, 32% (n=88/278) met the inclusion criteria and were advised to seek confirmatory testing. 41% (n=114/278) of patients were excluded for known diabetes. 73% of patients contacted (n=64/88) followed up with their FP. 12.5% (n=11/88) of patients had abnormal FPG, and of these 11% (n=10/88) were encouraged to initiate lifestyle modifications and 1% (n=1/88) was started on an oral hypoglycaemic agent. For 7% (n=6/88) of patients, FP's declined to do follow-up fasting blood work. CONCLUSIONS: Elevated RPG in the ED is useful for identification of patients at risk for IGM and in need of further diabetic screening. Emergency physicians should advise patients with elevated RPG to consider screening for diabetes. For ED screening to be successful, patient education and collaboration with FPs are essential.

Clinical impact of diagnostic imaging discrepancy by radiology trainees in an urban teaching hospital emergency department.

BACKGROUND: To characterize clinically significant diagnostic imaging (DI) discrepancies by radiology trainees and the impact on emergency department (ED) patients. METHODS: Consecutive case series methodology over a 6-month period in an urban, tertiary care teaching hospital. Emergency physicians (EPs) were recruited to flag discrepant DI interpretations by radiology trainees that the EP deemed clinically significant. Cases were characterized using chart review and EP interview. RESULTS: Twenty-eight discrepant reports were identified (representing 0.1% of 18,185 images interpreted). The mean time between provisional discrepant diagnosis (PDDx) and revised diagnosis (RDx) by attending radiology staff was 8.6 h (median 4.8 h, range 1.1-48.4), and 67.9% (n = 19) of the patients had left the ED by time of notification. The most frequently reported PDDx was CT abd/pelvis (32.1%, n = 9) and CT head (28.6%, n = 8). The impact of RDx was deemed major in 57.1% (n = 16) for reasons including altered admitting status (32.1%, n = 9), immediate subspecialty referral (n = 16, 57.1%), impact on management (25%, n = 7), and surgical management (21.4%, n = 6). EPs reported likely perceived impact of PDDx as resulting in increased pain (17. 9%, n = 5), morbidity (10.7%, n = 3), and prolonged hospitalization (25%, n = 7), but not altered long-term outcome or mortality. CONCLUSIONS: Relatively few clinically important discrepant reads were reported. Revised diagnosis (RDx) was associated with major clinical impact in 57.1% of reports, but few patients experienced increased morbidity, and none increased mortality. The importance of expedient communication of discrepant reports by staff radiologists is stressed, as is EP verification of patient contact information prior to discharge.

Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey.

OBJECTIVE: We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors. METHODS: A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec. RESULTS: Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 re-spondents (30.5% [95% confidence interval (CI) 19.9%-41.1%]) agreed with the statement, "I sometimes feel unsafe or un-qualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician" and 32 of 81 (39.5% [95% CI 28.2%-50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%-52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%-59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%-51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%-49.3%]), admission decisions (13/79, 16.5% [7.6%-25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%-25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%-61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%-50.2%]). CONCLUSION: Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.

Noncompletion of referrals to outpatient specialty clinics among patients discharged from the emergency department: a prospective cohort study.

OBJECTIVE: We sought to characterize patients who are referred from the emergency department (ED) to specialty clinics but do not complete the referral, and to identify reasons for their failure to follow up. METHODS: A prospective cohort study was carried out over 3 months of patients who were discharged from the ED of a teaching hospital with referral to internal medicine, cardiology or neurology clinics, but who did not complete the referral. Information on demographics, barriers to care and reasons for not completing the referral was obtained through a standardized telephone interview. RESULTS: Of 171 ED referrals, 42 (24.6%) were not completed. Interviews were completed for 71.4% (30 patients). Of the nonattenders, 80% were functional in English and most had high school (73.1%) or university (60.7%) education. Virtually all (93.0%) interviewees could get to hospital by themselves or have someone take them. Only 42.9% (12 patients) understood why the emergency physician (EP) requested consultation, and 42.9% (12 patients) described EP instructions as poor or fair. Primary reasons for noncompletion of consult were patient choice (46.7%, 95% confidence interval [CI] 27.1%-66.2%), physical or social barriers (13.3%, 95% CI 0.0%-27.2%), communication failure (20%, 95% CI 4.0%-36.0%) and consultant's refusal of the consultation (20% [95% CI 4.0%-36.0%]). All consultant refusals were from one internal medicine clinic, representing 42% (8/19) of ED referrals to that clinic. None of the 6 patients interviewed who were declined consultation was aware that their consultation had been refused. CONCLUSION: Patients discharged by the EP with referral to specialty clinics frequently do not complete the consultation. Causes for failure to follow up relate to patient decision, inadequate or poorly understood discharge information, and system factors. Institutional audits of patients who fail to complete follow-up may reveal unanticipated barriers to care.

Do as I say, not as I do: a survey of public impressions of queue-jumping and preferential access.

OBJECTIVES: The Canada Health Act legislates that Canadian citizens have access to healthcare that is publicly administered, universal, comprehensive, portable, and accessible (i.e. unimpeded by financial, clinical, or social factors). We surveyed public impressions and practices regarding preferential access to healthcare and queue jumping. METHODS: Households were randomly selected from the Toronto telephone directory. English speakers aged 18 years or older were solicited for a standardized telephone survey. Statistical analysis was performed using SPSS and SAS. RESULTS: Fifteen percent (n=101) of 668 solicited were surveyed. Ninety-five percent advocated equal access based on need. Support for queue jumping in the emergency department (ED) was strong for cases of emergency, severe pain, and pediatrics, equivocal for police, and minimal for the homeless, doctors, hospital administrators, and government officials. To improve a position on a waiting list, approximately half surveyed would call a friend who is a doctor, works for a doctor, or is a hospital administrator. Sixteen percent reported having done this. The likelihoods of offering material inducement for preferential access were 30 and 51% for low and high-impact medical scenarios, respectively. The likelihoods of offering nonmaterial inducement were 56 and 71%, respectively. Responses were not associated with sex, occupation, or education. CONCLUSIONS: Respondents expressed support for equal access based on need. Policy and scenario-type questions elicited different responses. Expressed beliefs may vary from personal practice. Clearly defined and enforced policies at the hospital and provincial level might enhance principles of fairness in the ED queue.

Emergency department discharge instructions comprehension and compliance study.

OBJECTIVES: To assess patient comprehension of emergency department discharge instructions and to describe other predictors of patient compliance with discharge instructions. METHODS: Patients departing from the emergency department of an inner-city teaching hospital were invited to undergo a structured interview and reading test, and to participate in a follow-up telephone interview 2 weeks later. Two physicians, blinded to the other's data, scored patient comprehension of discharge information and compliance with discharge instructions. Inter-rater reliability was assessed using a kappa-weighted statistic, and correlations were assessed using Spearman's rank correlation coefficient and Fisher's exact test. RESULTS: Of 106 patients approached, 88 (83%) were enrolled. The inter-rater reliability of physician rating scores was high (kappa = 0.66). Approximately 60% of subjects demonstrated reading ability at or below a Grade 7 level. Comprehension was positively associated with reading ability (r = 0.29, p = 0.01) and English as first language (r = 0.27, p = 0.01). Reading ability was positively associated with years of education (r = 0.43, p < 0.0001) and first language (r = 0.24, p = 0.03), and inversely associated with age (r = -0.21, p = 0.05). Non-English first language and need for translator were associated with poorer comprehension of discharge instructions but not related to compliance. Compliance with discharge instructions was correlated with comprehension (r = 0.31, p = 0.01) but not associated with age, language, education, years in anglophone country, reading ability, format of discharge instructions, follow-up modality or association with a family physician. CONCLUSIONS: Emergency department patients demonstrated poor reading skills. Comprehension was the only factor significantly related to compliance; therefore, future interventions to improve compliance with emergency department instructions will be most effective if they focus on improving comprehension.

Patients who leave the emergency department without being seen by a physician: a control-matched study.

OBJECTIVE: To describe the socio-demographic characteristics and clinical outcomes of patients who leave the emergency department (ED) without being seen by a physician. METHODS: This 3-month prospective study was conducted at a downtown Toronto teaching hospital. Patients who left the ED without being seen (LWBS) were matched with controls based on registration time and triage level. Subjects and controls were interviewed by telephone within 1 week after leaving the ED. RESULTS: During the study period, 386 (3.57%) of 10,808 ED patients left without being seen. One-third of these had no fixed address or no telephone, and only 92 (23.8%) consented to a telephone interview. They cited excessive wait time as the most common reason for leaving the ED (in 36.7% of cases). Despite leaving the ED without being seen, they were no more likely than those in the control group to seek follow-up medical attention (70 % in both groups). Among those from both groups who did seek follow-up, the LWBS patients were more likely to do so the same day or the day after leaving the ED. The LWBS patients often lacked a regular physician (39.1% v. 21.7%; p = 0.01) and were more likely to attend an ED or urgent care clinic (34.8% v. 12.0%; p < 0.001). Controls were more likely to follow up with a family physician (37.0% v. 23.9%; p = 0.06). The LWBS and control groups did not differ in subjective health status at 48 hours after leaving the ED, nor in subsequent re-investigation in hospital. CONCLUSIONS: Patients who leave the ED without being seen have different socio-demographic features, methods of accessing the health care system, affiliations and expectations than the general ED population. They are often socially disenfranchised, with limited access to traditional primary care. These patients are generally low acuity, but they are at risk of important and avoidable adverse outcomes.