Health system structure and its influence on outcomes: The Canadian experience.

Healthcare delivery systems in Canada are structured using three models: individual institutions, health regions, and single provincial systems, usually with smaller geographic zones. The comparative ability of these models to improve care, outcomes, and the Quadruple Aim is largely unstudied. We reviewed Canadian studies examining outcomes of provincial healthcare delivery system restructuring. Across models, results were inconsistent, and quality of evidence was low. For all provinces, primary care sits outside healthcare delivery systems, with limited governance and integration. The single provincial model can reduce costs of non-clinical support functions like finance, human resources, and analytics. This model may also be best at reducing variations in care, improving electronic information integration that enables clinical decision support and reporting, and supporting the provincial spread and scale of innovations, but further refinements are required and existing studies have major limitations, limiting definitive conclusions.

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome.

OBJECTIVES: One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients' preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome. METHODS: In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes-yes/no) and expectations (outcomes deemed 'very important'). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios. RESULTS: Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66-0.74). The predicted probability of a good outcome ranged from 44.4% (33.9-55.5) to 92.4% (88.4-95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations. CONCLUSIONS: Although external validation is required, our findings suggest that incorporation of patients' TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery.

OBJECTIVES: Having previously shown similar clinical outcomes, this study compared the healthcare resource utilization and direct costs in stable patients with RA followed in the nurse-led care (NLC) and rheumatologist-led care (RLC) models. METHODS: Previously collected clinical data were linked to data on practitioner claims, ambulatory care, and hospital discharges. Assessed resources included physician visits; emergency department (ED) visits; hospital admissions, and disease-modifying anti-rheumatic drugs (DMARDs). The mean per-patient resource utilization and cost (2020 Canadian dollars) over 1 year were compared between the groups using Wilcoxon rank-sum test. The mean per-patient cost of health services and total cost were also estimated using Generalized Linear Models (GLMs) accounting for the baseline differences between the groups. RESULTS: Overall, 244 patients were included. No differences in the number of visits to the ED or to general practice and internal medicine physicians and orthopedic surgeons were found. The NLC group had fewer hospitalizations than the RLC group (p-value=0.03). The mean cost of health services was not statistically different in NLC and RLC groups ($2275 vs. $3772, p-value=0.30). The RLC group included more patients on biologic DMARDs, contributing to a higher mean total cost than the NLC group ($9191 vs. $3056, p-value<0.01). The mean cost estimates with GLMs were consistent with the observed costs. CONCLUSIONS: A nurse-led model of care delivery for stable patients with RA was not associated with increases in healthcare resource utilization or cost as compared to RLC. NLC is one approach to meeting patient needs and better managing scarce healthcare resources.

Patient acceptable symptom state (PASS): thresholds for the EQ-5D-5L and Oxford hip and knee scores for patients with total hip and knee replacement.

PURPOSE: To define patient acceptable symptom state (PASS) cut-off values for the EQ-5D-5L and Oxford hip (OHS) and knee (OKS) scores 6 and 12 months after total hip (THR) or knee (TKR) replacement. To compare PASS cut-off values for the EQ-5D-5L scored using: (1) the Canadian value set, (2) the crosswalk value set, and (3) the equal weighted Level Sum Score (LSS). METHODS: We mailed questionnaires to consecutive patients following surgeon referral for primary THR or TKR and at 6 and 12 months post-surgery. Patient reported outcome measures (PROMs) were the EQ-5D-5L, the OHS, and OKS. We assessed PASS cut-off values for PROMs using percentile and ROC methods, with the Youden Index. RESULTS: Five hundred forty-two surgical patients (mean age, 64 years, 57% female, 49% THR) completed baseline and 12-month questionnaires. 89% of THR and 81% of TKR patients rated PASS as acceptable at 12 months. PASS cut-off values for THR for the EQ-5D-5L (Canadian) were 0.85 (percentile) and 0.84 (Youden) at 12 months. Cut-off values were similar for the LSS (0.85 and 0.85) and lower for the crosswalk value set (0.74 and 0.73), respectively. EQ-5D-5L cut-off values for TKR were Canadian, 0.77 (Percentile) and 0.78 (Youden), LSS, 0.75 and 0.80, and crosswalk, 0.67 and 0.74, respectively. Cut-off values 6 and 12 months post-surgery ranged from 38 to 39 for the OHS, and 28 to 36 for the OKS (range 0 worst to 48 best). CONCLUSION: PASS cut-off values for the EQ-5D-5L and Oxford scores varied, not only between methods and timing of assessment, but also by different EQ-5D-5L value sets, which vary between countries. Because of this variation, PASS cut-off values are not necessarily generalizable to other populations of TJR patients. We advise caution in interpreting PROMs when using EQ-5D-5L PASS cut-off values developed in different countries. A standardization of methods is needed before published cut-off values can be used with confidence in other populations.

The Effect of Patient Age and Surgical Appropriateness and Their Influence on Surgeon Recommendations for Primary TKA: A Cross-Sectional Study of 2,037 Patients.

BACKGROUND: Rising total knee arthroplasty (TKA) rates in younger patients raises concern about appropriateness. We asked: are younger individuals who seek consultation for TKA less likely to be appropriate for and, controlling for appropriateness, more likely to be recommended for surgery? METHODS: This cross-sectional study was nested within a prospective cohort study of knee osteoarthritis (OA) patients referred for TKA from 2014 to 2016 to centralized arthroplasty centers in Alberta, Canada. Pre-consultation, questionnaires assessed patients' TKA appropriateness (need, based on knee symptoms and prior treatment; readiness/willingness to undergo TKA; health status; and expectations) and contextual factors (for example, employment). Post-consultation, surgeons confirmed study eligibility and reported their TKA recommendation. Using generalized estimating equations to control for clustering by surgeon, we assessed relationships between patient age (<50, 50 to 59, ≥60 years) and TKA appropriateness and receipt of a surgeon TKA recommendation. RESULTS: Of 2,037 participants, 3.3% and 22.7% were <50 and 50 to 59 years of age, respectively, 58.7% were female, and 35.5% were employed. Compared with older participants, younger participants reported significantly worse knee symptoms, higher use of OA therapies, higher TKA readiness, and similar willingness, but had higher body mass index and were more likely to smoke and to consider the ability to participate in vigorous activities, for example, sports, as very important TKA outcomes. TKA was offered to 1,500 individuals (73.6% overall; 52.2%, 71.0%, and 75.4% of those <50, 50 to 59, and ≥60 years, respectively). In multivariate analyses, the odds of receiving a TKA recommendation were higher with greater TKA need and willingness, in nonsmokers, and in those who indicated that improved ability to go upstairs and to straighten the leg were very important TKA outcomes. Controlling for TKA appropriateness, patient age was not associated with surgeons' TKA recommendations. CONCLUSIONS: Younger individuals with knee OA referred for TKA had similar or greater TKA need, readiness, and willingness than older individuals. Incorporation of TKA appropriateness criteria into TKA decision-making may facilitate consideration of TKA benefits and risks in a growing population of young, obese individuals with knee OA. CLINICAL RELEVANCE: Younger people seeking TKA for knee OA had significant OA pain and disability despite recommended OA therapies, suggesting appropriateness for surgical consideration. However, they were significantly more likely to have morbid obesity, to smoke, and to consider return to vigorous activities, like sport, as important TKA outcomes. Whether the short- and longer-term risks of TKA are outweighed by the benefits is unclear and warrants additional research.

Relationship Between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One-Year Follow-Up.

OBJECTIVE: To determine the relationship between patients' preoperative readiness for total knee arthroplasty (TKA) and surgical outcome at 1 year post-TKA. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) who were ≥30 years and were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who underwent primary unilateral TKA completed questionnaires prior to TKA to assess pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), physical disability using the Knee Injury and Osteoarthritis Outcome Score physical function short form, perceived arthritis coping efficacy, general self-efficacy, depressed mood using the Patient Health Questionnaire 8, body mass index, comorbidities, and TKA readiness (patient acceptable symptom state; willingness to undergo TKA); these same individuals also completed the above questionnaires 1 year post-TKA to assess surgical outcomes. A good TKA outcome was defined as an individual having improved knee symptoms, measured using the Osteoarthritis Research Society International-Outcome Measures in Rheumatology responder criteria, and overall satisfaction with results of the TKA. Poisson regression with robust error estimation was used to estimate the relative risk (RR) of a good outcome for exposures, before and after controlling for covariates. RESULTS: Of 1,272 TKA recipients assessed at 1 year post-TKA, 1,053 with data for the outcome assessed in the study were included (mean ± SD age 66.9 ± 8.8 years; 58.6% female). Most patients (87.8%) were definitely willing to undergo TKA and had "unacceptable" knee symptoms (79.7%). Among patients who underwent TKA, 78.1% achieved a good outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms, and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with a greater likelihood of a good TKA outcome, with adjusted RRs of 1.18 (95% confidence interval [95% CI] 1.04-1.35) and 1.14 (95% CI 1.02-1.27), respectively. CONCLUSION: Among patients who underwent TKA for knee OA, patients' psychological readiness for TKA and willingness to undergo TKA were associated with a greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate the use of TKA.

Nurse-Led Care for Stable Patients with Rheumatoid Arthritis: Quality of Care in Routine Practice Compared to the Traditional Rheumatologist-Led Model.

INTRODUCTION: This pragmatic non-inferiority study assessed quality of care within a nurse-led care (NLC) model for stable patients with rheumatoid arthritis (RA) compared to the traditional rheumatologist-led care (RLC) model. METHODS: Data were collected through a chart review. Baseline demographic and clinical characteristics were compared using Chi-square test and t test. The primary outcome measure was the percentage of patients being in remission or low disease activity (R/LDA) with the Disease Activity Score (DAS-28) ≤ 3.2 at 1-year follow-up. Process measures included the percentages of patients with chart documentation of (1) comorbidity screening; (2) education on flare management, and (3) vaccinations screening. Outcomes were summarized using descriptive statistics. RESULTS: Each group included 124 patients. At baseline, demographic and clinical characteristics were comparable between the groups for most variables. Exceptions were the median (Q1, Q3) Health Assessment Questionnaire Disability Index scores [0 (0, 0.25) in NLC and 0.38 (0, 0.88) in RLC, p = 0.01], and treatment patterns with 3% of NLC and 38% of RLC patients receiving a biologic agent, p = 0.01. NLC was non-inferior to RLC with 97% of NLC and 92% of RLC patients being in R/LDA at 1-year follow-up. Patients in the NLC group had better documentation across all process measures. CONCLUSIONS: This study provided real-world evidence that the evaluated NLC model providing protocolized follow-up care for stable patients with RA is effective to address patients' needs for ongoing disease monitoring, chronic disease management, education, and support.

Immunogenicity and Safety of Reduced-Dose Intradermal vs Intramuscular Influenza Vaccines: A Systematic Review and Meta-analysis.

Importance: Low-dose intradermal influenza vaccines could be a suitable alternative to full intramuscular dose during vaccine shortages. Objective: To compare the immunogenicity and safety of the influenza vaccine at reduced or full intradermal doses with full intramuscular doses to inform policy design in the event of vaccine shortages. Data Sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies published from 2010 until June 5, 2020. Study Selection: All comparative studies across all ages assessing the immunogenicity or safety of intradermal and intramuscular influenza vaccinations were included. Data Extraction and Synthesis: Data were extracted by a single reviewer and verified by a second reviewer. Discrepancies between reviewers were resolved through consensus. Random-effects meta-analysis was conducted. Main Outcomes and Measures: Primary outcomes included geometric mean titer, seroconversion, seroprotection, and adverse events. Results: A total of 30 relevant studies were included; 29 studies were randomized clinical trials with 13 759 total participants, and 1 study was a cohort study of 164 021 participants. There was no statistically significant difference in seroconversion rates between the 3-µg, 6-µg, 7.5-µg, and 9-µg intradermal vaccine doses and the 15-µg intramuscular vaccine dose for each of the H1N1, H3N2, and B strains, but rates were significantly higher with the 15-µg intradermal dose compared with the 15-µg intramuscular dose for the H1N1 strain (rate ratio [RR], 1.10; 95% CI, 1.01-1.20) and B strain (RR, 1.40; 95% CI, 1.13-1.73). Seroprotection rates for the 9-µg and 15-µg intradermal doses did not vary significantly compared with the 15-µg intramuscular dose for all the 3 strains, except for the 15-µg intradermal dose for the H1N1 strain, for which rates were significantly higher (RR, 1.05; 95% CI, 1.01-1.09). Local adverse events were significantly higher with intradermal doses than with the 15-µg intramuscular dose, particularly erythema (3-µg dose: RR, 9.62; 95% CI, 1.07-86.56; 6-µg dose: RR, 23.79; 95% CI, 14.42-39.23; 9-µg dose: RR, 4.56; 95% CI, 3.05-6.82; 15-µg dose: RR, 3.68; 95% CI, 3.19-4.25) and swelling (3-µg dose: RR, 20.16; 95% CI, 4.68-86.82; 9-µg dose: RR, 5.23; 95% CI, 3.58-7.62; 15-µg dose: RR, 3.47 ; 95% CI, 2.21-5.45). Fever and chills were significantly more common with the 9-µg intradermal dose than the 15-µg intramuscular dose (fever: RR, 1.36; 95% CI, 1.03-1.80; chills: RR, 1.24; 95% CI, 1.03-1.50) while all other systemic adverse events were not statistically significant for all other doses. Conclusions and Relevance: These findings suggest that reduced-dose intradermal influenza vaccination could be a reasonable alternative to standard dose intramuscular vaccination.

Patients' Preoperative Expectations of Total Knee Arthroplasty and Satisfaction With Outcomes at One Year: A Prospective Cohort Study.

OBJECTIVE: To assess the relationship between patients' expectations for total knee arthroplasty (TKA) and satisfaction with surgical outcome. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) ages ≥30 years who were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess TKA expectations (17-item Hospital for Special Surgery [HSS] TKA Expectations questionnaire) and contextual factors (age, sex, Western Ontario and McMaster Universities Osteoarthritis Index pain score, Knee Injury and Osteoarthritis Outcome Score physical function short form [KOOS-PS], 8-item Patient Health Questionnaire depression scale, body mass index [BMI], comorbidities, and prior joint replacement), and 1-year post-TKA to assess overall satisfaction with TKA results. Using multivariate logistic regression, we examined the relationship between TKA expectations (HSS TKA outcomes considered to be very important) and postoperative satisfaction (very satisfied versus somewhat satisfied versus dissatisfied). Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. RESULTS: At 1 year, 1,266 patients with TKA (92.1%) reported their TKA satisfaction (mean ± SD age 67.2 ± 8.8 years, 60.9% women, and mean BMI 32.6 kg/m2 ); 74.7% of patients were very satisfied, 17.1% were somewhat satisfied, and 8.2% were dissatisfied. Controlling for other factors, an expectation of TKA to improve patients' ability to kneel was associated with lower odds of satisfaction (adjusted OR 0.725 [95% CI 0.54-0.98]). An expectation of TKA to improve psychological well-being was associated with lower odds of satisfaction for individuals in the lowest tertile of pre-TKA KOOS-PS scores (adjusted OR 0.49 [95% CI 0.28-0.84]), but higher odds for those in the highest tertile (adjusted OR 2.37 [95% CI 1.33-4.21]). CONCLUSION: In patients with TKA, preoperative expectations regarding kneeling and psychological well-being were significantly associated with the level of TKA satisfaction at 1 year. Ensuring that patients' expectations are achievable may enhance appropriate provision of TKA.

Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment.

BACKGROUND: Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU). OBJECTIVE: The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU. METHODS: The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more). RESULTS: There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system. CONCLUSIONS: It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.

Innovation in the Canadian health system.

The essence of human ingenuity is creation and novel ideas that result in collective and desired impact. Indeed, innovation is foundational to life in a changing world. In no situation today is this more relevant than in health systems, whether they be challenged to maintain population health, threatened by impending disasters, or expected to respond to the ever-expansive demand and inexorable course of those with chronic diseases. This article discusses health system innovation and its trajectory. It focuses on clinical innovation as a means of achieving high-level performance within a learning health system model. Examples of innovation in Canada are used to illustrate successful approaches worthy of broader consideration and pan-Canadian attention.

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement.

PURPOSE: To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction. METHODS: Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery. RESULTS: The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR. CONCLUSIONS: Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

Use of Recommended Non-surgical Knee Osteoarthritis Management in Patients prior to Total Knee Arthroplasty: A Cross-sectional Study.

OBJECTIVE: Our aim was to assess prior use of core recommended non-surgical treatment among patients with knee osteoarthritis (OA) scheduled for total knee arthroplasty (TKA), and to assess potential patient-level correlates of underuse, if found. METHODS: This was a cross-sectional study of patients undergoing TKA for primary knee OA at 2 provincial central intake hip and knee clinics in Alberta, Canada. Standardized questionnaires assessed sociodemographic characteristics, social support, coexisting medical conditions, OA symptoms and coping, and previous non-surgical management. Multivariable logistic regression was used to assess the patient-level variables independently associated with receipt of recommended non-surgical knee OA treatment, defined as prior use of pharmacotherapy for pain, rehabilitation strategies (exercise or physiotherapy), and weight loss if overweight or obese (body mass index ≥ 25 kg/m2). RESULTS: There were 1273 patients included: mean age 66.9 years (SD 8.7), 39.9% male, and 44.1% had less than post-secondary education. Recommended non-surgical knee OA treatment had been used by 59.7% of patients. In multivariable modeling, the odds of having received recommended non-surgical knee OA treatment were significantly and independently lower among individuals who were older (OR 0.97, 95% CI 0.95-0.99), male (OR 0.33, 0.25-0.45), and who lacked post-secondary education (OR 0.70, 0.53-0.93). CONCLUSION: In a large cross-sectional analysis of knee OA patients scheduled for TKA, 40% of individuals reported having not received core recommended non-surgical treatments. Older individuals, men, and those with less education had lower odds of having used recommended non-surgical OA treatments.

A Flight Simulator for Careers in Health Services and Policy Research.

If you always do what you've always done, you'll always get what you have always gotten. This is true for most things in life; it is true, too, for health services and policy research graduate training. The case for modernization of training programs is strong if you track the career outcomes for graduates, as has been done for 20 years and is described in this issue.

Decision-Making on New Non-Drug Health Technologies by Hospitals and Health Authorities in Canada.

INTRODUCTION: Unlike those for publicly funded drugs in Canada, coverage decision-making processes for non-drug health technologies (NDTs) are not well understood. OBJECTIVES: This paper aims to describe existing NDT decision-making processes in different healthcare organizations across Canada. METHODS: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. RESULTS: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. CONCLUSIONS: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.

The Introduction of New Non-Drug Health Technologies into Canadian Healthcare Institutions: Opportunities and Challenges.

INTRODUCTION: A recent pan-Canadian survey of 48 health organizations concluded that structures, processes, factors and information used to support funding decisions on new non-drug health technologies (NDTs) vary within and across jurisdictions in Canada. METHODS: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. RESULTS: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. CONCLUSIONS: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.

Frailty and Aging: How the Danish Experience Might Inform Canada.

Scandinavian countries are widely acknowledged as leaders in innovative models of care for their aging populations. To learn what might be potentially applicable to the health system in Canada, the Canadian Frailty Network (CFN) led a contingent of government, administrative, research and patient representatives to Denmark to directly observe Danish approaches for providing healthcare for older adults living with frailty. In this paper and based on what we learned from these observations, we discuss healthcare challenges faced by Canada's aging population for which Danish strategies provide clues as to where and how to improve care and system efficiencies, thereby maximizing the value of Canadian healthcare.

Facilitators of and barriers to adopting a restrictive red blood cell transfusion practice: a population-based cross-sectional survey.

BACKGROUND: Despite recommendations for restrictive approaches to red blood cell transfusion in the intensive care unit (ICU), variation from best practices persists. The aim of this study was to explore potential facilitators of and barriers to practising a restrictive red blood cell transfusion strategy among intensive care physicians using the theoretical domains framework. METHODS: We conducted an online population-based cross-sectional survey of all intensive care physicians in 1 health care system (Alberta). Survey questions were based on 6 key theoretical domains of the theoretical domains framework: Knowledge, Social/professional roles and identity, Motivation and goals, Beliefs about consequences, Social influences and Beliefs about capabilities. The survey was administered between July 27 and Oct. 6, 2017. Descriptive statistics (demographic and Likert scale data) and conventional content analysis (open-ended responses) were conducted. RESULTS: Forty-two intensive care physicians completed the survey (estimated response rate 56%). The respondents identified knowledge of published evidence, use of guidelines, improved outcomes, physician autonomy, and perceived culture of acceptance and collegial support as facilitators of practising a restrictive transfusion strategy. Identified barriers included potential impact on and cost to other clinical goals, conflicting practices and beliefs of physicians in other clinical specialties, deficits in medical trainees' skills and knowledge, and attitudinal barriers related to denial. INTERPRETATION: Using the theoretical domains framework, we identified 9 key self-reported facilitators of and barriers to intensive care physicians' transfusion behaviour. Understanding these determinants will help inform development and implementation of interventions within ICUs to encourage optimal use of red blood cell transfusion practices for nonbleeding patients whose condition is stable.

A retrospective observational analysis of red blood cell transfusion practices in stable, non-bleeding adult patients admitted to nine medical-surgical intensive care units.

BACKGROUND: Red blood cell (RBC) transfusions are common procedures performed in the intensive care unit (ICU). However, conservative transfusion approaches have been recommended to avoid RBC transfusions that are not clinically necessary and to achieve optimal patient outcomes. The objective of this study was to examine the utilization and costs of RBC transfusions in medical-surgical ICUs and to compare this information against clinical guideline recommendations for best practice. METHODS: Retrospective observational analysis of RBC transfusions in stable, non-bleeding adult patients was examined in a geographically-defined, population-based cohort of nine integrated ICUs between April 1, 2014 and December 31, 2016. RBC transfusions associated with a pre-transfusion hemoglobin value of 70 g/L or more were examined through linear and logistic regression. The total costs of RBC transfusions, based on the RBC unit cost, were estimated. RESULTS: A total of 4632 RBC transfusions (2287 ICU admissions) were included. Pre-transfusion hemoglobin values were identified for 4487 transfusions. On average, 61% occurred at or above a hemoglobin value of 70 g/L (mean 73.4 ± 9.2 g/L). Factors associated with such transfusions included being male, age over 75, Sequential Organ Failure Assessment (SOFA) score greater or equal to 10, transfer from operating room, gastrointestinal bleeding, and trauma. A pre-transfusion hemoglobin value at or above 70 g/L was associated with increased odds of ICU mortality; there was no impact on overall hospital mortality. The total estimated cost of RBC transfusions was $2.99M Canadian dollars (CAD), with $1.82M CAD attributed to those with a hemoglobin value at or above 70 g/L. CONCLUSIONS: Over half of the examined RBC transfusions may not have aligned with recommended best practice; this suggests significant opportunity for improvement. The present findings are an essential step towards optimizing RBC transfusions in the ICU.