Feasibility and Cost Analysis of Portable MRI Implementation in a Remote Setting in Canada.

OBJECTIVE: To conduct feasibility and cost analysis of portable MRI implementation in a remote setting where MRI access is otherwise unavailable. METHODS: Portable MRI (ultra-low field, 0.064T) was installed in Weeneebayko General Hospital, Moose Factory, Ontario. Adult patients, presenting with any indication for neuroimaging, were eligible for study inclusion. Scanning period was from November 14, 2021, to September 6, 2022. Images were sent via a secure PACS network for Neuroradiologist interpretation, available 24/7. Clinical indications, image quality, and report turnaround time were recorded. A cost analysis was conducted from a healthcare system's perspective in 2022 Canadian dollars, comparing cost of portable MRI implementation to transporting patients to a center with fixed MRI. RESULTS: Portable MRI was successfully implemented in a remote Canadian location. Twenty-five patients received a portable MRI scan. All studies were of diagnostic quality. No clinically significant pathologies were identified on any of the studies. However, based on clinical presentation and limitations of portable MRI resolution, it is estimated that 11 (44%) of patients would require transfer to a center with fixed MRI for further imaging workup. Cost savings were $854,841 based on 50 patients receiving portable MRI over 1 year. Five-year budget impact analysis showed nearly $8 million dollars saved. CONCLUSIONS: Portable MRI implementation in a remote setting is feasible, with significant cost savings compared to fixed MRI. This study may serve as a model to democratize MRI access, offer timely care and improved triaging in remote areas where conventional MRI is unavailable.

Health Resource and Cost Savings Achieved in a Multidisciplinary Lung Cancer Clinic.

Background: Lung cancer (LC) care is resource and cost intensive. We launched a Multidisciplinary LC Clinic (MDC), where patients with a new LC diagnosis received concurrent oncology consultation, resulting in improved time to LC assessment and treatment. Here, we evaluate the impact of MDC on health resource utilization, patient and caregiver costs, and secondary patient benefits. Methods: We retrospectively analyzed patients in a rapid assessment clinic with a new LC diagnosis pre-MDC (September 2016-February 2017) and post-MDC implementation (February 2017-December 2018). Data are reported as means; unpaired t-tests and ANOVA were used to assess for significance. We also conducted a cost analysis. Resource utilization, out-of-pocket costs, procedure-related costs, and indirect costs were evaluated from the societal perspective and presented in 2019 Canadian dollars (CAD); multi-way worst/best case and threshold sensitivity analyses were conducted. Results: We reviewed 428 patients (78 traditional model, 350 MDC). Patients in the MDC model required significantly fewer oncology visits from LC diagnosis to first LC treatment (1.62 vs. 2.68, p < 0.001), which was significant for patients with stage 1, 3, and 4 disease. Compared with the traditional model, there was no change in mean biopsies/patient (1.32 traditional vs. 1.17 MDC, p = 0.18) or staging investigations/patient (2.24 traditional vs. 2.02 MDC, p = 0.20). Post-MDC, there was an increase in invasive mediastinal staging for patients with stage 2/3 LC (15.0% vs. 60.0%, p < 0.001). Over 22 months, MDC resulted in savings of CAD 48,389 including CAD 24,167 CAD in direct patient out-of-pocket expenses. For the threshold analyses, MDC was estimated to cost CAD 25,708 per quality-adjusted life year (QALY), considered to be below current willingness to pay thresholds (at CAD 80,000 per QALY). MDC also facilitated oncology assessment for 29 non-LC patients. Conclusions: An MDC led to a reduction in patient visits and direct patient and caregiver costs.

Economic Burden and Healthcare Resource Use for Thoracic Aortic Dissections and Thoracic Aortic Aneurysms-A Population-Based Cost-of-Illness Analysis.

Background Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost-of-illness analysis was performed. From a single-payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (P<0.0001) and $13 M to $18 M for TAAs (P<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (P=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (P=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.

Use of instrumented lumbar spinal surgery for degenerative conditions: trends and costs over time in Ontario, Canada

Background: Instrumented lumbar surgeries, such as lumbar fusion and lumbar disc replacement, are increasingly being used in the United States for low back pain, with utilization rates approaching those of total joint arthroplasty. It is unknown whether there is a similar pattern in Canada. We sought to determine utilization rates and total medical costs of instrumented lumbar surgeries in a single-payer system and to compare these with the rates and costs of total hip and knee replacements. Methods: We included Ontarians aged 20 years and older who underwent instrumented lumbar surgery or total knee or total hip replacement between April 1993 and March 2012. Utilization and medical cost of the procedures were evaluated and compared using linear regression in a time-series analysis. Instrumented lumbar surgical procedures were stratified by age and main indication for surgery. Results: Utilization of instrumented lumbar surgeries rose from 6.2 to 14.2 procedures per 100 000 population between 1993 and 2012 (p < 0.001), well below the utilization of knee and hip arthroplasties. Patients were younger than 50 years for 29.2% of all instrumented lumbar surgery cases; annual procedure rates among those older than 80 years rose 7.6-fold. Direct medical costs of instrumented lumbar surgeries from 2002 to 2012 totaled $176 million. Spinal stenosis and spondylolisthesis were the most common indications for instrumented lumbar surgeries. Conclusion: Use of instrumented lumbar surgeries in Ontario's single-payer system has increased rapidly, especially among patients older than 80 years. In contrast to the situation in the United States, these rates were well below those of total joint arthroplasties. These data provide useful insights about resource allocation for surgical treatment of lumbar degenerative disorders.

Contexte: Les chirurgies lombaires instrumentées, telles que l'arthrodèse ou la prothèse discale lombaires, sont de plus en plus utilisées aux États-Unis pour le traitement de la lombalgie, leurs taux d'utilisation s'approchant de ceux de l'arthroplastie totale. On ignore si la tendance est la même au Canada. Nous avons voulu mesurer les taux d'utilisation et les coûts médicaux totaux des chirurgies lombaires instrumentées et les comparer aux taux et aux coûts de l'arthroplastie totale de la hanche et du genou. Méthodes: Nous avons inclus les Ontariens de 20 ans et plus ayant subi une chirurgie lombaire instrumentée ou une arthroplastie totale du genou ou de la hanche entre avril 1993 et mars 2012. L'utilisation et les coûts médicaux des interventions ont été évalués et comparés par analyse de régression linéaire des séries chronologiques. Les chirurgies lombaires ont été stratifiées selon l'âge et la principale indication. Résultats: Le recours aux chirurgies lombaires instrumentées a augmenté de 6,2 à 14,2 interventions par 100 000 de population entre 1993 et 2012 (p < 0,001), ce qui reste bien inférieur au recours à l'arthroplastie du genou et de la hanche. Les patients avaient moins de 50 ans pour 29,2 % de tous les cas de chirurgies lombaires instrumentées; le taux annuel d'interventions chez les patients de plus de 80 ans a augmenté selon un facteur de 7,6. Les coûts médicaux directs des chirurgies lombaires instrumentées ont totalisé 176 millions de dollars entre 2002 et 2012. La sténose rachidienne et le spondylolisthésis étaient les plus fréquentes indications des chirurgies lombaires instrumentées. Conclusion: L'utilisation de la chirurgie lombaire instrumentée pour le régime d'assurance santé à payeur unique ontarien a augmenté rapidement, particulièrement chez les patients de plus de 80 ans. Comparativement à la situation qui prévaut aux États-Unis, ces taux sont bien inférieurs aux taux d'arthroplasties totales. Ces données sont intéressantes du point de vue de l'allocation des ressources pour le traitement chirurgical de la dégénérescence discale lombaire.

Healthcare resource utilization and costs among patients with direct oral anticoagulant or warfarin-related major bleeding.

INTRODUCTION: Direct oral anticoagulants (DOACs) have expanded the options for antithrombotic therapy. DOAC-related major bleeds are associated with favorable outcomes compared to warfarin in clinical trials and routine practice. However, it is unclear whether management of DOAC-associated major bleeding incurs higher resource utilization and costs. MATERIALS AND METHODS: We screened medical records of patients ≥ 66 years with atrial fibrillation admitted to one of five tertiary care hospitals in Ontario, Canada with a hemorrhage. We abstracted bleeds involving DOACs or warfarin and linked them to administrative databases to capture length of hospital stay, blood product use, procedural interventions, intensive care unit (ICU) utilization and related direct medical costs. To control for confounders, multivariate logistic and linear regressions were used for binary and linear outcomes respectively. RESULTS: Among 19,061 records screened, 1978 (10.4%) cases involving 1632 patients met criteria of oral anticoagulant-associated bleeding. Baseline characteristics between DOAC and warfarin groups were similar. Blood product costs were higher for DOACs (all comparisons DOACs vs. warfarin, $1456 vs. $1109, mean difference $347, 95% CI $185 to $509), but length of stay and ICU use were similar. Mean direct medical costs did not differ ($9217 vs. $10,790, adjusted relative ratio 0.94, 95% CI 0.84-1.05). CONCLUSIONS: Prior to introduction of DOAC-specific reversal agents, resource utilization and medical costs were comparable between DOAC- and warfarin-associated major bleeds, despite marginally higher blood product costs incurred by the former. Resource intensity associated with anticoagulant-related bleeding remains high, and our data provide measures for cost-effectiveness evaluation of emerging DOAC antidotes.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 2: The direct and indirect costs of injury.

BACKGROUND: Ankle and foot sprains and fractures are prevalent injuries, which may result in substantial physical and economic consequences for the patient and place a financial burden on the health care system. Therefore, the objectives of this paper are to examine the direct and indirect costs of treating ankle and foot injuries (sprains, dislocations, fractures), as well as to provide an overview of the outcomes of full economic analyses of different treatment strategies. METHODS: A systematic review was carried out among seven databases to identify English language publications on the health economics of ankle and foot injury treatment published between 1980 and 2014. The direct and indirect costs were abstracted by two independent reviewers. All costs were adjusted for inflation and reported in 2016 US dollars (USD). RESULTS: Among 2047 identified studies, 32 were selected for analysis. The direct costs of ankle sprain management ranged from $292 to $2268 per patient (2016 USD), depending on the injury severity and treatment strategy. The direct costs of managing ankle fractures were higher ($1908-$19,555). Foot fracture treatment had similar direct costs ranging from $998 to $21,801. The economic evaluations were conducted from the societal or payer's perspectives. CONCLUSION: The costs of treating ankle and foot sprains and fractures varied among the studies, mostly due to differences in injury type and study characteristics, which impacted the ability of directly comparing the financial burden of treatment. Nonetheless, the review showed that the costs experienced by the patient and the health care system increased with injury complexity.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 1: Overview and critical appraisal.

BACKGROUND: Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment. METHODS: A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data. RESULTS: The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data. CONCLUSION: This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada.

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

Postoperative Remote Automated Monitoring: Need for and State of the Science.

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.

Epidemiology and management of thoracic aortic dissections and thoracic aortic aneurysms in Ontario, Canada: A population-based study.

OBJECTIVES: To determine hospital incidence, mortality, and management for thoracic aortic dissections and aneurysms. METHODS: A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of thoracic aortic dissections and aneurysms were identified between 2002 and 2014. Treatment and mortality trends were assessed. RESULTS: There were 5966 aortic dissections (Type A n = 2289 [38%] and Type B n = 3632 [61%]). Overall incidence proportion for aortic dissections was 4.6 per 100,000. There were 9392 thoracic aortic aneurysms with an overall incidence proportion of 7.6 per 100,000. The incidence for both dissections and aneurysms significantly increased over the 12-year study. Only 53% (1204 out of 2289) of Type A dissections underwent surgery. Type B dissection treatment was 83% (3000 out of 3632) medical, 10% (370 out of 3632) surgery, and 7% (262 out of 3632) endovascular. Thoracic aortic aneurysm treatment was 53% (4940 out of 9392) surgery, 44% (4129 out of 9392) medical, and 3% (323 out of 9392) endovascular. Thirty-five percent of known descending thoracic aortic aneurysms (323 out of 924) received a stent graft. Cardiac surgeons performed 87% of the open surgical repairs. Vascular surgeons performed 91% of the endovascular procedures. All-cause 3-year mortality significantly decreased for both aortic dissections (44% to 40%) and aneurysms (30% to 22%). All-cause hospital mortality also decreased. Women had worse outcomes than men. CONCLUSIONS: The incidence of thoracic aortic dissections and aneurysms increased over time but all-cause hospital and late outcomes improved. Gender differences exist. Men incur more disease but women have higher hospital mortality. Surgery was primarily referred to cardiac surgeons. Endovascular therapy was primarily referred to vascular surgeons.

Barriers and facilitators to postoperative pain management in Rwanda from the perspective of health care providers: A contextualization of the theory of planned behavior.

AIMS: Identify opportunities to improve knowledge translation for post-operative pain management in Rwanda by exploring clinician and environmental factors affecting this practice. METHODS: The theory of planned behavior (TPB) guided development of a questionnaire to measure intent to assess and treat postoperative pain. Focus groups and individual interviews were used to contextualize the final questionnaire and generate questions related to pain management practice. Health care providers from two Rwandan teaching hospitals involved in postoperative pain management completed the TPB questionnaire in May 2015. TPB subscale scores were analyzed to identify demographic and practice characteristics associated with intention to treat pain. The general linear model was used to test effect of attitudes, subjective norms, and perceived control on behavioral intent to treat pain. RESULTS: Forty-six percent of participants (N = 131) had training in acute pain management, 56% used a pain protocol, and 74% used pain scales. Tramadol (78%), morphine (79%), and paracetamol (75%) were used most often to treat pain. Drug availability was the most frequently reported barrier to treating pain. Though intention to treat pain was high, only attitudes and perceived control about assessing pain were associated with intention to treat pain. The theme of fear of the adverse effects of pain medications was consistent across focus groups and interviews in both sites. CONCLUSIONS: System and knowledge barriers exist: interventions to address these barriers may lead to improved postoperative pain care. Further validation of the TPB questionnaire is required to address cultural and language factors specific to the Rwandan context.

But: Améliorer le transfert des connaissances en matière de prise en charge de la douleur postopératoire au Rwanda en étudiant les facteurs environnementaux et les facteurs liés aux cliniciens qui affectent cette pratique.Méthodes: La théorie du comportement planifié (TCP) a guidé l'élaboration d'un questionnaire visant à mesurer l'intention d'évaluer et de traiter la douleur postopératoire. Des groupes de discussion et des entrevues individuelles ont été utilisées afin de contextualiser le questionnaire final et formuler des questions portant sur les pratiques en matière de gestion de la douleur. Les prestataires de soins de deux hôpitaux universitaires rwandais impliqués dans la prise en charge de la douleur postopératoire ont répondu au questionnaire fondé sur la TCP en mai 2015. Les scores obtenus pour les sous-échelles ont été analysés afin de cerner les caractérisriques démographiques et les caractéristiques liées aux pratiques qui étaient associées à l'intention de traiter la douleur. Le modèle linéaire général a été utilisé afin de tester l'effet des attitudes, des normes subjectives et du contrôle perçu sur l'intention comportementale de traiter la douleur.Résultats: Quarante-six pour cent des participants (N = 131) avaient une formation en prise en charge de la douleur aigue, 56 % utilisaient un protocole de prise en charge de la douleur et 74 % utilisaient des échelles d'évaluation de la douleur. Le tranadol (78 %), la morphine (79 %) et le paracétamol (75 %) étaient le plus souvent utilisés pour traiter la douleur. La disponibilité des médicaments était la barrière au traitement de la douleur la plus fréquemment citée. Bien que l'intention de traiter la douleur était élevée, seules les attitudes et le contrôle perçu au sujet de l'évaluation de la douleur étaient associés à l'intention de traiter la douleur. Le thème de la peur des effets indésirables des médicaments contre la douleur a été soulevé dans tous les groupes de discussions et les entrevues tenus dans les deux sites.Conclusions: Il existe des barrières systémiques et des barrières liées aux connaissances : des interventions visant à lever ces barrières pourraient mener à l'amélioration des soins postopératoires. Le questionnaire fondé sur la TCP doit être validé davantage afin d'aborder les facteurs liés à la culutre et au langage spécifiques au contexte rwandais.

Direct Oral Anticoagulant- or Warfarin-Related Major Bleeding: Characteristics, Reversal Strategies, and Outcomes From a Multicenter Observational Study.

BACKGROUND: Direct oral anticoagulants (DOACs) have expanded the armamentarium for antithrombotic therapy. Although DOAC-related major bleeding was associated with favorable outcomes compared with warfarin in clinical trials, warfarin effects were reversed in < 40% of cases, raising concerns about the generalizability of this finding. METHODS: Consecutive patients ≥ 66 years presented to five tertiary care hospitals across three cities in Ontario, Canada from October 2010 to March 2015 with diagnoses that included hemorrhage. Charts were screened for association with DOAC or warfarin use; eligible cases were abstracted and linked to administrative databases. RESULTS: Among 19,061 records screened, 2,002 (460 receiving DOAC, 1,542 receiving warfarin) were eligible. Reversal agents (72.9% vitamin K, 40.7% prothrombin complex concentrates) were frequently used in warfarin bleeding events. Red blood cell transfusions occurred more often in DOAC bleeding events than in warfarin events (52.0% vs 39.5%; adjusted relative risk [aRR], 1.32; 95% CI, 1.19-2.47). However, units of blood products transfused were not different between the two groups. Thirty-four DOAC cases (7.4%) received activated prothrombin complex concentrates or recombinant factor VIIa. In-hospital mortality was lower following DOAC bleeding events (9.8% vs 15.2%; aRR, 0.66; 95% CI, 0.49-0.89), although differences in 30-day mortality did not reach statistical significance (12.6% vs 16.3%; aRR, 0.79; 95% CI, 0.61-1.03). CONCLUSIONS: In this unselected cohort of patients with oral anticoagulant-related hemorrhage with high rates of warfarin reversal, in-hospital mortality was lower among DOAC-associated bleeding events. These findings support the safety of DOACs in routine care and present useful baseline measures for evaluations of DOAC-specific reversal agents.

Economies of scale: body mass index and costs of cardiac surgery in Ontario, Canada.

An obesity paradox has been described, whereby obese patients have better health outcomes than normal weight patients in certain clinical situations, including cardiac surgery. However, the relationship between body mass index (BMI) and resource utilization and costs in patients undergoing coronary artery bypass graft (CABG) surgery is largely unknown. We examined resource utilization and cost data for 53,224 patients undergoing CABG in Ontario, Canada over a 10-year period between 2002 and 2011. Data for costs during hospital admission and for a 1-year follow-up period were derived from the Institute for Clinical Evaluative Sciences, and analyzed according to pre-defined BMI categories using analysis of variance and multivariate models. BMI independently influenced healthcare costs. Underweight patients had the highest per patient costs ($50,124 ± $36,495), with the next highest costs incurred by morbidly obese ($43,770 ± $31,747) and normal weight patients ($42,564 ± $30,630). Obese and overweight patients had the lowest per patient costs ($40,760 ± $30,664 and $39,960 ± $25,422, respectively). Conversely, at the population level, overweight and obese patients were responsible for the highest total yearly population costs to the healthcare system ($92 million and $50 million, respectively, compared to $4.2 million for underweight patients). This is most likely due to the high proportion of CABG patients falling into the overweight and obese BMI groups. In the future, preoperative risk stratification and preparation based on BMI may assist in reducing surgical costs, and may inform health policy measures aimed at the management of weight extremes in the population.

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial.

OBJECTIVE:  To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains. DESIGN:  A randomised controlled trial of 503 participants followed for six months. SETTING:  Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada. PARTICIPANTS:  The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol. INTERVENTION:  Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy. MAIN OUTCOME MEASURES:  The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months. RESULTS:  The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score. CONCLUSIONS:  In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).

Perspectives, perceptions and experiences in postoperative pain management in developing countries: A focus group study conducted in Rwanda.

BACKGROUND: Access to postoperative acute pain treatment is an important component of perioperative care and is frequently managed by a multidisciplinary team of anesthesiologists, surgeons, pharmacists, technicians and nurses. In some developing countries, treatment modalities are often not performed due to scarce health care resources, knowledge deficiencies and cultural attitudes. OBJECTIVES: In advance of a comprehensive knowledge translation initiative, the present study aimed to determine the perspectives, perceptions and experiences of anesthesia residents regarding postoperative pain management strategies. METHODS: The present study was conducted using a qualitative assessment strategy in a large teaching hospital in Rwanda. During two sessions separated by seven days, a 10-participant semistructured focus group needs analysis was conducted with anesthesia residents at the Centre Hospitalier Universitaire de Kigali (Kigali, Rwanda). Field notes were analyzed using interpretative and descriptive phenomenological approaches. Participants were questioned regarding their perspectives, perceptions and experiences in pain management. RESULTS: The responses from the focus groups were related to five general areas: general patient and medical practice management; knowledge base regarding postoperative pain management; pain evaluation; institutional/system issues related to protocol implementation; and perceptions about resource allocation. Within these areas, challenges (eg, communication among stakeholders and with patients) and opportunities (eg, on-the-job training, use of protocols, routine pain assessment, participation in resource allocation decisions) were identified. CONCLUSIONS: The present study revealed the prevalent challenges residents perceive in implementing postoperative pain management strategies, and offers practical suggestions to overcoming them, primarily through training and the implementation of practice recommendations.

Body Mass Index, Outcomes, and Mortality Following Cardiac Surgery in Ontario, Canada.

BACKGROUND: The "obesity paradox" reflects an observed relationship between obesity and decreased morbidity and mortality, suggesting improved health outcomes for obese individuals. Studies examining the relationship between high body mass index (BMI) and adverse outcomes after cardiac surgery have reported conflicting results. METHODS AND RESULTS: The study population (N=78 762) was comprised of adult patients who had undergone first-time coronary artery bypass (CABG) or combined CABG/aortic valve replacement (AVR) surgery from April 1, 1998 to October 31, 2011 in Ontario (data from the Institute for Clinical Evaluative Sciences). Perioperative outcomes and 5-year mortality among pre-defined BMI (kg/m(2)) categories (underweight <20, normal weight 20 to 24.9, overweight 25 to 29.9, obese 30 to 34.9, morbidly obese >34.9) were compared using Bivariate analyses and Cox multivariate regression analysis to investigate multiple confounders on the relationship between BMI and adverse outcomes. A reverse J-shaped curve was found between BMI and mortality with their respective hazard ratios. Independent of confounding variables, 30-day, 1-year, and 5-year survival rates were highest for the obese group of patients (99.1% [95% Confidence Interval {CI}, 98.9 to 99.2], 97.6% [95% CI, 97.3 to 97.8], and 90.0% [95% CI, 89.5 to 90.5], respectively), and perioperative complications lowest. Underweight and morbidly obese patients had higher mortality and incidence of adverse outcomes. CONCLUSIONS: Overweight and obese patients had lower mortality and adverse perioperative outcomes after cardiac surgery compared with normal weight, underweight, and morbidly obese patients. The "obesity paradox" was confirmed for overweight and moderately obese patients. This may impact health resource planning, shifting the focus to morbidly obese and underweight patients prior to, during, and after cardiac surgery.

Predictors of hospital stay and home care services use: a population-based, retrospective cohort study in stage IV gastric cancer.

BACKGROUND: Home care services use has been proposed as a means of reducing costs in palliative care by decreasing hospital stay without impacting quality of clinical care; however, little is known about utilization of these services in the time following a terminal cancer diagnosis. AIM: To examine disease, patient and healthcare system predictors of hospital stay, and home care services use in metastatic gastric cancer patients. DESIGN: This is a population-based, retrospective cohort study. Chart review and administrative data were linked, using a 26-month time horizon to collect health services data. PARTICIPANTS: All patients diagnosed with metastatic gastric cancer in the province of Ontario between 2005 and 2008 were included in the study (n = 1433). RESULTS: Age, comorbidity, tumor location, and burden of metastatic disease were identified as predictors of hospital stay and receipt of home care services. Individuals who received home care services spent fewer days in hospital than individuals who did not (relative risk: 0.44; 95% confidence interval: 0.38-0.51). Patients who interacted with a high-volume oncology specialist had shorter cumulative hospital stay (relative risk: 0.62; 95% confidence interval: 0.54-0.71) and were less likely to receive home care services (relative risk: 0.80; 95% confidence interval: 0.72-0.88) than those who did not. CONCLUSION: Examining how differences in hospital stay and home care services use impact clinical outcomes and how policies may reduce costs to the healthcare system is necessary.