Peter Tugwell

University of Ottawa, Ottawa, Ontario, Canada

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Publications (700)3334.07 Total impact

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    J. André Knottnerus, Peter Tugwell
    Journal of Clinical Epidemiology 07/2015; 68(7). DOI:10.1016/j.jclinepi.2015.04.008
  • Journal of clinical epidemiology 07/2015; DOI:10.1016/j.jclinepi.2015.07.001
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    ABSTRACT: Assessing the availability of health services during humanitarian emergencies is essential for understanding the capacities and weaknesses of disrupted health systems. To improve the consistency of health facilities assessments, the World Health Organization has proposed the use of the Health Resources Availability Mapping System (HeRAMS) developed in Darfur, Sudan as a standardized assessment tool for use in future acute and protracted crises. This study provides an evaluation of HeRAMS' comprehensiveness, and investigates the methods, quality and comprehensiveness of health facilities data and tools in Haiti, where HeRAMS was not used. Tools and databases containing health facilities data in Haiti were collected using a snowball sampling technique, while HeRAMS was purposefully evaluated in Sudan. All collected tools were assessed for quality and comprehensiveness using a coding scheme based on the World Health Organization's health systems building blocks, the Global Health Cluster Suggested Set of Core Indicators and Benchmarks by Category, and the Sphere Humanitarian Charter and Minimum Standards in Humanitarian Response. Eight assessments and databases were located in Haiti, and covered a median of 3.5 of the 6 health system building blocks, 4.5 of the 14 Sphere standards, and 2 of the 9 Health Cluster indicators. None of the assessments covered all of the indicators in any of the assessment criteria and many lacked basic data, limiting the detail of analysis possible for calculating standardized benchmarks and indicators. In Sudan, HeRAMS collected data on 5 of the 6 health system building blocks, 13 of the 14 Sphere Standards, and collected data to allow the calculation of 7 of the 9 Health Cluster Core Indicators and Benchmarks. There is a need to agree upon essential health facilities data in disrupted health systems during humanitarian emergencies. Although the quality of the assessments in Haiti was generally poor, the large number of platforms and assessment tools deployed suggests that health facilities data can be collected even during acute emergencies. Further consensus is needed to establish essential criteria for data collection and to establish a core group of health systems assessment experts to be deployed during future emergencies.
    Conflict and Health 06/2015; 9:20. DOI:10.1186/s13031-015-0045-6
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    J André Knottnerus, Peter Tugwell
    Journal of clinical epidemiology 06/2015; 68(6):601-2. DOI:10.1016/j.jclinepi.2015.04.004
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    ABSTRACT: Background Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence. Objectives To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries. To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. Search methods We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases. Selection criteria For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water. Data collection and analysis We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies. We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups. For fluorosis data we calculated the log odds and presented them as probabilities for interpretation. Main results A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis. The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste. There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels. There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels. No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria. With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation. Authors' conclusions There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries. The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults. There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes. There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.
    Cochrane database of systematic reviews (Online) 06/2015;
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    J. André Knottnerus, Peter Tugwell
    Journal of Clinical Epidemiology 06/2015; 68(8). DOI:10.1016/j.jclinepi.2015.06.001
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    ABSTRACT: Pain is a patient-important outcome, but current reporting in randomized controlled trials and systematic reviews is often suboptimal, impeding clinical interpretation and decision making. A working group at the 2014 Outcome Measures in Rheumatology (OMERACT 12) was convened to provide guidance for reporting treatment effects regarding pain for individual studies and systematic reviews. For individual trials, authors should report, in addition to mean change, the proportion of patients achieving 1 or more thresholds of improvement from baseline pain (e.g., ≥ 20%, ≥ 30%, ≥ 50%), achievement of a desirable pain state (e.g., no worse than mild pain), and/or a combination of change and state. Effects on pain should be accompanied by other patient-important outcomes to facilitate interpretation. When pooling data for metaanalysis, authors should consider converting all continuous measures for pain to a 100 mm visual analog scale (VAS) for pain and use the established, minimally important difference (MID) of 10 mm, and the conventionally used, appreciably important differences of 20 mm, 30 mm, and 50 mm, to facilitate interpretation. Effects ≤ 0.5 units suggest a small or very small effect. To further increase interpretability, the pooled estimate on the VAS should also be transformed to a binary outcome and expressed as a relative risk and risk difference. This transformation can be achieved by calculating the probability of experiencing a treatment effect greater than the MID and the thresholds for appreciably important differences in pain reduction in the control and intervention groups. Presentation of relative effects regarding pain will facilitate interpretation of treatment effects.
    The Journal of Rheumatology 05/2015; DOI:10.3899/jrheum.141440
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    ABSTRACT: Objective. Pain is a patient-important outcome, but current reporting in randomized controlled trials and systematic reviews is often suboptimal, impeding clinical interpretation and decision making. Methods. A working group at the 2014 Outcome Measures in Rheumatology (OMERACT 12) was convened to provide guidance for reporting treatment effects regarding pain for individual studies and systematic reviews. Results. For individual trials, authors should report, in addition to mean change, the proportion of patients achieving 1 or more thresholds of improvement from baseline pain (e.g., ≥ 20%, ≥ 30%, ≥ 50%), achievement of a desirable pain state (e.g., no worse than mild pain), and/or a combination of change and state. Effects on pain should be accompanied by other patient-important outcomes to facilitate interpretation. When pooling data for metaanalysis, authors should consider converting all continuous measures for pain to a 100 mm visual analog scale (VAS) for pain and use the established, minimally important difference (MID) of 10 mm, and the conventionally used, appreciably important differences of 20 mm, 30 mm, and 50 mm, to facilitate interpretation. Effects ≤ 0.5 units suggest a small or very small effect. To further increase interpretability, the pooled estimate on the VAS should also be transformed to a binary outcome and expressed as a relative risk and risk difference. This transformation can be achieved by calculating the probability of experiencing a treatment effect greater than the MID and the thresholds for appreciably important differences in pain reduction in the control and intervention groups. Conclusion. Presentation of relative effects regarding pain will facilitate interpretation of treatment effects. (J Rheumatol First Release May 15 2015; doi:10.3899/jrheum.141440) Key Indexing Terms: OMERACT OUTCOMES PAIN CLINICAL TRIALS VISUAL ANALOG SCALE SYSTEMATIC REVIEWS
    The Journal of Rheumatology 05/2015; DOI:10.3899/jrheum.141440)
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    Peter Tugwell, J. André Knottnerus
    Journal of Clinical Epidemiology 05/2015; 68(7). DOI:10.1016/j.jclinepi.2015.05.010
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    ABSTRACT: Serious infections are a major concern for patients considering treatments for rheumatoid arthritis. Evidence is inconsistent as to whether biological drugs are associated with an increased risk of serious infection compared with traditional disease-modifying antirheumatic drugs (DMARDs). We did a systematic review and meta-analysis of serious infections in patients treated with biological drugs compared with those treated with traditional DMARDs. We did a systematic literature search with Medline, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from their inception to Feb 11, 2014. Search terms included "biologics", "rheumatoid arthritis" and their synonyms. Trials were eligible for inclusion if they included any of the approved biological drugs and reported serious infections. We assessed the risk of bias with the Cochrane Risk of Bias Tool. We did a Bayesian network meta-analysis of published trials using a binomial likelihood model to assess the risk of serious infections in patients with rheumatoid arthritis who were treated with biological drugs, compared with those treated with traditional DMARDs. The odds ratio (OR) of serious infection was the primary measure of treatment effect and calculated 95% credible intervals using Markov Chain Monte Carlo methods. The systematic review identified 106 trials that reported serious infections and included patients with rheumatoid arthritis who received biological drugs. Compared with traditional DMARDs, standard-dose biological drugs (OR 1·31, 95% credible interval [CrI] 1·09-1·58) and high-dose biological drugs (1·90, 1·50-2·39) were associated with an increased risk of serious infections, although low-dose biological drugs (0·93, 0·65-1·33) were not. The risk was lower in patients who were methotrexate naive compared with traditional DMARD-experienced or anti-tumour necrosis factor biological drug-experienced patients. The absolute increase in the number of serious infections per 1000 patients treated each year ranged from six for standard-dose biological drugs to 55 for combination biological therapy, compared with traditional DMARDs. Standard-dose and high-dose biological drugs (with or without traditional DMARDs) are associated with an increase in serious infections in rheumatoid arthritis compared with traditional DMARDs, although low-dose biological drugs are not. Clinicians should discuss the balance between benefit and harm with the individual patient before starting biological treatment for rheumatoid arthritis. Rheumatology Division at the University of Alabama at Birmingham. Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Lancet 05/2015; DOI:10.1016/S0140-6736(14)61704-9
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    ABSTRACT: Although protocol registration for systematic reviews is still not mandatory, reviewers should be strongly encouraged to register the protocol to identify the methodological approach, including all outcomes of interest. This will minimize the likelihood of biased decisions in reviews, such as selective outcome reporting. A group of international experts convened to address issues regarding the need to develop hierarchical lists of outcome measurement instruments for a particular outcome for metaanalyses. Multiple outcome measurement instruments exist to measure the same outcome. Metaanalysis of knee osteoarthritis (OA) trials, and the assessment of pain as an outcome, was used as an exemplar to assess how Outcome Measures in Rheumatology (OMERACT), the Cochrane Collaboration, and other international initiatives might contribute in this area. The meeting began with formal presentations of background topics, empirical evidence from the literature, and a brief introduction to 2 existing hierarchical lists of pain outcome measurement instruments recommended for metaanalyses of knee OA trials. After discussions, most participants agreed that there is a need to develop a methodology for generation of hierarchical lists of outcome measurement instruments to guide metaanalyses. Tools that could be used to steer development of such a prioritized list are the COSMIN checklist (Consensus-based Standards for the selection of health status Measurement Instruments) and the OMERACT Filter 2.0. We list meta-epidemiological research agenda items that address the frequency of reported outcomes in trials, as well as methodologies to assess the best measurement properties (i.e., truth, discrimination, and feasibility).
    The Journal of Rheumatology 05/2015; DOI:10.3899/jrheum.141384
  • Cochrane database of systematic reviews (Online) 04/2015;
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    ABSTRACT: Systematic reviews represent one of the most important tools for knowledge translation but users often struggle with understanding and interpreting their results. GRADE Summary-of-Findings tables have been developed to display results of systematic reviews in a concise and transparent manner. The current format of the Summary-of-Findings tables for presenting risks and quality of evidence improves understanding and assists users with finding key information from the systematic review. However, it has been suggested that additional methods to present risks and display results in the Summary-of-Findings tables are needed. We will conduct a non-inferiority parallel-armed randomized controlled trial to determine whether an alternative format to present risks and display Summary-of-Findings tables is not inferior compared to the current standard format. We will measure participant understanding, accessibility of the information, satisfaction, and preference for both formats. We will invite systematic review users to participate (that is clinicians, guideline developers, and researchers). The data collection process will be undertaken using the online 'Survey Monkey' system. For the primary outcome understanding, non-inferiority of the alternative format (Table A) to the current standard format (Table C) of Summary-of-Findings tables will be claimed if the upper limit of a 1-sided 95% confidence interval (for the difference of proportion of participants answering correctly a given question) excluded a difference in favor of the current format of more than 10%. This study represents an effort to provide systematic reviewers with additional options to display review results using Summary-of-Findings tables. In this way, review authors will have a variety of methods to present risks and more flexibility to choose the most appropriate table features to display (that is optional columns, risks expressions, complementary methods to display continuous outcomes, and so on). NCT02022631 (21 December 2013).
    Trials 04/2015; 16(1):164. DOI:10.1186/s13063-015-0649-6
  • Peter Tugwell, J. André Knottnerus
    Journal of clinical epidemiology 03/2015; 68(5). DOI:10.1016/j.jclinepi.2015.03.004
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    ABSTRACT: There is a large volume of health information available, and, if applied in clinical practice, may contribute to effective patient care. Despite an abundance of information, sub-optimal care is common. Many factors influence practitioners' use of health information, and format (electronic or other) may be one such factor. To assess the effects of interventions aimed at improving or increasing healthcare practitioners' use of electronic health information (EHI) on professional practice and patient outcomes. We searched The Cochrane Library (Wiley), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and LISA (EBSCO) up to November 2013. We contacted researchers in the field and scanned reference lists of relevant articles. We included studies that evaluated the effects of interventions to improve or increase the use of EHI by healthcare practitioners on professional practice and patient outcomes. We defined EHI as information accessed on a computer. We defined 'use' as logging into EHI. We considered any healthcare practitioner involved in patient care. We included randomized, non-randomized, and cluster randomized controlled trials (RCTs, NRCTs, CRCTs), controlled clinical trials (CCTs), interrupted time series (ITS), and controlled before-and-after studies (CBAs).The comparisons were: electronic versus printed health information; EHI on different electronic devices (e.g. desktop, laptop or tablet computers, etc.; cell / mobile phones); EHI via different user interfaces; EHI provided with or without an educational or training component; and EHI compared to no other type or source of information. Two review authors independently extracted data and assessed the risk of bias for each study. We used GRADE to assess the quality of the included studies. We reassessed previously excluded studies following our decision to define logins to EHI as a measure of professional behavior. We reported results in natural units. When possible, we calculated and reported median effect size (odds ratio (OR), interquartile ranges (IQR)). Due to high heterogeneity across studies, meta-analysis was not feasible. We included two RCTs and four CRCTs involving 352 physicians, 48 residents, and 135 allied health practitioners. Overall risk of bias was low as was quality of the evidence. One comparison was supported by three studies and three comparisons were supported by single studies, but outcomes across the three studies were highly heterogeneous. We found no studies to support EHI versus no alternative. Given these factors, it was not possible to determine the relative effectiveness of interventions. All studies reported practitioner use of EHI, two reported on compliance with electronic practice guidelines, and none reported on patient outcomes.One trial (139 participants) measured guideline adherence for an electronic versus printed guideline, but reported no difference between groups (median OR 0.85, IQR 0.74 to 1.08). One small cross-over trial (10 participants) reported increased use of clinical guidelines when provided with a mobile versus stationary, desktop computer (mean use per shift: intervention group (IG) 3.6, standard deviation (SD) 1.7 vs. control group (CG) 2.0 (SD 1.9), P value = 0.033). One cross-over trial (203 participants) reported that using a customized versus a generic interface had little impact on practitioners' use of EHI (mean difference in adjusted end-of-study rate: 0.77 logins/month/user, 95% confidence interval (CI) CI 0.43 to 1.11). Three trials included education or training and reported increased use of EHI by practitioners following training. This review provided no evidence that the use of EHI translates into improved clinical practice or patient outcomes, though it does suggest that when practitioners are provided with EHI and education or training, the use of EHI increases. We have defined use as the activity of logging into an EHI resource, but based on our findings use does not automatically translate to the application of EHI in practice. While using EHI may be an important component of evidence-based medicine, alone it is insufficient to improve patient care or clinical practices. For EHI to be applied in patient care, it will be necessary to understand why practitioners' are reluctant to apply EHI when treating people, and to determine the most effective way(s) to reduce this reluctance.
    Cochrane database of systematic reviews (Online) 03/2015; 3:CD004749. DOI:10.1002/14651858.CD004749.pub3
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    J. André Knottnerus, Peter Tugwell
    Journal of Clinical Epidemiology 02/2015; 68(4). DOI:10.1016/j.jclinepi.2015.02.004
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    ABSTRACT: Previous patient-level acute myocardial infarction (AMI) research has found higher hospital spending to be associated with improved survival; however, survivor-treatment selection bias traditionally has been overlooked. The purpose of this study was to examine the AMI cost-outcome relationship, taking into account this form of bias. Hospital Discharge Abstract data tracked costs for AMI hospitalizations. Ontario Vital Statistics data tracked patient mortality. A standard Cox survival model was compared to an extended Cox model using hospital costs as a time-varying covariate to examine the impact of cost on 1-year survival in a cohort of 30,939 first-time AMI patients in Ontario, Canada, from 2007 to 2010. Higher patient-level AMI spending decreased the hazard of dying (Standard Model: log-cost hazard ratio: 0.513, 95 percent CI: 0.479-0.549; Extended Model: log-cost hazard ratio: 0.700, 95 percent CI: 0.645-0.758); however, the protective effect was overestimated by 62 percent when survivor-treatment bias was overlooked. In the extended model, a 10 percent increase in spending was associated with a 3.6 percent decrease in hazard of death. The findings of this study suggest that if survivor-treatment bias is overlooked, future research may materially overstate the protective effect of patient-level spending on outcomes. © Health Research and Educational Trust.
    Health Services Research 02/2015; DOI:10.1111/1475-6773.12286
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    ABSTRACT: To develop a list of 5 tests or treatments used in rheumatology that have evidence indicating that they may be unnecessary and thus should be reevaluated by rheumatology healthcare providers and patients. Using the Delphi method, a committee of 16 rheumatologists from across Canada and an allied health professional generated a list of tests, procedures, or treatments in rheumatology that may be unnecessary, nonspecific, or insensitive. Items with high content agreement and perceived relevance advanced to a survey of Canadian Rheumatology Association (CRA) members. CRA members ranked these top items based on content agreement, effect, and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential effect on patients, and the member survey results. Five candidate items selected were then subjected to a literature review. A group of patient collaborators with rheumatic diseases also reviewed these items. Sixty-four unique items were proposed and after 3 Delphi rounds, this list was narrowed down to 13 items. In the member-wide survey, 172 rheumatologists responded (36% of those contacted). The respondent characteristics were similar to the membership at large in terms of sex and geographical distribution. Five topics (antinuclear antibodies testing, HLA-B27 testing, bone density testing, bone scans, and bisphosphonate use) with high ratings on agreement and effect were chosen for literature review. The list of 5 items has identified starting points to promote discussion about practices that should be questioned to assist rheumatology healthcare providers in delivering high-quality care.
    The Journal of Rheumatology 02/2015; 42(4). DOI:10.3899/jrheum.141140
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    ABSTRACT: This article reports the findings of a scoping review assessing the extent and ways in which migrants have been included in health impact assessments (HIAs) and HIA evaluations worldwide. A total of 117 HIAs and two HIA evaluations were included. Only 14% of hand-searched HIAs mentioned migrants, 5% analysed migrants and only 2% included them in their recommendations. Nonetheless, migrants would be expected to be part of the analysis based on the reasons for which migrants were most commonly mentioned. Although the majority of HIAs included in the review mentioned migrants in baseline conditions and impact analysis steps, migrants were seldom included in recommendations. Furthermore, the use of frameworks or tools guiding the completion of an HIA was negatively associated with the inclusion of migrants in recommendations. This is a pivotal risk of frameworks not mentioning migrants. Although workshops and stakeholder engagement were a frequent way of including migrants in HIAs, this usually involved organizations representing migrants, and only seldom included members of the migrant community themselves. The main barriers to including migrants in the HIA impact analysis were the lack of available data on migrants and the significant additional resources required to gather and analyse additional data on migrants. Guidance is needed on ways to optimally include migrants in HIAs and ensure that recommendations for mitigation measures are optimal.
    Environmental Impact Assessment Review 01/2015; 50:16–24. DOI:10.1016/j.eiar.2014.08.009
  • Peter Tugwell, J. André Knottnerus
    Journal of Clinical Epidemiology 01/2015; 68(3). DOI:10.1016/j.jclinepi.2015.01.007

Publication Stats

33k Citations
3,334.07 Total Impact Points

Institutions

  • 1993–2015
    • University of Ottawa
      • • Department of Medicine
      • • Department of Epidemiology and Community Medicine
      • • Institute of Population Health
      Ottawa, Ontario, Canada
    • American College of Rheumatology
      Atlanta, Georgia, United States
  • 2014
    • Ottawa Hospital Research Institute
      Ottawa, Ontario, Canada
  • 1992–2013
    • The Ottawa Hospital
      • Department of Medicine
      Ottawa, Ontario, Canada
  • 2012
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
  • 2004–2012
    • Population Health Research Institute
      Hamilton, Ontario, Canada
  • 2011
    • University of Melbourne
      Melbourne, Victoria, Australia
  • 2010
    • University of Nottingham
      Nottigham, England, United Kingdom
    • Geisel School of Medicine at Dartmouth
      Hanover, New Hampshire, United States
  • 2008
    • Centro de Estudios en Cardiología Intervencionista
      Buenos Aires, Buenos Aires F.D., Argentina
  • 2007–2008
    • The University of Edinburgh
      • Osteoarticular Research Group
      Edinburgh, Scotland, United Kingdom
    • Ludwig-Maximilian-University of Munich
      • Department of Physical Medicine and Rehabilitation
      München, Bavaria, Germany
  • 2003–2007
    • Chulalongkorn University
      • Department of Medicine
      Bangkok, Bangkok, Thailand
    • Queen's University
      • Division of Rheumatology
      Kingston, Ontario, Canada
  • 2002
    • National Institute for Health and Clinical Excellence
      Londinium, England, United Kingdom
    • Ottawa University
      اوتاوا، کانزاس, Kansas, United States
  • 1980–2002
    • McMaster University
      • • Department of Clinical Epidemiology and Biostatistics
      • • Department of Medicine
      • • Department of Family Medicine
      Hamilton, Ontario, Canada
  • 2001
    • Mayo Clinic - Rochester
      • Department of Health Science Research
      Rochester, MN, United States
    • Collateral Analytics
      Honolulu, Hawaii, United States
  • 2000
    • University Health Network
      • Arthritis and Immune Disorder Research Center
      Toronto, Ontario, Canada
  • 1999
    • University of Alberta
      Edmonton, Alberta, Canada
    • University of Vienna
      Wien, Vienna, Austria
    • Academia Nacional de Medicina, Buenos Aires
      Buenos Aires, Buenos Aires F.D., Argentina
    • University of New South Wales
      Kensington, New South Wales, Australia
  • 1995
    • Brigham and Women's Hospital
      Boston, Massachusetts, United States
  • 1985–1995
    • University of Toronto
      Toronto, Ontario, Canada
  • 1993–1994
    • Maastricht University
      • Department of Internal Medicine
      Maestricht, Limburg, Netherlands
  • 1990–1994
    • St. Joseph's Healthcare Hamilton
      Hamilton, Ontario, Canada
    • University of Kansas
      Lawrence, Kansas, United States
  • 1989–1994
    • Government of Ontario, Canada
      XIA, Ontario, Canada
  • 1988
    • University of British Columbia - Vancouver
      • Division of Rheumatology
      Vancouver, British Columbia, Canada