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ABSTRACT: Background and Objective: In developed countries, injection drug users have the highest prevalence and incidence of hepatitis C virus (HCV) infection. Clinicians and policy makers have several options for reducing morbidity and mortality related to HCV infection, including preventing new infections, screening high-risk populations, and optimizing uptake and delivery of antiviral therapy. Cost-effectiveness analyses provide an estimate of the value for money associated with adopting healthcare interventions. Our objective was to determine the cost effectiveness of hepatitis C interventions (prevention, screening, treatment) targeting substance users and other groups with a high proportion of substance users. Methods: We conducted a systematic search of MEDLINE, EMBASE, CINAHL, HealthSTAR and EconLit, and the grey literature. Studies were critically appraised using the Drummond and Jefferson, Neumann et al. and Philips et al. checklists. We developed and applied a quality appraisal instrument specific to cost-effectiveness analyses of HCV interventions. In addition, we summarized cost-effectiveness estimates using a single currency and year ($US, year 2009 values). Results: Twenty-one economic evaluations were included, which addressed prevention (three), screening (ten) and treatment (eight). The quality of the analyses varied greatly. A significant proportion did not incorporate important aspects of HCV natural history, disease costs and antiviral therapy. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (less costly and more effective) to $US603 352 per QALY. However, many ICERs were less than $US100 000 per QALY. Screening and treatment interventions involving pegylated interferon and ribavirin were generally cost effective at the $US100 000 per QALY threshold, with the exception of some subgroups, such as immune compromised patients with genotype 1 infections. Conclusions: No clear consensus emerged from the studies demonstrating that prevention, screening or treatment provides better value for money as each approach can be economically attractive in certain subgroups. More high-quality economic evaluations of preventing, identifying and treating HCV infection in substance users are needed.
PharmacoEconomics 11/2012; 30(11):1015-34. · 2.66 Impact Factor
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ABSTRACT: BACKGROUND: Multi-disciplinary heart failure (HF) clinics have been shown to improve outcomes for HF patients in randomized clinical trials. However, it is unclear how widely available specialized HF clinics are in Ontario. Also, the service models of current clinics have not been described. It is therefore uncertain whether the efficacy of HF clinics in trials is generalizable to the HF clinics currently operating in the province. METHODS: As part of a comprehensive evaluation of HF clinics in Ontario, we performed an environmental scan to identify all HF clinics operating in 2010. A semi-structured interview was conducted to understand the scope of practice. The intensity and complexity of care offered were quantified through the use of a validated instrument, and clinics were categorized as high, medium or low intensity clinics. RESULTS: We identified 34 clinics with 143 HF physicians. We found substantial regional disparity in access to care across the province. The majority of HF physicians were cardiologists (81%), with 81% of the clinics physically based in hospitals, of which 26% were academic centers. There was a substantial range in the complexity of services offered, most notably in the intensity of education and medication management services offered. All the clinics focused on ambulatory care, with only one having an in-patient focus. None of the HF clinics had a home-based component to care. CONCLUSIONS: Multiple HF clinics are currently operating in Ontario with a wide spectrum of care models. Further work is necessary to understand which components lead to improved patient outcomes.
BMC Health Services Research 08/2012; 12(1):236. · 1.66 Impact Factor
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ABSTRACT: Background: Although return-to-work (RTW) interventions have been shown to be cost-effective, most previous economic analyses have focused on the insurer's perspective. Employers can also incur costs when supporting the RTW of their employees. Objective: To identify a key set of items for estimating the costs of RTW interventions from the employer's perspective, and to identify and value the costs and consequences of a RTW intervention. Participants: Employers with knowledge of the economic costs of RTW. Methods: A survey of 10 workplaces with RTW programs was conducted. The survey consisted of semi-structured interviews with a human resources or occupational health and safety representative from each enrolled workplace. Results: The interviews were reviewed and from them key items were identified for estimating the costs of RTW interventions from the employer's perspective. Employers identified the following costs: medical, equipment, training and education, wage replacement and productivity, and claims administration when assisting an employee's RTW. Conclusions: Even in a jurisdiction with workers' compensation insurance, employers incur costs associated with RTW programs. It is important to consider these costs, from the perspective of the employer, when studying the cost-effectiveness of RTW interventions or programs.
Work 05/2012; 43(3):255-62. · 0.52 Impact Factor
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Linda J. Carroll,
Lena W. Holm,
Sheilah Hogg-Johnson,
Pierre Côté,
J. David Cassidy,
Scott Haldeman,
Margareta Nordin,
Eric L. Hurwitz,
Eugene J. Carragee, Gabrielle van der Velde,
Paul M. Peloso,
Jaime Guzman
[show abstract]
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ABSTRACT: Study DesignBest evidence synthesis.
ObjectiveTo perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades
I–III whiplash-associated disorders (WAD).
Summary of Background DataKnowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning
management and intervention strategies and effective compensation policies to decrease the burden of WAD.
MethodsThe Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted
a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated
disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.
ResultsWe found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical
review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The
evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1year after their injuries. Greater
initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision
itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors
such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There
is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.
ConclusionThe Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course
and prognosis for WAD. Recovery of WAD seems to be multifactorial.
European Spine Journal 04/2012; 17:83-92. · 1.97 Impact Factor
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Sheilah Hogg-Johnson, Gabrielle van der Velde,
Linda J. Carroll,
Lena W. Holm,
J. David Cassidy,
Jamie Guzman,
Pierre Côté,
Scott Haldeman,
Carlo Ammendolia,
Eugene Carragee,
Eric Hurwitz,
Margareta Nordin,
Paul Peloso
[show abstract]
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ABSTRACT: Study DesignBest evidence synthesis.
ObjectiveTo undertake a best evidence synthesis of the published evidence on the burden and determinants of neck pain and its associated
disorders in the general population.
Summary of Background DataThe evidence on burden and determinants of neck has not previously been summarized.
MethodsThe Bone and Joint Decade 2000−2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and
critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Studies meeting
criteria for scientific validity were included in a best evidence synthesis.
ResultsWe identified 469 studies on burden and determinants of neck pain, and judged 249 to be scientifically admissible; 101 articles
related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person
years (disc herniation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during
competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30%
and 50%; the 12-month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and
prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to
tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent
other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing.
ConclusionNeck pain is common. Nonmodifiable risk factors for neck pain included age, gender, and genetics. Modifiable factors included
smoking, exposure to tobacco, and psychological health. Disc degeneration was not identified as a risk factor. Future research
should concentrate on longitudinal designs exploring preventive strategies and modifiable risk factors for neck pain.
European Spine Journal 04/2012; 17:39-51. · 1.97 Impact Factor
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Linda J. Carroll,
J. David Cassidy,
Paul M. Peloso,
Lori Giles-Smith,
C. Sam Cheng,
Stephen W. Greenhalgh,
Scott Haldeman, Gabrielle van der Velde,
Eric L. Hurwitz,
Pierre Côté,
Margareta Nordin,
Sheilah Hogg-Johnson,
Lena W. Holm,
Jaime Guzman,
Eugene J. Carragee
[show abstract]
[hide abstract]
ABSTRACT: Study DesignBest evidence synthesis.
ObjectiveTo provide a detailed description of the methods undertaken in a systematic search and perform a best evidence synthesis on
the frequency, determinants, assessment, interventions, course and prognosis of neck pain, and its associated disorders.
Summary of Background DataNeck pain is an important cause of health burden; however, the published information is vast, and stakeholders would benefit
from a summary of the best evidence.
MethodsThe Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders conducted a systematic search and
critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain. Citations were
screened for relevance to the Neck Pain Task Force mandate, using a priori criteria, and relevant studies were critically reviewed for their internal scientific validity. Findings from studies meeting
criteria for scientific validity were synthesized into a best evidence synthesis.
ResultsWe found 31,878 citations, of which 1203 were relevant to the mandate of the Neck Pain Task Force. After critical review,
552 studies (46) were judged scientifically admissible and were compiled into the best evidence synthesis.
ConclusionThe Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders undertook a best evidence synthesis
to establish a baseline of the current best evidence on the epidemiology, assessment and classification of neck pain, as well
as interventions and prognosis for this symptom. This article reports the methods used and the outcomes from the review. We
found that 46 of the research literature was of acceptable scientific quality to inform clinical practice, policy-making,
and future research.
European Spine Journal 04/2012; 17:33-38. · 1.97 Impact Factor
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Pierre Côté, Gabrielle van der Velde,
J. David Cassidy,
Linda J. Carroll,
Sheilah Hogg-Johnson,
Lena W. Holm,
Eugene J. Carragee,
Scott Haldeman,
Margareta Nordin,
Eric L. Hurwitz,
Jaime Guzman,
Paul M. Peloso
[show abstract]
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ABSTRACT: Study DesignSystematic review and best evidence synthesis.
ObjectivesTo describe the prevalence and incidence of neck pain and disability in workers; to identify risk factors for neck pain in
workers; to propose an etiological diagram; and to make recommendations for future research.
Summary of Background DataPrevious reviews of the etiology of neck pain in workers relied on cross-sectional evidence. Recently published cohorts and
randomized trials warrant a re-analysis of this body of research.
MethodsWe systematically searched Medline for literature published from 1980–2006. Retrieved articles were reviewed for relevance.
Relevant articles were critically appraised. Articles judged to have adequate internal validity were included in our best
evidence synthesis.
ResultsOne hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible. The annual
prevalence of neck pain varied from 27.1% in Norway to 47.8% in Québec, Canada. Each year, between 11% and 14.1% of workers
were limited in their activities because of neck pain. Risk factors associated with neck pain in workers include age, previous
musculoskeletal pain, high quantitative job demands, low social support at work, job insecurity, low physical capacity, poor
computer workstation design and work posture, sedentary work position, repetitive work and precision work. We found preliminary
evidence that gender, occupation, headaches, emotional problems, smoking, poor job satisfaction, awkward work postures, poor
physical work environment, and workers’ ethnicity may be associated with neck pain. There is evidence that interventions aimed
at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers.
ConclusionNeck disorders are a significant source of pain and activity limitations in workers. Most neck pain results from complex relationships
between individual and workplace risk factors. No prevention strategies have been shown to reduce the incidence of neck pain
in workers.
European Spine Journal 04/2012; 17:60-74. · 1.97 Impact Factor
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Lena W. Holm,
Linda J. Carroll,
J. David Cassidy,
Sheilah Hogg-Johnson,
Pierre Côté,
Jamie Guzman,
Paul Peloso,
Margareta Nordin,
Eric Hurwitz, Gabrielle van der Velde,
Eugene Carragee,
Scott Haldeman
[show abstract]
[hide abstract]
ABSTRACT: Study DesignBest evidence synthesis.
ObjectiveTo undertake a best evidence synthesis on the burden and determinants of whiplash-associated disorders (WAD) after traffic
collisions.
Study DesignSummary of Background Data. Previous best evidence synthesis on WAD has noted a lack of evidence regarding incidence of and
risk factors for WAD. Therefore there was a warrant of a reanalyze of this body of research.
MethodsA systematic search of Medline was conducted. The reviewers looked for studies on neck pain and its associated disorders published
1980 –2006. Each relevant study was independently and critically reviewed by rotating pairs of reviewers. Data from studies
judged to have acceptable internal validity (scientifically admissible) were abstracted into evidence tables, and provide
the body of the best evidence synthesis.
ResultsThe authors found 32 scientifically admissible studies related to the burden and determinants of WAD. In the Western world,
visits to emergency rooms due to WAD have increased over the past 30years. The annual cumulative incidence of WAD differed
substantially between countries. They found that occupant seat position and collision impact direction were associated with
WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury
claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although
the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension
during rear-end collisions had a preventive effect on reporting WAD, especially in females.
ConclusionWAD after traffic collisions affects many people. Despite many years of research, the evidence regarding risk factors for
WAD is sparse but seems to include personal, societal, and environmental factors. More research including, well-defined studies
with accurate denominators for calculating risk, and better consideration of confounding factors, are needed.
European Spine Journal 04/2012; 17:52-59. · 1.97 Impact Factor
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Eric L. Hurwitz,
Eugene J. Carragee, Gabrielle van der Velde,
Linda J. Carroll,
Margareta Nordin,
Jaime Guzman,
Paul M. Peloso,
Lena W. Holm,
Pierre Côté,
Sheilah Hogg-Johnson,
J. David Cassidy,
Scott Haldeman
[show abstract]
[hide abstract]
ABSTRACT: Study Design.Best evidence synthesis.
Objective.To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain
and its associated disorders.
Summary of Background Data.No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders
in the past decade.
Methods.We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness,
and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific
merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis.
Results.Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible,
and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated
disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or
physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level
laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however,
none of the active treatments was clearly superior to any other in either the short-or long-term. For both whiplash-associated
disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible
are relatively more effective than interventions that do not have such a focus.
Conclusion.Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative
strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing
self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms
and on the design and evaluation of neck pain prevention strategies.
European Spine Journal 04/2012; 17:123-152. · 1.97 Impact Factor
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Linda J. Carroll,
Sheilah Hogg-Johnson,
Pierre Côté, Gabrielle van der Velde,
Lena W. Holm,
Eugene J. Carragee,
Eric L. Hurwitz,
Paul M. Peloso,
J. David Cassidy,
Jaime Guzman,
Margareta Nordin,
Scott Haldeman
[show abstract]
[hide abstract]
ABSTRACT: Study DesignBest-evidence synthesis.
ObjectiveTo perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in workers.
Summary of Background DataKnowledge of the course of neck pain in workers guides expectations for recovery. Identifying prognostic factors assists in
planning effective workplace policies, formulating interventions and promoting lifestyle changes to decrease the frequency
and burden of neck pain in the workplace.
MethodsThe Bone and Joint Decade 2000−2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted
a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated
disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis.
ResultsWe found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical
review, 70 (31%) were accepted on scientific merit; 14 of these studies related to course and prognostic factors in working
populations. Between 60% and 80% of workers with neck pain reported neck pain1year later. Few workplace or physical job demands
were identified as being linked to recovery from neck pain. However, workers with little influence on their own work situation
had a slightly poorer prognosis, and white-collar workers had a better prognosis than blue-collar workers. General exercise
was associated with better prognosis; prior neck pain and prior sick leave were associated with poorer prognosis.
ConclusionThe Neck Pain Task Force presents a report of current best evidence on course and prognosis for neck pain. Few modifiable
prognostic factors were identified; however, having some influence over one's own job and being physically active seem to
hold promise as prognostic factors.
European Spine Journal 04/2012; 17:93-100. · 1.97 Impact Factor
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Margareta Nordin,
Eugene J. Carragee,
Sheilah Hogg-Johnson,
Shira Schecter Weiner,
Eric L. Hurwitz,
Paul M. Peloso,
Jaime Guzman, Gabrielle van der Velde,
Linda J. Carroll,
Lena W. Holm,
Pierre Côté,
J. David Cassidy,
Scott Haldeman
[show abstract]
[hide abstract]
ABSTRACT: Study DesignBest evidence synthesis.
ObjectiveTo critically appraise and synthesize the literature on assessment of neck pain.
Summary of Background DataThe published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic
reviews of this literature.
MethodsThe Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the
literature (published 1980– 2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.
ResultsWe found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening
protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care
after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in
assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical
examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception
is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence
that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports
using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid
self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with
neck pain.
ConclusionThe scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients
with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective
tests is lacking. There is support for subjective self-report assessment in monitoring patients’ course, response to treatment,
and in clinical research.
European Spine Journal 04/2012; 17:101-122. · 1.97 Impact Factor
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Eugene J. Carragee,
Eric L. Hurwitz,
Ivan Cheng,
Linda J. Carroll,
Margareta Nordin,
Jaime Guzman,
Paul Peloso,
Lena W. Holm,
Pierre Côthé,
Sheilah Hogg-Johnson, Gabrielle van der Velde,
J. David Cassidy,
Scott Haldeman
[show abstract]
[hide abstract]
ABSTRACT: Study DesignBest evidence synthesis.
ObjectiveTo identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain
alone or with radicular pain in the absence of serious pathologic disease.
Summary of Background DataThere have been no comprehensive systematic literature or evidence-based reviews published on this topic.
MethodsWe systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions
for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about
the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis.
ResultsOf the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding
treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections,
cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found
there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear
from the evidence that long-term out comes are improved with the surgical treatment of cervical radiculopathy compared to
non operative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be
reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical
foramenal or epidural injections are associated with relatively frequent minor adverse events (5%–20%); however, serious adverse
events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications
are seen in approximately 4% of patients.
ConclusionSurgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients
with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear
serious pathology, seems to lack scientific support.
European Spine Journal 04/2012; 17:153-169. · 1.97 Impact Factor
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Jaime Guzman,
Eric L. Hurwitz,
Linda J. Carroll,
Scott Haldeman,
Pierre Côté,
Eugene J. Carragee,
Paul M. Peloso, Gabrielle van der Velde,
Lena W. Holm,
Sheilah Hogg-Johnson,
Margareta Nordin,
J. David Cassidy
[show abstract]
[hide abstract]
ABSTRACT: Study DesignIterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence
on neck pain and its associated disorders.
ObjectiveTo provide an integrated model for linking the epidemiology of neck pain with its management and consequences, and to help
organize and interpret existing knowledge, and to highlight gaps in the current literature.
Summary of Background DataThe wide variability of scientific and clinical approaches to neck pain described in the literature requires a unified conceptual
model for appropriate interpretation of the research evidence.
MethodsThe 12-member Scientific Secretariat of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders
critically reviewed and eventually accepted as scientifically admissible a total of 552 scientific papers. The group met face-to-face
on 18 occasions and had frequent additional telephone conference meetings over a 6-year period to discuss and interpret this
literature and to agree on a conceptual model, which would accommodate findings. Models and definitions published in the scientific
literature were discussed and repeatedly modified until the model and case definitions presented here were finally approved
by the group.
ResultsOur new conceptual model is centered on the person with neck pain or who is at risk for neck pain. Neck pain is viewed as
an episodic occurrence over a lifetime with variable recovery between episodes. The model outlines the options available to
individuals who are dealing with neck pain, along with factors that determine options, choices, and consequences. The short-
and long-term impacts of neck pain are also considered. Finally, the model includes a 5-axis classification of neck pain studies
based on how subjects were recruited into each study.
ConclusionThe Scientific Secretariat found the conceptual model helpful in interpreting the available scientific evidence. We believe
it can assist people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions.
European Spine Journal 04/2012; 17:14-23. · 1.97 Impact Factor
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Harindra C Wijeysundera,
Nicholas Mitsakakis,
William Witteman,
Mike Paulden, Gabrielle van der Velde,
Jack V Tu,
Douglas S Lee,
Shaun G Goodman,
Robert Petrella,
Martin O'Flaherty,
Simon Capewell,
Murray Krahn
[show abstract]
[hide abstract]
ABSTRACT: Quality indicators in coronary heart disease (CHD) measure the practice gap between optimal care and current clinical practice. However, the potential impact of achieving quality indicator benchmarks remains unknown.
Using a validated, epidemiologic model of CHD in Ontario, Canada, we estimated the potential impact on mortality of improved utilization on CHD quality indicators from 2005 levels to recommend benchmark utilization of 90%. Eight CHD disease subgroups were evaluated, including inpatients with acute myocardial infarction (AMI), acute coronary syndromes, and heart failure, in addition to ambulatory patients who were post-acute myocardial infarction survivors, or had heart failure, chronic stable angina, hypertension, or hyperlipidemia. The primary outcome was the predicted mortality reduction associated with meeting quality indicator targets for each CHD subgroup-treatment combination.
In 2005, there were 10,060 CHD deaths in Ontario, representing an age-adjusted CHD mortality of 191 per 100,000 people. By meeting quality indicator utilization benchmarks, mortality could be potentially reduced by approximately 20% (95% confidence interval 17.8-21.1), representing approximately 1960 avoidable deaths. The bulk of this potential benefit was in ambulatory patients with chronic stable angina (36% of reduction) and heart failure (31% of reduction). The biggest drivers were optimizing angiotensin-converting enzyme inhibitor use in chronic stable angina patients (approximately 440 avoidable deaths) and β-blocker use in heart failure (approximately 400 avoidable deaths).
These findings reinforce the importance of quality indicators and could aid policy makers in prioritizing strategies to meet the goals outlined in the Canadian Heart Health Strategy and Action Plan for reducing cardiovascular mortality.
The Canadian journal of cardiology 09/2011; 27(6):756-62. · 3.36 Impact Factor
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Gabrielle van der Velde,
Pierre Côté,
Ahmed M Bayoumi,
J David Cassidy,
Eleanor Boyle,
Heather M Shearer,
Maja Stupar,
Craig Jacobs,
Carlo Ammendolia,
Simon Carette,
Maurits van Tulder
[show abstract]
[hide abstract]
ABSTRACT: Whiplash injury affects 83% of persons in a traffic collision and leads to whiplash-associated disorders (WAD). A major challenge facing health care decision makers is identifying cost-effective interventions due to lack of economic evidence. Our objective is to compare the cost-effectiveness of: 1) physician-based education and activation, 2) a rehabilitation program developed by Aviva Canada (a group of property and casualty insurance providers), and 3) the legislated standard of care in the Canadian province of Ontario: the Pre-approved Framework Guideline for Whiplash developed by the Financial Services Commission of Ontario.
The economic evaluation will use participant-level data from the University Health Network Whiplash Intervention Trial and will be conducted from the societal perspective over the trial's one-year follow-up. Resource use (costs) will include all health care goods and services, and benefits provided during the trial's 1-year follow-up. The primary health effect will be the quality-adjusted life year. We will identify the most cost-effective intervention using the incremental cost-effectiveness ratio and incremental net-benefit. Confidence ellipses and cost-effectiveness acceptability curves will represent uncertainty around these statistics, respectively. A budget impact analysis will assess the total annual impact of replacing the current legislated standard of care with each of the other interventions. An expected value of perfect information will determine the maximum research expenditure Canadian society should be willing to pay for, and inform priority setting in, research of WAD management.
Results will provide health care decision makers with much needed economic evidence on common interventions for acute whiplash management.
http://ClinicalTrials.gov identifier NCT00546806 [Trial registry date: October 18, 2007; Date first patient was randomized: February 27, 2008].
BMC Public Health 07/2011; 11:594. · 2.00 Impact Factor
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Arthritis care & research. 01/2011; 63(1):65-78.
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Harindra C Wijeysundera,
Márcio Machado,
Xuesong Wang, Gabrielle Van Der Velde,
Nancy Sikich,
William Witteman,
Jack V Tu,
Douglas S Lee,
Shaun G Goodman,
Robert Petrella,
Martin O'Flaherty,
Simon Capewell,
Murray Krahn
[show abstract]
[hide abstract]
ABSTRACT: Specialized multidisciplinary clinics have been shown to reduce mortality in heart failure (HF). Our objective was to evaluate the cost-effectiveness of this model of care delivery.
We performed a cost-effectiveness analysis, with a 12-year time horizon, from the perspective of the Ontario Ministry of Health and Long-term Care, comparing a standard care cohort, consisting of all patients admitted to hospital with HF in 2005, to a hypothetical cohort treated in HF clinics. Survival curves describing the natural history of HF were constructed using mortality estimates from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study. Survival benefits and resource uptake associated with HF clinics were estimated from a meta-analysis of published trials. HF clinics costs were obtained by costing a representative clinic in Ontario. Health-related costs were determined through linkage to administrative databases. Outcome measures included life expectancy (years), costs (in 2008 Canadian dollars) and the incremental cost-effectiveness ratio (ICER).
HF clinics were associated with a 29% reduction in all-cause mortality (risk ratio [RR] 0.71; 95% confidence interval [CI] 0.56-0.91) but a 12% increase in hospitalizations (RR 1.12; 95% CI 0.92-1.135). The cost of care in HF clinics was $52 per 30 patient-days. Projected life-expectancy of HF clinic patients was 3.91 years, compared to 3.21 years for standard care. The 12-year cumulative cost per patient in the HF clinic group was $66,532 versus $53,638 in the standard care group. The ICER was $18,259/life-year gained.
HF clinics appear to be a cost effective way of delivering ambulatory care to HF patients.
Value in Health 12/2010; 13(8):915-21. · 2.19 Impact Factor
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[show abstract]
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ABSTRACT: The pursuit of interpretability of longitudinal measures of patient outcome has led to several methods for defining minimal amounts of change or final states that are important. Little is known about the best method. The purpose of this study was to directly compare methods using diagnostic utility to evaluate their usefulness.
Secondary analysis of longitudinal cohort data of persons attending physiotherapy for shoulder pain. Disability of the arm, shoulder, and hand outcome fielded at baseline and 3 months. Published methods were used to define positive response in scores: minimal change, final state, and combined change and final state. Proportions described as improved were compared (Kappa) and diagnostic testing techniques used to evaluate the strengths of each.
Only moderate agreement was found between methods (Kappa=0.47). Minimal clinically important differences were most sensitive but not specific. Final states were less sensitive, more specific, and most accurate. Combinations were slightly less specific.
A new approach allowed us to evaluate the relative merits and risks of different approaches to interpreting longitudinal patient outcomes. Our study points to a combination of change greater than error and/or a final score within general population norms as being the most clinically sensible with strong diagnostic accuracy.
Journal of clinical epidemiology 11/2010; 64(5):487-96. · 2.96 Impact Factor
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Harindra C Wijeysundera,
Márcio Machado,
Farah Farahati,
Xuesong Wang,
William Witteman, Gabrielle van der Velde,
Jack V Tu,
Douglas S Lee,
Shaun G Goodman,
Robert Petrella,
Martin O'Flaherty,
Murray Krahn,
Simon Capewell
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ABSTRACT: Coronary heart disease (CHD) mortality has declined substantially in Canada since 1994.
To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments.
Prospective analytic study of the Ontario, Canada, population aged 25 to 84 years between 1994 and 2005, using an updated version of the validated IMPACT model, which integrates data on population size, CHD mortality, risk factors, and treatment uptake changes. Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and (1) evidence-based therapies in 8 distinct CHD subpopulations (acute myocardial infarction [AMI], acute coronary syndromes, secondary prevention post-AMI, chronic coronary artery disease, heart failure in the hospital vs in the community, and primary prevention for hyperlipidemia or hypertension) and (2) population trends in 6 risk factors (smoking, diabetes mellitus, systolic blood pressure, plasma cholesterol level, exercise, and obesity).
The number of deaths prevented or delayed in 2005; secondary outcome measures were improvements in medical treatments and trends in risk factors.
Between 1994 and 2005, the age-adjusted CHD mortality rate in Ontario decreased by 35% from 191 to 125 deaths per 100,000 inhabitants, translating to an estimated 7585 fewer CHD deaths in 2005. Improvements in medical and surgical treatments were associated with 43% (range, 11% to 124%) of the total mortality decrease, most notably in AMI (8%; range, -5% to 40%), chronic stable coronary artery disease (17%; range, 7% to 35%), and heart failure occurring while in the community (10%; range, 6% to 31%). Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed (48% of total; range, 28% to 64%), specifically, reductions in total cholesterol (23%; range, 10% to 33%) and systolic blood pressure (20%; range, 13% to 26%). Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6% (range, 4% to 8%) and 2% (range, 1% to 4%), respectively.
Between 1994 and 2005, there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments, each explaining about half of the decrease.
JAMA The Journal of the American Medical Association 05/2010; 303(18):1841-7. · 30.03 Impact Factor
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ABSTRACT: To elicit neck pain (NP) patients' preference scores for their current health, and investigate the association between their scores and NP disability.
Rating scale scores (RSs) and standard gamble scores (SGs) for current health were elicited from chronic NP patients (n=104) and patients with NP following a motor vehicle accident (n=116). Patients were stratified into Von Korff Pain Grades: Grade I (low-intensity pain, few activity limitations); Grade II (high-intensity pain, few activity limitations); Grade III (pain with high disability levels, moderate activity limitations); and Grade IV (pain with high disability levels, several activity limitations). Multivariable regression quantified the association between preference scores and NP disability.
Mean SGs and RSs were as follows: Grade I patients: 0.81, 0.76; Grade II: 0.70, 0.60; Grade III: 0.64, 0.44; Grade IV: 0.57, 0.39. The association between preference scores and NP disability depended on type of NP and preference-elicitation method. Chronic NP patients' scores were more strongly associated with depressive symptoms than with NP disability. In both samples, NP disability explained little more than random variance in SGs, and up to 51% of variance in RSs.
Health-related quality-of-life is considerably diminished in NP patients. Depressive symptoms and preference-elicitation methods influence preference scores that NP patients assign to their health.
Quality of Life Research 03/2010; 19(5):687-700. · 2.30 Impact Factor
