Nancy Sikich

Health Canada, Ottawa, Ontario, Canada

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Publications (53)188.31 Total impact

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    ABSTRACT: Purpose: Care at end-of-life consumes approximately 9% of the Ontario health-care budget. To support policy development, we evaluated the cost-effectiveness of palliative team care. Methods: Study design: cost-effective and cost-utility analyses from the societal and health-care payer’s perspectives. Target population: patients nearing end-of-life (according to observed population-based setting-specific patterns of palliative services) over the last year of life (a one-year time horizon) and their primary informal caregivers. Comparators: “usual care” with current palliative services, “in-home palliative team care” with service provision at home or in long-term care home, “in-patient palliative team care”, and “comprehensive palliative team care” by a single team with care coordination across settings. We included health care costs (2013 Canadian dollars; including costs of home care, long-term care, hospital care, outpatient services, drugs, and physician billings), and additional costs of private insurance, out-of-pocket expenses, and time lost from paid work. Effectiveness measures included days at home and percentage dying at home (base case analysis), and quality-adjusted life days (QALD; sensitivity analysis). We developed a state-transition microsimulation model to simulate palliative care needs by the target population. Model inputs were obtained from an end-of-life cohort of Ontarian decedents (n= 256,284) assembled from linked health administration databases (2007-2009), systematic reviews of randomized controlled trials evaluating palliative team care, and published literature. We conducted one-way and probabilistic sensitivity analyses. Results: In-home palliative team care dominated usual care, with an expected $4,424 healthcare cost saving (via reduced ER visits and hospital admissions), approximately 5.8 more days at home, 10.3% more home deaths, and 0.47 QALDs gained [with a 72% likelihood of being cost-effective at $50k per QALY]. In-patient team care appeared to dominate usual care (corresponding values: $1,643, 0.65 days, -0.2% and 0.27 QALDs [38%]). Comprehensive palliative team care was associated with $527 additional cost, 1.4 more days at home, 1.7% more home deaths, and 2.65 QALDs gained, corresponding to an estimated cost of approximately $72k per QALY [32%]. Results from the societal perspective were similar, mainly due to a lack of data regarding the team’s effects on quality-of-life, time and costs associated with care giving. Conclusions: In-home palliative team care is cost-effective. Firm conclusions are not possible regarding the cost-effectiveness of in-patient and comprehensive team care.
    The 36th Annual Meeting of the Society for Medical Decision Making; 10/2014
  • Value in Health 05/2014; 17(3):A128-A129. DOI:10.1016/j.jval.2014.03.746 · 2.89 Impact Factor
  • Value in Health 05/2014; 17(3):A150. DOI:10.1016/j.jval.2014.03.875 · 2.89 Impact Factor
  • Value in Health 05/2014; 17(3):A152. DOI:10.1016/j.jval.2014.03.886 · 2.89 Impact Factor
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    ABSTRACT: In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.AFTER AN INITIAL REVIEW OF HEALTH TECHNOLOGY ASSESSMENTS AND SYSTEMATIC REVIEWS OF COPD LITERATURE, AND CONSULTATION WITH EXPERTS, MAS IDENTIFIED THE FOLLOWING TOPICS FOR ANALYSIS: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.Chronic Obstructive Pulmonary Disease (COPD) Evidentiary FrameworkInfluenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisSmoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCommunity-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisPulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisLong-Term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHome Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy ModelEXPERIENCES OF LIVING AND DYING WITH COPD: A Systematic Review and Synthesis of the Qualitative Empirical LiteratureFOR MORE INFORMATION ON THE QUALITATIVE REVIEW, PLEASE CONTACT MITA GIACOMINI AT: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.FOR MORE INFORMATION ON THE ECONOMIC ANALYSIS, PLEASE VISIT THE PATH WEBSITE: http://www.path-hta.ca/About-Us/Contact-Us.aspx.The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact. Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammation throughout the airways, parenchyma, and pulmonary vasculature. The inflammation causes repeated cycles of injury and repair in the airway wall- inflammatory cells release a variety of chemicals and lead to cellular damage. The inflammation process also contributes to the loss of elastic recoil pressure in the lung, thereby reducing the driving pressure for expiratory flow through narrowed and poorly supported airways, in which airflow resistance is significantly increased. Expiratory flow limitation is the pathophysiological hallmark of COPD. Exacerbations of COPD contribute considerably to morbidity and mortality, and impose a burden on the health care system. They are a leading cause of emergency room visits and hospitalizations, particularly in the winter. In Canada, the reported average cost for treating a moderate exacerbation is $641; for a major exacerbation, the cost is $10,086. The objective of this study was to evaluate the cost-effectiveness and budget impact of the following interventions in moderate to very severe COPD, investigated in the Medical Advisory Secretariat Chronic Obstructive Pulmonary Disease Mega-Analysis Series: smoking cessation programs in moderate COPD in an outpatient setting:- intensive counselling (IC) versus usual care (UC)- nicotine replacement therapy (NRT) versus UC- IC + NRT versus placebo- bupropion versus placebomultidisciplinary care (MDC) teams versus UC in moderate to severe COPD in an outpatient settingpulmonary rehabilitation (PR) versus UC following acute exacerbations in moderate to severe COPDlong-term oxygen therapy (LTOT) versus UC in severe hypoxemia in COPD in an outpatient settingventilation:- noninvasive positive pressure ventilation (NPPV) + usual medical care versus usual medical care in acute respiratory failure due to an acute exacerbation in severe COPD in an inpatient setting- weaning with NPPV versus weaning with invasive mechanical ventilation in acute respiratory failure due to an acute exacerbation in very severe COPD in an inpatient setting A cost-utility analysis was conducted using a Markov probabilistic model. The model consists of different health states based on the Global Initiative for Chronic Obstructive Lung Disease COPD severity classification. Patients were assigned different costs and utilities depending on their severity health state during each model cycle. In addition to moving between health states, patients were at risk of acute exacerbations of COPD in each model cycle. During each cycle, patients could have no acute exacerbation, a minor acute exacerbation, or a major exacerbation. For the purposes of the model, a major exacerbation was defined as one that required hospitalization. Patients were assigned different costs and utilities in each model cycle, depending on whether they experienced an exacerbation, and its severity. Starting cohorts reflected the various patient populations from the trials analyzed. Incremental cost-effectiveness ratios (ICERs)-that is, costs per quality-adjusted life-year (QALY)-were estimated for each intervention using clinical parameters and summary estimates of relative risks of (re)hospitalization, as well as mortality and abstinence rates, from the COPD mega-analysis evidence-based analyses. A budget impact analysis was also conducted to project incremental costs already being incurred or resources already in use in Ontario. Using provincial data, medical literature, and expert opinion, health system impacts were calculated for the strategies investigated. All costs are reported in Canadian dollars. All smoking cessation programs were dominant (i.e., less expensive and more effective overall). Assuming a base case cost of $1,041 and $1,527 per patient for MDC and PR, the ICER was calculated to be $14,123 per QALY and $17,938 per QALY, respectively. When the costs of MDC and PR were varied in a 1-way sensitivity analysis to reflect variation in resource utilization reported in the literature, the ICER increased to $55,322 per QALY and $56,270 per QALY, respectively. Assuming a base case cost of $2,261 per year per patient for LTOT as reported by data from the Ontario provincial program, the ICER was calculated to be $38,993 per QALY. Ventilation strategies were dominant (i.e., cheaper and more effective), as reflected by the clinical evidence of significant in-hospital days avoided in the study group. Ontario currently pays for IC through physician billing (translating to a current burden of $8 million) and bupropion through the Ontario Drug Benefit program (translating to a current burden of almost $2 million). The burden of NRT was projected to be $10 million, with future expenditures of up to $1 million in Years 1 to 3 for incident cases. Ontario currently pays for some chronic disease management programs. Based on the most recent Family Health Team data, the costs of MDC programs to manage COPD were estimated at $85 million in fiscal year 2010, with projected future expenditures of up to $51 million for incident cases, assuming the base case cost of the program. However, this estimate does not accurately reflect the current costs to the province because of lack of report by Family Health Teams, lack of capture of programs outside this model of care by any data set in the province, and because the resource utilization and frequency of visits/follow-up phone calls were based on the findings in the literature rather than the actual Family Health Team COPD management programs in place in Ontario. Therefore, MDC resources being utilized in the province are unknown and difficult to measure. Data on COPD-related hospitalizations were pulled from Ontario administrative data sets and based on consultation with experts. Half of hospitalized patients will access PR resources at least once, and half of these will repeat the therapy, translating to a potential burden of $17 million to $32 million, depending on the cost of the program. These resources are currently being absorbed, but since utilization is not being captured by any data set in the province, it is difficult to quantify and estimate. Provincial programs may be under-resourced, and patients may not be accessing these services effectively. (ABSTRACT TRUNCATED)
    Ontario Health Technology Assessment Series 01/2012; 12(12):1-61.
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    ABSTRACT: In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.AFTER AN INITIAL REVIEW OF HEALTH TECHNOLOGY ASSESSMENTS AND SYSTEMATIC REVIEWS OF COPD LITERATURE, AND CONSULTATION WITH EXPERTS, MAS IDENTIFIED THE FOLLOWING TOPICS FOR ANALYSIS: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.Chronic Obstructive Pulmonary Disease (COPD) Evidentiary FrameworkInfluenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisSmoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCommunity-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisPulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisLong-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHome Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy ModelEXPERIENCES OF LIVING AND DYING WITH COPD: A Systematic Review and Synthesis of the Qualitative Empirical LiteratureFOR MORE INFORMATION ON THE QUALITATIVE REVIEW, PLEASE CONTACT MITA GIACOMINI AT: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.FOR MORE INFORMATION ON THE ECONOMIC ANALYSIS, PLEASE VISIT THE PATH WEBSITE: http://www.path-hta.ca/About-Us/Contact-Us.aspx.The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact. The objective of this evidence-based analysis was to determine the effectiveness and cost-effectiveness of multidisciplinary care (MDC) compared with usual care (UC, single health care provider) for the treatment of stable chronic obstructive pulmonary disease (COPD). CLINICAL NEED: CONDITION AND TARGET POPULATION Chronic obstructive pulmonary disease is a progressive disorder with episodes of acute exacerbations associated with significant morbidity and mortality. Cigarette smoking is linked causally to COPD in more than 80% of cases. Chronic obstructive pulmonary disease is among the most common chronic diseases worldwide and has an enormous impact on individuals, families, and societies through reduced quality of life and increased health resource utilization and mortality. The estimated prevalence of COPD in Ontario in 2007 was 708,743 persons. TECHNOLOGY: Multidisciplinary care involves professionals from a range of disciplines, working together to deliver comprehensive care that addresses as many of the patient's health care and psychosocial needs as possible. TWO VARIABLES ARE INHERENT IN THE CONCEPT OF A MULTIDISCIPLINARY TEAM: i) the multidisciplinary components such as an enriched knowledge base and a range of clinical skills and experiences, and ii) the team components, which include but are not limited to, communication and support measures. However, the most effective number of team members and which disciplines should comprise the team for optimal effect is not yet known. What is the effectiveness and cost-effectiveness of MDC compared with UC (single health care provider) for the treatment of stable COPD? A literature search was performed on July 19, 2010 using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 1, 1995 until July 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. health technology assessments, systematic reviews, or randomized controlled trialsstudies published between January 1995 and July 2010;COPD study populationstudies comparing MDC (2 or more health care disciplines participating in care) compared with UC (single health care provider) grey literatureduplicate publicationsnon-English language publicationsstudy population less than 18 years of age OUTCOMES OF INTEREST: hospital admissionsemergency department (ED) visitsmortalityhealth-related quality of lifelung function The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses. The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence: HighFurther research is very unlikely to change confidence in the estimate of effect.ModerateFurther research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.LowFurther research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.Very LowAny estimate of effect is very uncertain. Six randomized controlled trials were obtained from the literature search. Four of the 6 studies were completed in the United States. The sample size of the 6 studies ranged from 40 to 743 participants, with a mean study sample between 66 and 71 years of age. Only 2 studies characterized the study sample in terms of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD stage criteria, and in general the description of the study population in the other 4 studies was limited. The mean percent predicted forced expiratory volume in 1 second (% predicted FEV(1)) among study populations was between 32% and 59%. Using this criterion, 3 studies included persons with severe COPD and 2 with moderate COPD. Information was not available to classify the population in the sixth study. Four studies had MDC treatment groups which included a physician. All studies except 1 reported a respiratory specialist (i.e., respiratory therapist, specialist nurse, or physician) as part of the multidisciplinary team. The UC group was comprised of a single health care practitioner who may or may not have been a respiratory specialist. A meta-analysis was completed for 5 of the 7 outcome measures of interest including: health-related quality of life,lung function,all-cause hospitalization,COPD-specific hospitalization, andmortality.There was only 1 study contributing to the outcome of all-cause and COPD-specific ED visits which precluded pooling data for these outcomes. Subgroup analyses were not completed either because heterogeneity was not significant or there were a small number of studies that were meta-analysed for the outcome. QUALITY OF LIFE: Three studies reported results of quality of life assessment based on the St. George's Respiratory Questionnaire (SGRQ). A mean decrease in the SGRQ indicates an improvement in quality of life while a mean increase indicates deterioration in quality of life. In all studies the mean change score from baseline to the end time point in the MDC treatment group showed either an improvement compared with the control group or less deterioration compared with the control group. The mean difference in change scores between MDC and UC groups was statistically significant in all 3 studies. The pooled weighted mean difference in total SGRQ score was -4.05 (95% confidence interval [CI], -6.47 to 1.63; P = 0.001). The GRADE quality of evidence was assessed as low for this outcome. LUNG FUNCTION: Two studies reported results of the FEV(1) % predicted as a measure of lung function. (ABSTRACT TRUNCATED)
    Ontario Health Technology Assessment Series 01/2012; 12(5):1-51.
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    ABSTRACT: Patients who undergo prolonged surgical procedures are at risk of developing pressure ulcers. Recent systematic reviews suggest that pressure redistribution overlays on operating tables significantly decrease the associated risk. Little is known about the cost effectiveness of using these overlays in a prevention program for surgical patients. Using a Markov cohort model, we evaluated the cost effectiveness of an intraoperative prevention strategy with operating table overlays made of dry, viscoelastic polymer from the perspective of a health care payer over a 1-year period. We simulated patients undergoing scheduled surgical procedures lasting ≥90 min in the supine or lithotomy position. Compared with the current practice of using standard mattresses on operating tables, the intraoperative prevention strategy decreased the estimated intraoperative incidence of pressure ulcers by 0.51%, corresponding to a number-needed-to-treat of 196 patients. The average cost of using the operating table overlay was $1.66 per patient. Compared with current practice, this intraoperative prevention strategy would increase slightly the quality-adjusted life days of patients and by decreasing the incidence of pressure ulcers, this strategy would decrease both hospital and home care costs for treating fewer pressure ulcers originated intraoperatively. The cost savings was $46 per patient, which ranged from $13 to $116 by different surgical populations. Intraoperative prevention was 99% likely to be more cost effective than the current practice. In patients who undergo scheduled surgical procedures lasting ≥90 min, this intraoperative prevention strategy could improve patients' health and save hospital costs. The clinical and economic evidence support the implementation of this prevention strategy in settings where it has yet to become current practice.
    Surgery 07/2011; 150(1):122-32. DOI:10.1016/j.surg.2011.03.002 · 3.11 Impact Factor
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    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. · 2.89 Impact Factor
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    ABSTRACT: Purpose: New pressure ulcers (PU) occur in many patients undergoing elective surgery (7%-66%). We evaluated the cost-effectiveness of GFOs in support of guideline recommendations by the Ontario Health Technology Assessment Committee. Methods: Study design: Cost-utility analysis, third-party payer perspective, 1-year time horizon, 2009 Canadian $. Population: patients undergoing a planned major surgical procedure (e.g. > 90 minutes). Comparators: GFO versus standard OR surfaces (STD). Decision model: A 21-state, 1-day-cycle Markov model calibrated to reproduce stage-specific hospital-acquired PU (H-A PU) prevalence reported by the Toronto Tri-Hospital Survey (n=1,118 patients). Input data: Effectiveness: Recent systematic reviews of preventive interventions identified three RCTs evaluating overlays for OR tables. In surgical patients, gel-filled overlays (GFO) significantly decrease early and mostly intact skin PUs one-day post-operation (RR: 0.53; 95% CI: 0.33-0.85), according to a well-designed 1998-RCT (n=446). Cost: Each GFO costs $878. A case-control design was used to obtain stage-specific PU-attributable inpatient [post discharge] costs, n=3,780 PU cases [n=21,578 home care clients] from the Ontario Case Costing Initiative [interRAI -Home Care] database. Controls were matched to PU cases by age groups, gender, admission diagnosis, and Charlson co-morbidity [Activity of Daily Living] score. PU-attributable inpatient [home care] costs were cost differences between cases and controls: $11,967 [$57/week], $12,951 [$81/week] and $21,797 [$105/week] for stages 2-4, respectively. Health utility: Similarly, a utility decrement estimate attributable to PU stage 2-4 versus 0-1 of 6.1% (3.9%, 8.3%) was obtained using data from the Minimum Data Set – Health Status Index (n=18,321 nursing home residents). This was applied to a mean utility of 0.44 for hospitalized patients from a published study (n=1,207). Results: The prevalence of hospital acquired PU was projected to be 13.3% (12.3, 13.6) among GFO patients, and 16.6% (15.6, 17.0) among STD patients, with an estimated NNT=30 (29, 35). A GFO could be used for approximately 1,500 procedures over 2 years. Estimated QALY gained per person with GFOs was 0.00152 (0.00054, 0.00360) and cost saving $225 ($76, $647; $169 in-patient and $56 post-discharge costs). Probabilistic sensitivity analysis showed a 99% chance of higher net benefit with GFOs. Conclusions: The use of GFOs in surgical patients with a major surgical procedure is highly economically attractive.
    The 31th Annual Meeting of the Society for Medical Decision Making; 10/2009
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    ABSTRACT: Purpose: ","serif";"> In Ontario, case managers of home care clients can provide pressure-redistribution mattresses (PRM) only for TREATMENT of severe pressure ulcers. We evaluated the cost effectiveness of a strategy to identify and offer PREVENTIVE PRMs to high risk clients. Methods: ","serif";"> Study design:","serif";"> Cost-utility analysis, health ministry perspective, lifetime time horizon, 2009 Canadian $. Subsequently, population-based projections were derived to evaluate related health system implications. Population: long-stay clients of 14 Ontario Community Care Access Centers (251,027 clients/year). Comparators: PRMs for high risk clients (identified via a validated Minimum Data Set - Pressure Ulcer Risk Assessment - MDS-PURS score of 1+ {i.e. ≥ 1}, 2+ or 3+) versus clients on home mattresses (HMs). Effectiveness:","serif";"> Systematic reviews estimated that PRM reduced PU incidence by 60% (RR: 0.40, 95%CI: 0.21, 0.74). Decision model: A weekly-cycle Markov cohort model to simulate 1) care transitions across settings and 2) PU prognosis. The model was calibrated to reflect prevalence and incidence among 77,381 long-stay HC clients. Input data:","serif";"> The mattress cost: $325 - $450. Setting-specific costs were derived using data from MDS-HC (n=21,578 clients), Ontario Case Costing (n=3,780 patients), and the MDS (n=18,321 residents). Health utility","serif";">: A utility decrement estimate attributable to PU stage 2-4 of 6.1% (3.9%, 8.3%) was derived using data from the MDS – Health Status Index (n=18,321). Mean MDS-HIS utility for HC clients (n=332) was 0.56. ","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";"> Results: ","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";"> The one-year PU incidence among all clients was 2.25%. It was reduced to 0.99%, 1.52% and 1.85% if AFMs were prescribed to the 70%, 28% and 9% high risk clients according to MDS-PURS 1+, +2, and +3 risk level, respectively. The associated number-needed-to-treat was 79, 137 and 258, respectively. According to the cost-utility analysis, AFMs were associated with an expected QALY gain per home care client of 0.0069, 0.0031 and 0.0012, respectively. The associated cost saving was $34, $31, and $21, respectively. At the population level, the expected cost saving with AFMs was $8.5M, $7.8M and $5.5M, respectively. The respective net cost after AFM implementation cost was $48M, $7.8M and $5.5M.","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";"> Conclusions: ","serif";"> Offering AFMs to high risk clients was projected to be highly economically attractive, and associated with substantial aggregate cost savings. Offering AFMs only to the highest risk groups may be the most feasible strategy in the current climate of fiscal constraint.","serif";">","serif";">","serif";">","serif";">","serif";">","serif";">","serif";"
    The 31th Annual Meeting of the Society for Medical Decision Making; 10/2009
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    ABSTRACT: This study describes the development of a framework for health technology decisions, for Ontario Health Technology Advisory Committee (OHTAC) in Ontario, Canada. OHTAC convened a "Decision Determinants Sub-Committee" in January 2007, which undertook a systematic literature review and conducted key informant interviews to develop an explicit decision-making framework. The "Decision Determinants Sub-Committee" offered recommendations about decision criteria, and the process by which decisions are made. Decision criteria include (i) overall clinical benefit, (ii) consistency with societal and ethical values, (iii) value for money, and (iv) feasibility of adoption into the health system. The decision process should be transparent and fair and should use a deliberative process in delivering recommendations. This methodology is currently being pilot tested in a live environment: OHTAC. It will be evaluated and revised according to its feasibility, acceptability, and perceived usefulness.
    International Journal of Technology Assessment in Health Care 02/2009; 25(2):141-50. DOI:10.1017/S0266462309090199 · 1.56 Impact Factor
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    ABSTRACT: The current standard of care for fluid resuscitation of hemorrhagic hypotensive patients involves the use of crystalloid solutions. Traumatic brain injury (TBI) is often associated with hemorrhage and hypotension, which can contribute significantly to morbidity and mortality. Guidelines for the choice of fluid resuscitation and the use of red blood cell transfusions are not yet clear in the context of brain injury. Various fluid resuscitation strategies were evaluated in Sprague-Dawley rats using fresh blood, normal saline, hypertonic saline, and albumin fluid resuscitation protocols. Mean arterial blood pressure (MAP) and cerebral oximetry were assessed in hemorrhaged groups and the mean population spike amplitudes (PSA) from the hippocampus were examined in fluid percussion injured (FPI) animals subject to hemorrhage and fluid resuscitation. MAP in control animals, hemorrhage and hemorrhage + albumin treated groups was 82.4 +/- 1.5 mm Hg, 55.7 +/- 1.5 mm Hg, and 97.0 +/- 3.4 mm Hg, respectively. Arterial PaO2 was higher in albumin-treated animals relative to other fluid alternatives. Regional tissue oxygen tension (PbrO2) levels in hemorrhaged animals reached significantly higher levels in albumin treated group compared with in normal saline and hypertonic saline (p < 0.001, p = 0.034, respectively). After FPI+hemorrhage, PSA values in albumin- resuscitated animals were significantly higher than in normal saline-resuscitated animals (p = 0.012). The results of normal saline resuscitation, relative to other fluid alternatives, suggest that a re-evaluation of current treatment strategies in hemorrhagic hypotensive TBI patients is warranted. Albumin demonstrated the greatest beneficial effects on neurophysiology endpoints over crystalloid alternatives. These data suggests that albumin resuscitation may play an important role in the treatment of hemorrhagic hypotension and TBI.
    The Journal of trauma 03/2008; 64(2):348-57. DOI:10.1097/01.ta.0000245973.71929.db · 2.96 Impact Factor
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    ABSTRACT: Anemia may worsen neurological outcomes following traumatic brain injury (TBI) by undefined mechanisms. We hypothesized that hemodilutional anemia accentuates hypoxic cerebral injury following TBI. Anesthetized rats underwent unilateral TBI or sham injury (n > or = 7). Target hemoglobin concentrations between 50 and 70 g/l were achieved by exchanging 40-50% of the blood volume (1:1) with pentastarch. The effect of TBI, anemia, and TBI-anemia was assessed by measuring brain tissue oxygen tension (Pbr(O(2))), regional cerebral blood flow (rCBF), jugular venous oxygen saturation (Sjv(O(2))), cerebral contusion area, and nuclear staining for programmed cell death. Baseline postinjury Pbr(O(2)) values in the TBI and TBI-anemia groups (9.3 +/- 1.3 and 11.3 +/- 4.1 Torr, respectively) were lower than the uninjured controls (18.2 +/- 5.2 Torr, P < 0.05 for both). Hemodilution caused a further reduction in Pbr(O(2)) in the TBI-anemia group relative to the TBI group without anemia (7.8 +/- 2.7 vs. 14.8 +/- 3.9 Torr, P < 0.05). The rCBF remained stable after TBI and increased comparably after hemodilution in both anemia and TBI-anemia groups. The Sjv(O(2)) was elevated after TBI (87.4 +/- 8.9%, P < 0.05) and increased further following hemodilution (95.0 +/- 1.6%, P < 0.05). Cerebral contusion area and nuclear counts for programmed cell death were increased following TBI-anemia (4.1 +/- 3.0 mm(2) and 686 +/- 192, respectively) relative to TBI alone (1.3 +/- 0.3 mm(2) and 404 +/- 133, respectively, P < 0.05 for both). Hemodilutional anemia reduced cerebral Pbr(O(2)) and oxygen extraction and increased cell death following TBI. These results support our hypothesis that acute anemia accentuated hypoxic cerebral injury after neurotrauma.
    Journal of Applied Physiology 09/2007; 103(3):1021-9. DOI:10.1152/japplphysiol.01315.2006 · 3.43 Impact Factor
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    ABSTRACT: The aim of this study was to describe a comprehensive continuum that has developed in Ontario between government and key stakeholder groups, including hospitals, physicians, academic institutions, clinical epidemiologists, health economists, industry, and bioethicists to achieve evidence-based recommendations for policy development. The various components of the comprehensive model that has evolved to develop an evidentiary platform for policy development are summarized, and the flow between these components is described. The development of the Ontario Health Technology Advisory Committee (OHTAC) and associated programs demonstrate the need to go beyond the traditional steps taken within most health technology assessment paradigms. These components include pragmatic postmarketing studies, human factors, and safety analyses, and formalized interactions with a broad spectrum of potential end-users of each technology, experts, and industry. Thesecomponents, taken together with an expanded systematic review to include a range of economic analyses, and societal impacts augment the traditional systematic review processes. This approach has been found to be important in assisting decision making and has resulted in an 81 percent conversion from evidence to policy consideration for eighty-three technologies that had been assessed at the time this article was submitted. The comprehensive model, centered around OHTAC, has added important new dimensions to health policy by improving its relevance to decision makers and providing an accountable and transparent basis for government to invest appropriately in health technologies. This study could also form a basis for further research into appropriate methodologies and outcome measurements as they relate to each component of this approach.
    International Journal of Technology Assessment in Health Care 02/2007; 23(3):299-309. DOI:10.1017/S0266462307070456 · 1.56 Impact Factor
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    ABSTRACT: To investigate dexmedetomidine in children, the authors performed an open-label study of the pharmacokinetics and pharmacodynamics of dexmedetomidine. Thirty-six children were assigned to three groups; 24 received dexmedetomidine and 12 received no drug. Three doses of dexmedetomidine, 2, 4, and 6 microg x kg x h, were infused for 10 min. Cardiorespiratory responses and sedation were recorded for 24 h. Plasma concentrations of dexmedetomidine were collected for 24 h and analyzed. Pharmacokinetic variables were determined using nonlinear mixed effects modeling (NONMEM program). Cardiorespiratory responses were analyzed. Thirty-six children completed the study. There was an apparent difference in the pharmacokinetics between Canadian and South African children. The derived volumes and clearances in the Canadian children were V1 = 0.81 l/kg, V2 = 1.0 l/kg, Cl1 (systemic clearance) = 0.013 l x kg x min, Cl2 = 0.030 l x kg x min. The intersubject variabilities for V1, V2, and Cl1 were 45%, 38%, and 22%, respectively. Plasma concentrations in South African children were 29% less than in Canadian children. The volumes and clearances in the South African children were 29% larger. The terminal half-life was 110 min (1.8 h). Median absolute prediction error for the two-compartment mammillary model was 18%. Heart rate and systolic blood pressure decreased with time and with increasing doses of dexmedetomidine. Respiratory rate and oxygen saturation (in air) were maintained. Sedation was transient. The pharmacokinetics of dexmedetomidine in children are predictable with a terminal half-life of 1.8 h. Hemodynamic responses decreased with increasing doses of dexmedetomidine. Respiratory responses were maintained, whereas sedation was transient.
    Anesthesiology 01/2007; 105(6):1098-110. DOI:10.1097/00000542-200612000-00009 · 6.17 Impact Factor
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    ABSTRACT: Haemodilution has been associated with neurological morbidity in surgical patients. This study tests the hypothesis that inhibition of cerebral vasodilatation by systemic beta2 adrenergic blockade would impair cerebral oxygen delivery leading to tissue hypoxia in severely haemodiluted rats. Under general anaesthesia, cerebral tissue probes were placed to measure temperature, regional cerebral blood flow (rCBF) and tissue oxygen tension (P(Br)O2) in the parietal cerebral cortex or hippocampus. Baseline measurements were established before and after systemic administration of either a beta2 antagonist (10 mg kg(-1) i.v., ICI 118, 551) or saline vehicle. Acute haemodilution was then performed by simultaneously exchanging 50% of the estimated blood volume (30 ml kg(-1)) with pentastarch. Arterial blood gases (ABGs), haemoglobin concentration (co-oximetry), mean arterial blood pressure (MAP) and heart rate (HR) were also measured. Data were analysed using a two-way anova and post hoc Tukey's test [mean (sd)]. Haemodilution reduced the haemoglobin concentration comparably in all groups [71 (9) g litre(-1)]. There were no differences in ABGs, co-oximetry, HR and MAP measurements between control and beta2 blocked rats, either before or 60 min after drug or vehicle administration. In rats treated with the beta2 antagonist there was a significant reduction in parietal cerebral cortical temperature, regional blood flow and tissue oxygen tension, relative to control rats, 60 min after haemodilution (P<0.05 for each). These differences were not observed when probes were placed in the hippocampus. Systemic beta2 adrenergic blockade inhibited the compensatory increase in parietal cerebral cortical oxygen delivery after haemodilution thereby reducing cerebral cortical tissue oxygen tension.
    BJA British Journal of Anaesthesia 12/2006; 97(5):617-23. DOI:10.1093/bja/ael238 · 4.35 Impact Factor
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    ABSTRACT: Background: To investigate dexmedetomidine in children, the authors performed an open-label study of the pharmacokinetics and pharmacodynamics of dexmedetomidine.
    Anesthesiology 11/2006; 105(6):1098-1110. · 6.17 Impact Factor
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    Canadian Journal of Anaesthesia 06/2005; 52(S1). DOI:10.1007/BF03023096 · 2.50 Impact Factor
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    Canadian Journal of Anaesthesia 06/2005; 52. DOI:10.1007/BF03023235 · 2.50 Impact Factor
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    Nancy Sikich, Jerrold Lerman
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    ABSTRACT: Emergence delirium has been investigated in several clinical trials. However, no reliable and valid rating scale exists to measure this phenomenon in children. Therefore, the authors developed and evaluated the Pediatric Anesthesia Emergence Delirium (PAED) scale to measure emergence delirium in children. A list of scale items that were statements describing the emergence behavior of children was compiled, and the items were evaluated for content validity and statistical significance. Items that satisfied these evaluations comprised the PAED scale. Each item was scored from 1 to 4 (with reverse scoring where applicable), and the scores were summed to obtain a total scale score. The degree of emergence delirium varied directly with the total score. Fifty children were enrolled to determine the reliability and validity of the PAED scale. Scale validity was evaluated using five hypotheses: The PAED scale scores correlated negatively with age and time to awakening and positively with clinical judgment scores and Post Hospital Behavior Questionnaire scores, and were greater after sevoflurane than after halothane. The sensitivity of the scale was also determined. Five of 27 items that satisfied the content validity and statistical analysis became the PAED scale: (1) The child makes eye contact with the caregiver, (2) the child's actions are purposeful, (3) the child is aware of his/her surroundings, (4) the child is restless, and (5) the child is inconsolable. The internal consistency of the PAED scale was 0.89, and the reliability was 0.84 (95% confidence interval, 0.76-0.90). Three hypotheses supported the validity of the scale: The scores correlated negatively with age (r = -0.31, P <0.04) and time to awakening (r = -0.5, P <0.001) and were greater after sevoflurane anesthesia than halothane (P <0.008). The sensitivity was 0.64. These results support the reliability and validity of the PAED scale.
    Anesthesiology 06/2004; 100(5):1138-45. DOI:10.1097/00000542-200405000-00015 · 6.17 Impact Factor

Publication Stats

1k Citations
188.31 Total Impact Points

Top co-authors View all

Institutions

  • 2014
    • Health Canada
      Ottawa, Ontario, Canada
  • 2007–2011
    • Ontario Ministry Of Health And Long-Term Care
      Toronto, Ontario, Canada
  • 2008
    • Christus St. Michaels' Hospital
      텍사캐나, Arkansas, United States
  • 1994–2007
    • University of Toronto
      • Department of Anesthesia
      Toronto, Ontario, Canada
  • 2004
    • St. Michael's Hospital
      Toronto, Ontario, Canada
  • 1992–2002
    • SickKids
      Toronto, Ontario, Canada