[Show abstract][Hide abstract] ABSTRACT: An increasing proportion of critically ill patients are elderly (ie, >or= 65 years of age). This poses complex challenges and choices for the management of elderly patients. Outcome following admission to the ICU has been traditionally concerned with mortality. Beyond mortality, outcomes such as functional status and health-related quality of life (HRQOL) have assumed greater importance. This article reviews the literature, published in English from 1990 to December 2003, pertaining to HRQOL and functional status outcomes of elderly patients. Functional status and HRQOL of elderly survivors of ICUs has been underinvestigated. There is no agreement as to the optimal instrument choice, and differences between studies preclude meaningful comparison or pooling of results.
[Show abstract][Hide abstract] ABSTRACT: This study examined whether emergency physicians (EPs) exposed to multiple dissemination strategies for the Ottawa Ankle Rules (OARs) would reduce extremity radiography use. We conducted a prospective cohort study comparing intervention (n = 2) with control (n = 2) hospitals over a 2-year period. All EPs received the paper-based rules during the run-in phase; EPs in the intervention hospitals were also subjected in sequence to valid dissemination approaches. Provincewide dissemination of the OARs did not decrease radiography during the run-in period (92% vs. 93%; P =.36). Sequential directed education and personalized feedback strategies failed to reduce radiographic ordering rates (P =.54) or the ordering of both foot and ankle radiographs (P =.11) over time. The use of radiography did not decrease despite the use of a variety of dissemination strategies. Additional research is required to determine the most effective methods of incorporating guidelines into emergency practice.
American Journal of Emergency Medicine 06/2004; 22(3):149-55. DOI:10.1016/j.ajem.2004.02.002 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Prairie Pilot Diabetes Surveillance Project was organized to design and test a prototype population-based surveillance system, using administrative data, for a chronic disease exemplar - diabetes mellitus. The Canadian model of a public health surveillance system for chronic conditions described here specifies a process by which administrative and claims data arising from provincial health insurance programs are merged into an annual person-level summary file (APLSF), yielding one summary record for each person insured within each province. The APLSF is the basis for a variety of estimates, including incidence, prevalence, mortality, complication rates and health services utilization. The model was used to produce comparable interprovincial estimates of several parameters with respect to diabetes for the entire population in the provinces of Alberta, Manitoba and Saskatchewan. All processing of identifiable health data occurred within the provinces where the data were generated. Combining results across provinces was based on further aggregation of the summary data from each province and not by pooling of identifiable person-level data. On the basis of preliminary outputs for diabetes mellitus, the model appears to provide coherent estimates of key diabetes parameters and reflects anticipated differences in health services and outcomes, by disease state. Three characteristics of the model recommend it as a resource for non-communicable disease surveillance in Canada: a) it maximizes the utility of existing data; b) it includes both those with and those without the disease in question; and c) it respects provincial legislation regarding personal health data, yet permits reporting of multi-provincial, population-based data.
Chronic diseases in Canada 02/2004; 25(1):7-12. · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examines the pattern of incidence and health service utilisation of cerebrovascular disease cases in urban and rural areas within a publicly funded health care system.
A population-based study covering a large geographic region, using population-wide administrative health data. Age- and sex-standardised incidence and mortality rates were calculated for rural and urban areas. Final status (discharge or death), place of service and place of residence were reported for all cases across several different subsets of cerebrovascular disease.
The province of Alberta, located in western Canada.
Incident cases of cerebrovascular disease (stroke and transient ischaemic attack) and 4 different definitions of incident stroke were identified from data on emergency department admissions in the 1999/2000 fiscal year.
The rate of cerebrovascular disease per 10,000 was similar between urban (13.24) and rural (13.82) areas. Rural residents frequently reported their incident episode to urban emergency departments. Although the mortality is similar between urban and rural residents, rural dwellers die more frequently in the emergency department setting than urban dwellers, who die more often as in-patients.
Overall mortality is similar between urban and rural residents. A large proportion of rural residents receive diagnoses and treatment for cerebrovascular disease in urban areas. Location of service and location of death differs between rural and urban cases of cerebrovascular disease.
[Show abstract][Hide abstract] ABSTRACT: The diagnosis of cerebrovascular disease (CBVD) from administrative data has been critically examined by epidemiologists in recent years. Much of the existing literature suggests that hospital discharge diagnoses based on ICD-9-CM codes are an unreliable source of information for determining a diagnosis of stroke, particularly when four- and five-digit codes are used. We examined how diagnoses for CBVD in hospital inpatient and outpatient facilities vary between rural and urban areas and among the 16 administrative health regions. Our analysis revealed differences in diagnostic patterns between the two sources of data, differences between rural and urban areas, and variation across most of the regions. Geographic variation in health service utilization, diagnostic practices, specialty of the physician making the diagnosis, and disease burden may explain our findings. Our results suggest that the diagnosis of patients attending rural facilities are either coded differently (and less precisely) than those of urban residents or are coded more precisely only after the patients attend urban facilities. Regional differences in coding practices show that any CBVD surveillance system based on administrative data requires a large-scale (in this case, province-wide) and person-oriented approach.
Chronic diseases in Canada 02/2003; 24(1):9-16. · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Physicians argue that patient preferences influence their test ordering and their potential for compliance with clinical practice guidelines (CPG). This study was conducted to evaluate patient satisfaction with clinical practice in emergency department (ED) settings using a validated and widely publicized set of CPGs. Patients presenting to 4 hospital EDs were eligible if they had sustained acute ankle or foot injuries. All sites were involved with the dissemination of radiography CPG, and use of radiography was determined by treating physicians. Telephone follow-up was attempted for all patients who did not receive ankle or foot radiography (Group 1). A random sample of 25% of patients who had a normal radiograph interpretation (Group 2) was also chosen for follow-up. Structured telephone interviews were administered and included information on post-encounter health care utilization, subsequent radiography, and patient satisfaction. A structured questionnaire was administered to all ED physicians (N = 60) to elicit their perspectives on the clinical practice guidelines. In Group 1, 342 (69%) of 494 non-radiographed patients were successfully contacted. In Group 2, 623 (77%) of 812 patients with normal ED radiographs, were successfully contacted. After ED discharge, 86 (25%) Group 1 and 191 (31%) Group 2 patients had visited another physician within 2 weeks of the initial ED encounter (P =.07). Subsequent ankle radiography was similar between the groups (38 [11%] in Group 1 vs. 59 [10%] in Group 2; P =.38). Patients appeared to be similarly highly satisfied with physician care (P =.58) and with discharge instructions (P =.12) in both groups. Overall, 76% of physicians supported the use of CPGs; however, 78% reported that patient expectations influenced their application of the Ottawa Ankle Rules. This study suggests that patients are equally satisfied with care, access additional health care services similarly and obtain the same percentage of radiographs irrespective of the initial ED ankle/foot radiograph ordering. These results may help physicians in re-evaluating their perceptions that patient expectation influence utilization and have important implications in guideline development.
American Journal of Emergency Medicine 02/2002; 20(1):18-22. DOI:10.1053/ajem.2002.30105 · 1.27 Impact Factor