Irfan Dhalla

Facing up to the prescription opioid crisis

Deaths resulting from prescription opioids tripled in the United States between 1999 and 2007 and are also increasing in many other countries, including the United Kingdom. Irfan A Dhalla, Navindra Persaud, and David N Juurlink describe how this situation developed and propose several ways to reduce morbidity and mortality from opioids

Activity-Based Funding of Hospitals and Its Impact on Mortality, Readmission, Discharge Destination, Severity of Illness, and Volume of Care: A Systematic Review and Meta-Analysis

Background Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care. Methods We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication. Results Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk u200a=u200a1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences. Conclusions Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

Perspectives on the National Institute for Health and Clinical Excellence's recommendations to use health technologies only in research

BACKGROUNDnThe concept of using public funds to pay for healthcare interventions only when provided in the context of ongoing research is receiving increasing attention worldwide. Nevertheless, these decisions are often controversial and implementation can be problematic.nnnOBJECTIVESnThe aim of this study was to investigate the views of United Kingdom stakeholders on the current arrangements for implementing only in research (OIR) decisions and to investigate how improvements might be made.nnnMETHODSnAfter an internal review of previous OIR decisions issued by the National Institute for Health and Clinical Excellence (NICE), deliberations by NICEs Citizens Council, and an international workshop convened by NICE and the United States Agency for Healthcare Research and Quality, thirteen key stakeholders and experts from academia, industry, government, and the National Health Service (NHS) were interviewed using a semistructured interview guide. Interview transcripts were subjected to a framework-based analysis using computer-assisted qualitative data analysis software.nnnRESULTSnAll interviewees endorsed the use of the OIR option. There was a high degree of consensus for several suggestions regarding how the use of the OIR option might be improved. For example, there was universal agreement that a formal process should be established to prioritize research needs arising from OIR decisions and that funds for publicly funded research projects should be channeled in a manner that would better motivate healthcare providers to participate in OIR-related research.nnnCONCLUSIONSnThe findings of this study suggest several potential modifications of the OIR pathway in the United Kingdom and may also be helpful to health technology assessment agencies in other countries that already use or are considering using an OIR-like option to reduce the uncertainty inherent in health technology assessment.

Comparative Effectiveness Research in Ontario, Canada: Producing Relevant and Timely Information for Health Care Decision Makers

CONTEXTnComparative effectiveness research is increasingly being recognized as a method to link research with the information needs of decision makers. As the United States begins to invest in comparative effectiveness, it would be wise to look at other functioning research networks to understand the infrastructure and funding required to support them.nnnMETHODSnThis case study looks at the comparative effectiveness research network in Ontario, Canada, for which a neutral coordinating committee is responsible for prioritizing topics, assessing evidence, providing recommendations on coverage decisions, and determining pertinent research questions for further evaluation. This committee is supported by the Medical Advisory Secretariat and several large research institutions. This article analyzes the infrastructure and cost needed to support this network and offers recommendations for developing policies and methodologies to support comparative effectiveness research in the United States.nnnFINDINGSnThe research network in place in Ontario explicitly links decision making with evidence generation, in a transparent, timely, and efficient way. Funding is provided by the Ontario government through a reliable and stable funding mechanism that helps ensure that the studies it supports are relevant to decision makers.nnnCONCLUSIONSnWith the recent allocation of funds to support comparative effectiveness research from the American Recovery and Reinvestment Act, the United States should begin to construct an infrastructure that applies these features to make sure that evidence generated from this effort positively affects the quality of health care delivered to patients.

The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable?

Abstract An understanding of what complex medical patients with chronic conditions, family members and healthcare professionals perceive to be the key reasons for the readmission is important to preventing their occurrence. In this context, we undertook a study to understand the perceptions of patients, family members and healthcare professionals regarding the reasons for, and preventability of, readmissions. An exploratory case design with semi-structured interviews was conducted with 49 participants, including patients, family members, nurses, case managers, physicians, discharge planners from a general internal medicine unit at a large and academic hospital. Data were analyzed using a directed content analysis approach that involved three investigators. Two contrasting themes emerged from the analysis of interview data set. The first theme was readmissions as preventable occurrences. Our analyses elucidated contributing factors to readmissions during the patients’ hospital stay and after the patients were discharged. The second theme was readmissions as inevitable, occurring due to the progression of disease. Our study findings indicate that some readmissions are perceived to be inevitable due to the burden of disease while others are perceived to be preventable and associated with factors both in hospital and post-discharge. Continued interprofessional efforts are required to identify patients at risk for readmission and to organize and deliver care to improve health outcomes after hospitalization.

Mechanical thrombectomy in patients with acute ischemic stroke: a cost-utility analysis

BACKGROUNDnThe beneficial effects of endovascular treatment with new-generation mechanical thrombectomy devices compared with intravenous thrombolysis alone to treat acute large-artery ischemic stroke have been shown in randomized controlled trials (RCTs). This study aimed to estimate the cost utility of mechanical thrombectomy compared with the established standard of care.nnnMETHODSnWe developed a Markov decision process analytic model to assess the cost-effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis versus treatment with intravenous thrombolysis alone from the public payer perspective in Canada. We conducted comprehensive literature searches to populate model inputs. We estimated the efficacy of mechanical thrombectomy plus intravenous thrombolysis from a meta-analysis of 5 RCTs, and we used data from the Oxford Vascular Study to model long-term clinical outcomes. We calculated incremental cost-effectiveness ratios (ICER) using a 5-year time horizon.nnnRESULTSnThe base case analysis showed the cost and effectiveness of treatment with mechanical thrombectomy plus intravenous thrombolysis to be

Mechanical Thrombectomy in Acute Ischemic Stroke: A Systematic Review

126u202f939 and 1.484 quality-adjusted life-years (QALYs), respectively, and the cost and effectiveness of treatment with intravenous thrombolysis alone to be

Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review

124u202f419 and 1.273 QALYs, respectively. The mechanical thrombectomy plus intravenous thrombolysis strategy was associated with an ICER of

Increase in Utilization of Afterhours Medical Imaging: A Study of Three Canadian Academic Centers

11u202f990 per QALY gained. Probabilistic sensitivity analysis showed that the probability of treatment with mechanical thrombectomy plus intravenous thrombolysis being cost-effective was 57.5%, 89.7% and 99.6% at thresholds of

Prescription of Opioids for Opioid-Naive Medical Inpatients

20u202f000,