Lesley Soril

The Rick Hansen Spinal Cord Injury Registry (RHSCIR): a national patient-registry.

Study design:Development of a prospective patient registry.Objective:To develop a patient registry for persons with traumatic spinal cord injuries (SCI), which can be used to answer research questions and improve patient outcomes.Setting:Nine provinces in Canada.Methods:The Rick Hansen Spinal Cord Injury Registry (RHSCIR) is part of the Translational Research Program of the Rick Hansen Institute. The launch of RHSCIR in 2004 heralded the initiation of the first nation-wide SCI patient registry within Canada. Currently, RHSCIR is being implemented in 14 cities located in 9 provinces, and there are over 1500 individuals who have sustained an acute traumatic SCI registered to date. Data are captured from the pre-hospital, acute and rehabilitation phases of care, and participants are followed in the community at 1, 2, 5 and then every 5 years post-injury.Results:During the development of RHSCIR, there were many challenges that were overcome in selecting data elements, establishing the governance structure, and creating a patient privacy and confidentiality framework across multiple provincial jurisdictions. The benefits of implementing a national registry are now being realized. The collection of an internationally standardized set of clinical information is helping inform clinicians of beneficial interventions and encouraging a shift towards evidence-based practices. Furthermore, through RHSCIR, a network is forming amongst SCI clinicians and researchers, which is fostering new collaborations and the launch of multi-center clinical trials.Conclusions:For networks that are establishing SCI registries, the experiences and lessons learned in the development of RHSCIR may provide useful insights and guidance.

Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions

Objective The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population. Methods Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized. Results Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of

Modeling the Patient Journey from Injury to Community Reintegration for Persons with Acute Traumatic Spinal Cord Injury in a Canadian Centre

742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of

Radiofrequency Ablation for Chronic Low Back Pain: A Systematic Review of Randomized Controlled Trials

15,513/patient. Conclusions The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.

Characteristics of frequent users of the emergency department in the general adult population: A systematic review of international healthcare systems

Background A patient’s journey through the health care system is influenced by clinical and system processes across the continuum of care. Methods To inform optimized access to care and patient flow for individuals with traumatic spinal cord injury (tSCI), we developed a simulation model that can examine the full impact of therapeutic or systems interventions across the care continuum for patients with traumatic spinal cord injuries. The objective of this paper is to describe the detailed development of this simulation model for a major trauma and a rehabilitation centre in British Columbia (BC), Canada, as part of the Access to Care and Timing (ACT) project and is referred to as the BC ACT Model V1.0. Findings To demonstrate the utility of the simulation model in clinical and administrative decision-making we present three typical scenarios that illustrate how an investigator can track the indirect impact(s) of medical and administrative interventions, both upstream and downstream along the continuum of care. For example, the model was used to estimate the theoretical impact of a practice that reduced the incidence of pressure ulcers by 70%. This led to a decrease in acute and rehabilitation length of stay of 4 and 2 days, respectively and a decrease in bed utilization of 9% and 3% in acute and rehabilitation. Conclusion The scenario analysis using the BC ACT Model V1.0 demonstrates the flexibility and value of the simulation model as a decision-making tool by providing estimates of the effects of different interventions and allowing them to be objectively compared. Future work will involve developing a generalizable national Canadian ACT Model to examine differences in care delivery and identify the ideal attributes of SCI care delivery.

Effective use of the built environment to manage behavioural and psychological symptoms of dementia: a systematic review.

Low back pain affects a considerable proportion of the population and can significantly decrease quality of life. Radiofrequency ablation is an emerging technique that may offer relief from pain for patients experiencing chronic low back pain. This systematic review of the procedure aimed to summarize its efficacy in the treatment of pain in different regions of the low back.

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Adult and Youth Populations: A Systematic Literature Review and Meta-Analysis.

OBJECTIVES The objectives of this study were to synthesize and compare population characteristics associated with frequent emergency department (ED) use within and across healthcare systems. METHODS A systematic review of literature published between 1950 and 2015 was conducted. Healthcare systems of included studies were categorized using the Rothgang-Wendt typology. Demographic, clinical and health service utilization characteristics of frequent ED users in the general adult population were identified within each healthcare system. Pooled estimates, stratified by healthcare system, were calculated to compare the association of each characteristic with frequent, compared to non-frequent, emergency room use. RESULTS Twenty moderate to high quality comparative cohort studies were included. Among these, five healthcare systems were identified: National Health Insurance; Private Healthcare; National Health Service; Social Health Insurance and Etatist Social Health Insurance. Many similar characteristics were observed: in most healthcare systems, frequent ED users were more likely to be older, female, and have a mental health diagnosis. Previous hospitalizations and high primary care use (>3 visits/year) were associated with future frequent ED use in the NHIS and NHS systems. CONCLUSIONS Observed similarities suggest that frequent ED use may not differ from one healthcare system to the next. With increasing need to develop solutions for high ED utilization world-wide, targeted efforts must be made to bolster dissemination and uptake of effective interventions across healthcare contexts.

Impact of Cost-Sharing Mechanisms on Patient-Borne Medication Costs

Objective To determine the effectiveness of built environment interventions in managing behavioural and psychological symptoms of dementia (BPSD) among residents in long-term care settings. Methods Systematic review of literature published from 1995–2013. Studies were included if they: were randomized controlled trials, quasi-experimental trials, or comparative cohort studies; were in long-term or specialized dementia care; included residents with dementia and BPSD; and examined effectiveness of a built environment intervention on frequency and/or severity of BPSD. Quality of included studies was assessed using the Downs and Black Checklist. Study design, patient population, intervention, and outcomes were extracted and narratively synthesized. Results Five low to moderate quality studies were included. Three categories of interventions were identified: change/redesign of existing physical space, addition of physical objects to environment, and type of living environment. One of the two studies that examined change/redesign of physical spaces reported improvements in BPSD. The addition of physical objects to an existing environment (n = 1) resulted in no difference in BPSD between treatment and control groups. The two studies that examined relocation to a novel living environment reported decreased or no difference in the severity and/or frequency of BPSD post-intervention. No studies reported worsening of BPSD following a built environment intervention. Conclusions The range of built environment interventions is broad, as is the complex and multi-dimensional nature of BPSD. There is inconclusive evidence to suggest a built environment intervention which is clinically superior in long-term care settings. Further high-quality methodological and experimental studies are required to demonstrate the feasibility and effectiveness of such interventions.

Achieving optimal technology use: A proposed model for health technology reassessment

BACKGROUND Between 30% and 60% of individuals with major depressive disorder will have treatment-resistant depression (TRD): depression that does not subside with pharmaceutical treatment. Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment for TRD. OBJECTIVE To establish the efficacy and optimal protocol for rTMS among adults and youth with TRD. DATA SOURCES Two systematic reviews were conducted: one to determine the efficacy of rTMS for adults with TRD and another to determine the effectiveness of rTMS for youth with TRD. For adults, MEDLINE, Cochrane Central Register of Controlled Trials, PubMed, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, and Health Technology Assessment Database were searched from inception until January 10, 2014 with no language restrictions. Terms aimed at capturing the target diagnosis, such as depression and depressive disorder, were combined with terms describing the technology, such as transcranial magnetic stimulation and rTMS. Results were limited to studies involving human participants and designed as a randomized controlled trial. For youth, the search was altered to include youth only (aged 13-25 years) and all study designs. When possible, meta-analysis of response and remission rates was conducted. STUDY SELECTION Seventy-three articles were included in this review: 70 on adult and 3 on youth populations. RESULTS Meta-analysis comparing rTMS and sham in adults found statistically significant results favoring rTMS for response (RR: 2.35 [95% CI, 1.70-3.25]) and remission (RR: 2.24 [95% CI, 1.53-3.27]). No statistically significant differences were found when comparing high- and low-frequency, unilateral and bilateral, low- and high-intensity rTMS or rTMS and electroconvulsive therapy (ECT). While meta-analysis of results from the youth literature was not possible, the limited evidence base suggests that rTMS may be effective for treating TRD in youth. CONCLUSIONS The evidence available on the use of rTMS for adults with TRD indicates that rTMS is approximately twice as effective as a sham procedure, although the optimal rTMS protocol remains unclear. Evidence also indicates that rTMS is as effective as ECT and appears promising as a treatment for youth with TRD; however, the evidence base is underdeveloped.

Unpacking early experiences with health technology reassessment in a complex healthcare system

Background Treatment of chronic diseases, predominantly managed through the use of outpatient medications, can be costly to the patient—even those who are insured. Insurance plans use 2 strategies to share costs with patients: deductibles (the patient pays the full cost of medications up to a fixed maximum over a given period), and copayments (either fixed amounts per prescription, or a percentage of each prescription). Insurers use cost-sharing to offset their total expenditures and the theory of moral hazard that having patients contribute financially to their medication expenses may give them an incentive to reduce inappropriate consumption of medications. In practice, studies have found that patients who perceive financial barriers are less likely to adhere to therapies and more likely to have adverse clinical events.1,2 In the current climate, where all Americans are required to carry health insurance, physicians should be aware of which insurance plan designs may result in higher out-of-pocket payments and potentially predispose patients to cost-related nonadherence.