Publications by authors named "Ana P Johnson"

22 Publications

  • Page 1 of 1

Economic Burden and Healthcare Resource Use for Thoracic Aortic Dissections and Thoracic Aortic Aneurysms-A Population-Based Cost-of-Illness Analysis.

J Am Heart Assoc 2020 06 27;9(11):e014981. Epub 2020 May 27.

Institute for Clinical and Evaluative Sciences Queen's University Kingston Ontario, Canada.

Background Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost-of-illness analysis was performed. From a single-payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (<0.0001) and $13 M to $18 M for TAAs (<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.
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http://dx.doi.org/10.1161/JAHA.119.014981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428990PMC
June 2020

Use of instrumented lumbar spinal surgery for degenerative conditions: trends and costs over time in Ontario, Canada

Can J Surg 2019 12;62(6):393-401

From the Department of Medicine, University of Toronto, Toronto, Ont. (Y. Xu); ICES, Queen’s University, Kingston, Ont. (Y. Xu, Whitehead, J. Xu, Johnson); the Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, Ont. (Yen); and the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Johnson).

Background: Instrumented lumbar surgeries, such as lumbar fusion and lumbar disc replacement, are increasingly being used in the United States for low back pain, with utilization rates approaching those of total joint arthroplasty. It is unknown whether there is a similar pattern in Canada. We sought to determine utilization rates and total medical costs of instrumented lumbar surgeries in a single-payer system and to compare these with the rates and costs of total hip and knee replacements.

Methods: We included Ontarians aged 20 years and older who underwent instrumented lumbar surgery or total knee or total hip replacement between April 1993 and March 2012. Utilization and medical cost of the procedures were evaluated and compared using linear regression in a time-series analysis. Instrumented lumbar surgical procedures were stratified by age and main indication for surgery.

Results: Utilization of instrumented lumbar surgeries rose from 6.2 to 14.2 procedures per 100 000 population between 1993 and 2012 (p < 0.001), well below the utilization of knee and hip arthroplasties. Patients were younger than 50 years for 29.2% of all instrumented lumbar surgery cases; annual procedure rates among those older than 80 years rose 7.6-fold. Direct medical costs of instrumented lumbar surgeries from 2002 to 2012 totaled $176 million. Spinal stenosis and spondylolisthesis were the most common indications for instrumented lumbar surgeries.

Conclusion: Use of instrumented lumbar surgeries in Ontario’s single-payer system has increased rapidly, especially among patients older than 80 years. In contrast to the situation in the United States, these rates were well below those of total joint arthroplasties. These data provide useful insights about resource allocation for surgical treatment of lumbar degenerative disorders.
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http://dx.doi.org/10.1503/cjs.017016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6877392PMC
December 2019

Potential impact of changes in administrative database coding methodology on research and policy decisions: an example from the Ontario Health Insurance Plan.

Can J Anaesth 2020 04 17;67(4):487-488. Epub 2019 Oct 17.

Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada.

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http://dx.doi.org/10.1007/s12630-019-01511-8DOI Listing
April 2020

Healthcare resource utilization and costs among patients with direct oral anticoagulant or warfarin-related major bleeding.

Thromb Res 2019 Oct 2;182:12-19. Epub 2019 Aug 2.

Health Services and Policy Research Institute, Queen's University, Kingston, Canada; Department of Public Health Sciences, Queen's University, Kingston, Canada. Electronic address:

Introduction: Direct oral anticoagulants (DOACs) have expanded the options for antithrombotic therapy. DOAC-related major bleeds are associated with favorable outcomes compared to warfarin in clinical trials and routine practice. However, it is unclear whether management of DOAC-associated major bleeding incurs higher resource utilization and costs.

Materials And Methods: We screened medical records of patients ≥ 66 years with atrial fibrillation admitted to one of five tertiary care hospitals in Ontario, Canada with a hemorrhage. We abstracted bleeds involving DOACs or warfarin and linked them to administrative databases to capture length of hospital stay, blood product use, procedural interventions, intensive care unit (ICU) utilization and related direct medical costs. To control for confounders, multivariate logistic and linear regressions were used for binary and linear outcomes respectively.

Results: Among 19,061 records screened, 1978 (10.4%) cases involving 1632 patients met criteria of oral anticoagulant-associated bleeding. Baseline characteristics between DOAC and warfarin groups were similar. Blood product costs were higher for DOACs (all comparisons DOACs vs. warfarin, $1456 vs. $1109, mean difference $347, 95% CI $185 to $509), but length of stay and ICU use were similar. Mean direct medical costs did not differ ($9217 vs. $10,790, adjusted relative ratio 0.94, 95% CI 0.84-1.05).

Conclusions: Prior to introduction of DOAC-specific reversal agents, resource utilization and medical costs were comparable between DOAC- and warfarin-associated major bleeds, despite marginally higher blood product costs incurred by the former. Resource intensity associated with anticoagulant-related bleeding remains high, and our data provide measures for cost-effectiveness evaluation of emerging DOAC antidotes.
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http://dx.doi.org/10.1016/j.thromres.2019.07.026DOI Listing
October 2019

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada.

Can J Aging 2019 03 22;38(1):51-58. Epub 2018 Nov 22.

Department of Public Health Sciences,Queen's University.

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.
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http://dx.doi.org/10.1017/S0714980818000387DOI Listing
March 2019

Postoperative Remote Automated Monitoring: Need for and State of the Science.

Can J Cardiol 2018 07 25;34(7):850-862. Epub 2018 Apr 25.

McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.
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http://dx.doi.org/10.1016/j.cjca.2018.04.021DOI Listing
July 2018

Epidemiology and management of thoracic aortic dissections and thoracic aortic aneurysms in Ontario, Canada: A population-based study.

J Thorac Cardiovasc Surg 2018 06 27;155(6):2254-2264.e4. Epub 2018 Feb 27.

Institute for Clinical and Evaluative Sciences, Queen's University, Kingston, Ontario, Canada.

Objectives: To determine hospital incidence, mortality, and management for thoracic aortic dissections and aneurysms.

Methods: A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of thoracic aortic dissections and aneurysms were identified between 2002 and 2014. Treatment and mortality trends were assessed.

Results: There were 5966 aortic dissections (Type A n = 2289 [38%] and Type B n = 3632 [61%]). Overall incidence proportion for aortic dissections was 4.6 per 100,000. There were 9392 thoracic aortic aneurysms with an overall incidence proportion of 7.6 per 100,000. The incidence for both dissections and aneurysms significantly increased over the 12-year study. Only 53% (1204 out of 2289) of Type A dissections underwent surgery. Type B dissection treatment was 83% (3000 out of 3632) medical, 10% (370 out of 3632) surgery, and 7% (262 out of 3632) endovascular. Thoracic aortic aneurysm treatment was 53% (4940 out of 9392) surgery, 44% (4129 out of 9392) medical, and 3% (323 out of 9392) endovascular. Thirty-five percent of known descending thoracic aortic aneurysms (323 out of 924) received a stent graft. Cardiac surgeons performed 87% of the open surgical repairs. Vascular surgeons performed 91% of the endovascular procedures. All-cause 3-year mortality significantly decreased for both aortic dissections (44% to 40%) and aneurysms (30% to 22%). All-cause hospital mortality also decreased. Women had worse outcomes than men.

Conclusions: The incidence of thoracic aortic dissections and aneurysms increased over time but all-cause hospital and late outcomes improved. Gender differences exist. Men incur more disease but women have higher hospital mortality. Surgery was primarily referred to cardiac surgeons. Endovascular therapy was primarily referred to vascular surgeons.
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http://dx.doi.org/10.1016/j.jtcvs.2017.11.105DOI Listing
June 2018

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 2: The direct and indirect costs of injury.

Foot (Edinb) 2019 Jun 20;39:115-121. Epub 2017 Jul 20.

Department of Public Health Sciences, Queen's University, Canada.

Background: Ankle and foot sprains and fractures are prevalent injuries, which may result in substantial physical and economic consequences for the patient and place a financial burden on the health care system. Therefore, the objectives of this paper are to examine the direct and indirect costs of treating ankle and foot injuries (sprains, dislocations, fractures), as well as to provide an overview of the outcomes of full economic analyses of different treatment strategies.

Methods: A systematic review was carried out among seven databases to identify English language publications on the health economics of ankle and foot injury treatment published between 1980 and 2014. The direct and indirect costs were abstracted by two independent reviewers. All costs were adjusted for inflation and reported in 2016 US dollars (USD).

Results: Among 2047 identified studies, 32 were selected for analysis. The direct costs of ankle sprain management ranged from $292 to $2268 per patient (2016 USD), depending on the injury severity and treatment strategy. The direct costs of managing ankle fractures were higher ($1908-$19,555). Foot fracture treatment had similar direct costs ranging from $998 to $21,801. The economic evaluations were conducted from the societal or payer's perspectives.

Conclusion: The costs of treating ankle and foot sprains and fractures varied among the studies, mostly due to differences in injury type and study characteristics, which impacted the ability of directly comparing the financial burden of treatment. Nonetheless, the review showed that the costs experienced by the patient and the health care system increased with injury complexity.
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http://dx.doi.org/10.1016/j.foot.2017.07.003DOI Listing
June 2019

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 1: Overview and critical appraisal.

Foot (Edinb) 2019 Jun 1;39:106-114. Epub 2017 Jul 1.

Department of Public Health Sciences, Queen's University, Canada.

Background: Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment.

Methods: A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data.

Results: The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data.

Conclusion: This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.
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http://dx.doi.org/10.1016/j.foot.2017.04.003DOI Listing
June 2019

Direct Oral Anticoagulant- or Warfarin-Related Major Bleeding: Characteristics, Reversal Strategies, and Outcomes From a Multicenter Observational Study.

Chest 2017 07 17;152(1):81-91. Epub 2017 Feb 17.

Centre for Health Services and Policy Research, Queen's University, Kingston, ON, Canada; Department of Public Health Sciences, Queen's University, Kingston, ON, Canada. Electronic address:

Background: Direct oral anticoagulants (DOACs) have expanded the armamentarium for antithrombotic therapy. Although DOAC-related major bleeding was associated with favorable outcomes compared with warfarin in clinical trials, warfarin effects were reversed in < 40% of cases, raising concerns about the generalizability of this finding.

Methods: Consecutive patients ≥ 66 years presented to five tertiary care hospitals across three cities in Ontario, Canada from October 2010 to March 2015 with diagnoses that included hemorrhage. Charts were screened for association with DOAC or warfarin use; eligible cases were abstracted and linked to administrative databases.

Results: Among 19,061 records screened, 2,002 (460 receiving DOAC, 1,542 receiving warfarin) were eligible. Reversal agents (72.9% vitamin K, 40.7% prothrombin complex concentrates) were frequently used in warfarin bleeding events. Red blood cell transfusions occurred more often in DOAC bleeding events than in warfarin events (52.0% vs 39.5%; adjusted relative risk [aRR], 1.32; 95% CI, 1.19-2.47). However, units of blood products transfused were not different between the two groups. Thirty-four DOAC cases (7.4%) received activated prothrombin complex concentrates or recombinant factor VIIa. In-hospital mortality was lower following DOAC bleeding events (9.8% vs 15.2%; aRR, 0.66; 95% CI, 0.49-0.89), although differences in 30-day mortality did not reach statistical significance (12.6% vs 16.3%; aRR, 0.79; 95% CI, 0.61-1.03).

Conclusions: In this unselected cohort of patients with oral anticoagulant-related hemorrhage with high rates of warfarin reversal, in-hospital mortality was lower among DOAC-associated bleeding events. These findings support the safety of DOACs in routine care and present useful baseline measures for evaluations of DOAC-specific reversal agents.
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http://dx.doi.org/10.1016/j.chest.2017.02.009DOI Listing
July 2017

Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial.

BMJ 2016 Nov 16;355:i5650. Epub 2016 Nov 16.

Queen's University School of Rehabilitation Therapy, Kingston, ON, Canada.

Objective:  To assess the efficacy of a programme of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains.

Design:  A randomised controlled trial of 503 participants followed for six months.

Setting:  Participants were recruited from two tertiary acute care settings in Kingston, ON, Canada.

Participants:  The broad inclusion criteria were patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain. Exclusions were patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilisation and those unable to accommodate the time intensive study protocol.

Intervention:  Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised programme of physiotherapy.

Main Outcome Measures:  The primary outcome of efficacy was the proportion of participants reporting excellent recovery assessed with the foot and ankle outcome score (FAOS). Excellent recovery was defined as a score ≥450/500 at three months. A difference of at least 15% increase in the absolute proportion of participants with excellent recovery was deemed clinically important. Secondary analyses included the assessment of excellent recovery at one and six months; change from baseline using continuous scores at one, three, and six months; and clinical and biomechanical measures of ankle function, assessed at one, three, and six months.

Results:  The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval -3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analysed as a continuous change score.

Conclusions:  In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol.Trial registration ISRCTN 74033088 (www.isrctn.com/ISRCTN74033088).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112179PMC
http://dx.doi.org/10.1136/bmj.i5650DOI Listing
November 2016

Economies of scale: body mass index and costs of cardiac surgery in Ontario, Canada.

Eur J Health Econ 2017 May 11;18(4):471-479. Epub 2016 May 11.

Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.

An obesity paradox has been described, whereby obese patients have better health outcomes than normal weight patients in certain clinical situations, including cardiac surgery. However, the relationship between body mass index (BMI) and resource utilization and costs in patients undergoing coronary artery bypass graft (CABG) surgery is largely unknown. We examined resource utilization and cost data for 53,224 patients undergoing CABG in Ontario, Canada over a 10-year period between 2002 and 2011. Data for costs during hospital admission and for a 1-year follow-up period were derived from the Institute for Clinical Evaluative Sciences, and analyzed according to pre-defined BMI categories using analysis of variance and multivariate models. BMI independently influenced healthcare costs. Underweight patients had the highest per patient costs ($50,124 ± $36,495), with the next highest costs incurred by morbidly obese ($43,770 ± $31,747) and normal weight patients ($42,564 ± $30,630). Obese and overweight patients had the lowest per patient costs ($40,760 ± $30,664 and $39,960 ± $25,422, respectively). Conversely, at the population level, overweight and obese patients were responsible for the highest total yearly population costs to the healthcare system ($92 million and $50 million, respectively, compared to $4.2 million for underweight patients). This is most likely due to the high proportion of CABG patients falling into the overweight and obese BMI groups. In the future, preoperative risk stratification and preparation based on BMI may assist in reducing surgical costs, and may inform health policy measures aimed at the management of weight extremes in the population.
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http://dx.doi.org/10.1007/s10198-016-0803-4DOI Listing
May 2017

Perspectives, perceptions and experiences in postoperative pain management in developing countries: A focus group study conducted in Rwanda.

Pain Res Manag 2015 Sep-Oct;20(5):255-60

Background: Access to postoperative acute pain treatment is an important component of perioperative care and is frequently managed by a multidisciplinary team of anesthesiologists, surgeons, pharmacists, technicians and nurses. In some developing countries, treatment modalities are often not performed due to scarce health care resources, knowledge deficiencies and cultural attitudes.

Objectives: In advance of a comprehensive knowledge translation initiative, the present study aimed to determine the perspectives, perceptions and experiences of anesthesia residents regarding postoperative pain management strategies.

Methods: The present study was conducted using a qualitative assessment strategy in a large teaching hospital in Rwanda. During two sessions separated by seven days, a 10-participant semistructured focus group needs analysis was conducted with anesthesia residents at the Centre Hospitalier Universitaire de Kigali (Kigali, Rwanda). Field notes were analyzed using interpretative and descriptive phenomenological approaches. Participants were questioned regarding their perspectives, perceptions and experiences in pain management.

Results: The responses from the focus groups were related to five general areas: general patient and medical practice management; knowledge base regarding postoperative pain management; pain evaluation; institutional/system issues related to protocol implementation; and perceptions about resource allocation. Within these areas, challenges (eg, communication among stakeholders and with patients) and opportunities (eg, on-the-job training, use of protocols, routine pain assessment, participation in resource allocation decisions) were identified.

Conclusions: The present study revealed the prevalent challenges residents perceive in implementing postoperative pain management strategies, and offers practical suggestions to overcoming them, primarily through training and the implementation of practice recommendations.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596633PMC
http://dx.doi.org/10.1155/2015/297384DOI Listing
July 2016

Body Mass Index, Outcomes, and Mortality Following Cardiac Surgery in Ontario, Canada.

J Am Heart Assoc 2015 Jul 9;4(7). Epub 2015 Jul 9.

Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada (J.L.P., B.M.).

Background: The "obesity paradox" reflects an observed relationship between obesity and decreased morbidity and mortality, suggesting improved health outcomes for obese individuals. Studies examining the relationship between high body mass index (BMI) and adverse outcomes after cardiac surgery have reported conflicting results.

Methods And Results: The study population (N=78 762) was comprised of adult patients who had undergone first-time coronary artery bypass (CABG) or combined CABG/aortic valve replacement (AVR) surgery from April 1, 1998 to October 31, 2011 in Ontario (data from the Institute for Clinical Evaluative Sciences). Perioperative outcomes and 5-year mortality among pre-defined BMI (kg/m(2)) categories (underweight <20, normal weight 20 to 24.9, overweight 25 to 29.9, obese 30 to 34.9, morbidly obese >34.9) were compared using Bivariate analyses and Cox multivariate regression analysis to investigate multiple confounders on the relationship between BMI and adverse outcomes. A reverse J-shaped curve was found between BMI and mortality with their respective hazard ratios. Independent of confounding variables, 30-day, 1-year, and 5-year survival rates were highest for the obese group of patients (99.1% [95% Confidence Interval {CI}, 98.9 to 99.2], 97.6% [95% CI, 97.3 to 97.8], and 90.0% [95% CI, 89.5 to 90.5], respectively), and perioperative complications lowest. Underweight and morbidly obese patients had higher mortality and incidence of adverse outcomes.

Conclusions: Overweight and obese patients had lower mortality and adverse perioperative outcomes after cardiac surgery compared with normal weight, underweight, and morbidly obese patients. The "obesity paradox" was confirmed for overweight and moderately obese patients. This may impact health resource planning, shifting the focus to morbidly obese and underweight patients prior to, during, and after cardiac surgery.
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http://dx.doi.org/10.1161/JAHA.115.002140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608091PMC
July 2015

Predictors of hospital stay and home care services use: a population-based, retrospective cohort study in stage IV gastric cancer.

Palliat Med 2015 Feb 24;29(2):147-56. Epub 2014 Oct 24.

Department of Public Health Sciences, Queen's University, Kingston, ON, Canada Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Centre for Health Services and Policy Research, Queen's University, Kingston, ON, Canada.

Background: Home care services use has been proposed as a means of reducing costs in palliative care by decreasing hospital stay without impacting quality of clinical care; however, little is known about utilization of these services in the time following a terminal cancer diagnosis.

Aim: To examine disease, patient and healthcare system predictors of hospital stay, and home care services use in metastatic gastric cancer patients.

Design: This is a population-based, retrospective cohort study. Chart review and administrative data were linked, using a 26-month time horizon to collect health services data.

Participants: All patients diagnosed with metastatic gastric cancer in the province of Ontario between 2005 and 2008 were included in the study (n = 1433).

Results: Age, comorbidity, tumor location, and burden of metastatic disease were identified as predictors of hospital stay and receipt of home care services. Individuals who received home care services spent fewer days in hospital than individuals who did not (relative risk: 0.44; 95% confidence interval: 0.38-0.51). Patients who interacted with a high-volume oncology specialist had shorter cumulative hospital stay (relative risk: 0.62; 95% confidence interval: 0.54-0.71) and were less likely to receive home care services (relative risk: 0.80; 95% confidence interval: 0.72-0.88) than those who did not.

Conclusion: Examining how differences in hospital stay and home care services use impact clinical outcomes and how policies may reduce costs to the healthcare system is necessary.
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http://dx.doi.org/10.1177/0269216314554325DOI Listing
February 2015

A population-based study of the resource utilization and costs of managing resectable non-small cell lung cancer.

Lung Cancer 2014 Nov 20;86(2):281-7. Epub 2014 Sep 20.

Department of Public Health Sciences, Queen's University, Ontario, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada; Centre for Health Services and Policy Research, Queen's University, Ontario, Canada. Electronic address:

Objectives: Surgical resection and adjuvant chemotherapy have become standard of care for treating resectable early stage non-small cell lung cancer (NSCLC). The purpose was to describe and compare the overall and regional resource utilization and costs of resected NSCLC treated with and without adjuvant chemotherapy.

Materials & Methods: A population-based retrospective cohort study of resected NSCLC patients, diagnosed between 2004 and 2006 (representing the cohort immediately affected by the change in clinical practice) was performed using administrative data. Patients were followed for four years from the date of surgery. The healthcare system perspective was used, and cost estimates (2012 US$) were derived from administrative data and the literature.

Results: 3354 patients were included. The average cost per patient treated with surgery and adjuvant chemotherapy was $37,860.88 and was significantly higher than the average cost per patient treated with surgery alone $32,221.45 (p<0.0001). Among regions, the costs of patients treated with surgery and chemotherapy ($32,672-$45,453) and the costs of those treated with surgery alone ($28,679-$36,845) varied significantly (p<0.0001). Rates of chemotherapy, the proportion of patients who received any imaging scans, hospitalizations, specialist visits, emergency room visits, mean number of imaging scans, general physician visits, and blood transfusions all varied significantly among geographic regions.

Conclusions: This population-based study demonstrates an average cost per patient similar to that shown in randomized controlled trials; however, costs for either treatment approach varied by geographic region. Understanding the regional variation in costs and resource utilization is important with respect to delivering optimal treatment in a cost-effective strategy.
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http://dx.doi.org/10.1016/j.lungcan.2014.09.013DOI Listing
November 2014

Prescribing patterns of novel oral anticoagulants following regulatory approval for atrial fibrillation in Ontario, Canada: a population-based descriptive analysis.

CMAJ Open 2013 Sep 16;1(3):E115-9. Epub 2013 Oct 16.

The Department of Population Health Sciences, Queen's University, Kingston, Ont.;

Background: The clinical armamentarium for anticoagulation has expanded substantially since the recent approval of dabigatran, rivaroxaban and apixaban for the prevention of stroke in atrial fibrillation. However, patients in the general population often differ from participants in clinical trials. In this study, we assessed the uptake of these novel oral anticoagulants in Ontario, Canada, within the first 2 years after dabigatran's approval for this indication.

Methods: Using data on province-wide prescription volumes, we conducted a time-series analysis of prescription trends between October 2010 and September 2012 for all orally administered anticoagulants (warfarin, dabigatran and rivaroxaban) that were available in this period. We stratified dabigatran prescription rates by age group (20-39, 40-59, 60-64, 65-84 and ≥ 85 yr). We compared the proportion of dabigatran prescriptions to patients aged 65 or older with similar data from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) study.

Results: Over the 24-month study period, we found that prescriptions for the novel anticoagulants rose more than 20-fold, to represent 21.1% of all prescriptions of oral anticoagulants by September 2012. The rise in prescriptions was due primarily to an increase in dabigatran use. Prescription rates of dabigatran were highest among people aged 85 years or more, a group at increased risk of bleeding who are markedly older than the average participant in the clinical trial in which the drug was tested (71 yr). In September 2012, most of the dabigatran prescriptions were for the lower-dose formulation (110 mg) in the older groups (58.8% of dabigatran prescriptions in the 65-84 age group and 93.6% in the oldest group).

Interpretation: We observed rapid growth in the uptake of the novel oral anticoagulants since their approval for use in patients with atrial fibrillation, especially among those aged 85 years or more. This increase in use in the oldest group, a population at high risk of bleeding, signals the need to evaluate outcomes of use of novel oral anticoagulants in the clinical setting.
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http://dx.doi.org/10.9778/cmajo.20130032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986013PMC
September 2013

Development of advance care planning research priorities: a call to action.

J Palliat Care 2013 ;29(2):99-106

Queen's Health Services Research Facility, Queen's University, Abramsky Hall, 21 Arch Street, Room 311, Kingston, Ontario, Canada.

The objective of this study was to develop a national, prioritized research agenda for advance care planning (ACP). We first identified a list of comprehensive ACP research topics and determined priority criteria through focus groups. We next conducted a survey wherein importance weights were assigned to priority criteria and each ACP topic was rated. We combined weights and ratings into overall scores. A total of 17 ACP topics were developed and placed into four categories: patients and family members, the general public, professionals, and the healthcare system. Four main priority criteria were created: feasibility, consistency with ethical and societal values, economic considerations, and impact. Of the 100 individuals we invited to participate in the survey, 62 accepted. Prioritized topics centred largely on the impact of ACP on health resource utilization, communicating advance care planning across settings, and the preferred manner of engaging patients in ACP.
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August 2013

A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies.

Sex Transm Dis 2011 Oct;38(10):889-91

Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.
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http://dx.doi.org/10.1097/OLQ.0b013e318223be77DOI Listing
October 2011

Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation.

Crit Care Med 2011 Jul;39(7):1792-9

Department of Medicine, Queen's University, Kingston, Ontario, Canada.

Objective: Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes.

Interventions: The use of procalcitonin-guided antibiotic therapy.

Methods And Main Results: We searched computerized databases, reference lists of pertinent articles, and personal files. We included randomized controlled trials conducted in the intensive care unit that compared a procalcitonin-guided strategy to usual care and reported on antibiotic utilization and clinically important outcomes. Results were qualitatively and quantitatively summarized. On the basis of no effect in hospital mortality or hospital length of stay, a cost or cost-minimization analysis was conducted using the costs of procalcitonin testing and antibiotic acquisition and administration. Costs were determined from the literature and are reported in 2009 Canadian dollars. Five articles met the inclusion criteria. Procalcitonin-guided strategies were associated with a significant reduction in antibiotic use (weighted mean difference -2.14 days, 95% confidence interval -2.51 to -1.78, p < .00001). No effect was seen of a procalcitonin-guided strategy on hospital mortality (risk ratio 1.06, 95% confidence interval 0.86-1.30, p = .59; risk difference 0.01, 95% confidence interval -0.04 to +0.07, p = .61) and intensive care unit and hospital lengths of stay. The cost model revealed that, for the base case scenario (daily price of procalcitonin Can$49.42, 6 days of procalcitonin measurement, and 2-day difference in antibiotic treatment between procalcitonin-guided therapy and usual care), the point at which the cost of testing equals the cost of antibiotics saved is when daily antibiotics cost Can$148.26 (ranging between Can$59.30 and Can$296.52 on the basis of different assumptions in sensitivity analyses).

Conclusions: Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality.
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http://dx.doi.org/10.1097/CCM.0b013e31821201a5DOI Listing
July 2011

Economics of chronic pain: How can science guide health policy?

Can J Anaesth 2010 Jun;57(6):530-8

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http://dx.doi.org/10.1007/s12630-010-9307-3DOI Listing
June 2010

Health technology assessment: a comprehensive framework for evidence-based recommendations in Ontario.

Int J Technol Assess Health Care 2009 Apr;25(2):141-50

Queen's University, Abramsky Hall, 21 Arch Street, Room 311, Kingston, Ontario K7L 3N6, Canada.

Objectives: This study describes the development of a framework for health technology decisions, for Ontario Health Technology Advisory Committee (OHTAC) in Ontario, Canada.

Methods: 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.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1017/S0266462309090199DOI Listing
April 2009