Publications by authors named "Beate Sander"

96 Publications

Entomological characterization of Aedes mosquitoes and arbovirus detection in Ibagué, a Colombian city with co-circulation of Zika, dengue and chikungunya viruses.

Parasit Vectors 2021 Sep 6;14(1):446. Epub 2021 Sep 6.

Centro de Investigaciones en Microbiología y Parasitología Tropical (CIMPAT), Universidad de Los Andes, Bogotá, Colombia.

Background: Dengue, Zika and chikungunya are arboviruses of significant public health importance that are transmitted by Aedes aegypti and Aedes albopictus mosquitoes. In Colombia, where dengue is hyperendemic, and where chikungunya and Zika were introduced in the last decade, more than half of the population lives in areas at risk. The objective of this study was to characterize Aedes spp. vectors and study their natural infection with dengue, Zika and chikungunya in Ibagué, a Colombian city and capital of the department of Tolima, with case reports of simultaneous circulation of these three arboviruses.

Methods: Mosquito collections were carried out monthly between June 2018 and May 2019 in neighborhoods with different levels of socioeconomic status. We used the non-parametric Friedman, Mann-Whitney and Kruskal-Wallis tests to compare mosquito density distributions. We applied logistic regression analyses to identify associations between mosquito density and absence/presence of breeding sites, and the Spearman correlation coefficient to analyze the possible relationship between climatic variables and mosquito density.

Results: We collected Ae. aegypti in all sampled neighborhoods and found for the first time Ae. albopictus in the city of Ibagué. A greater abundance of mosquitoes was collected in neighborhoods displaying low compared to high socioeconomic status as well as in the intradomicile compared to the peridomestic space. Female mosquitoes predominated over males, and most of the test females had fed on human blood. In total, four Ae. aegypti pools (3%) were positive for dengue virus (serotype 1) and one pool for chikungunya virus (0.8%). Interestingly, infected females were only collected in neighborhoods of low socioeconomic status, and mostly in the intradomicile space.

Conclusions: We confirmed the co-circulation of dengue (serotype 1) and chikungunya viruses in the Ae. aegypti population in Ibagué. However, Zika virus was not detected in any mosquito sample, 3 years after its introduction into the country. The positivity for dengue and chikungunya viruses, predominance of mosquitoes in the intradomicile space and the high proportion of females fed on humans highlight the high risk for arbovirus transmission in Ibagué, but may also provide an opportunity for establishing effective control strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13071-021-04908-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419972PMC
September 2021

Ontario's COVID-19 Modelling Consensus Table: mobilizing scientific expertise to support pandemic response.

Can J Public Health 2021 Aug 30. Epub 2021 Aug 30.

Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Setting: COVID-19 has highlighted the need for credible epidemiological models to inform pandemic policy. Traditional mechanisms of commissioning research are ill-suited to guide policy during a rapidly evolving pandemic. At the same time, contracting with a single centre of expertise has been criticized for failing to reflect challenges inherent in specific modelling approaches.

Intervention: This report describes an alternative approach to mobilizing scientific expertise. Ontario's COVID-19 Modelling Consensus Table (MCT) was created in March 2020 to enable rapid communication of credible estimates of the impact of COVID-19 and to accelerate learning on how the disease is spreading and what could slow its transmission. The MCT is a partnership between the province and academic modellers and consists of multiple groups of experts, health system leaders, and senior decision-makers. Armed with Ministry of Health data, the MCT meets once per week to share results from modelling exercises, generate consensus judgements of the likely future impact of COVID-19, and discuss decision-makers' priorities.

Outcomes: The MCT has enabled swift access to data for participants, a structure for developing consensus estimates and communicating these to decision-makers, credible models to inform health system planning, and increased transparency in public reporting of COVID-19 data. It has also facilitated the rapid publication of research findings and its incorporation into government policy.

Implications: The MCT approach is one way to quickly draw on scientific advice outside of government and public health agencies. Beyond speed, this approach allows for nimbleness as experts from different organizations can be added as needed. It also shows how universities and research institutes have a role to play in crisis situations, and how this expertise can be marshalled to inform policy while respecting academic freedom and confidentiality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.17269/s41997-021-00559-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8404759PMC
August 2021

Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study.

Ann Epidemiol 2021 Jul 25. Epub 2021 Jul 25.

St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; Public Health Ontario, Toronto, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto Public Health, City of Toronto, Toronto, Canada; Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montréal, Canada; Departments of Community Health Sciences and Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Canada; Centre for Health Informatics, University of Calgary, Calgary, Canada; Capacity Planning and Analytics Division, Ontario Ministry of Health, Toronto, Canada; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, United States.

Background: Inequities in the burden of COVID-19 were observed early in Canada and around the world suggesting economically marginalized communities faced disproportionate risks. However, there has been limited systematic assessment of how heterogeneity in risks has evolved in large urban centers over time.

Purpose: To address this gap, we quantified the magnitude of risk heterogeneity in Toronto, Ontario from January-November, 2020 using a retrospective, population-based observational study using surveillance data.

Methods: We generated epidemic curves by social determinants of health (SDOH) and crude Lorenz curves by neighbourhoods to visualize inequities in the distribution of COVID-19 and estimated Gini coefficients. We examined the correlation between SDOH using Pearson-correlation coefficients.

Results: Gini coefficient of cumulative cases by population size was 0.41 (95% confidence interval [CI]:0.36-0.47) and estimated for: household income (0.20, 95%CI: 0.14-0.28); visible minority (0.21, 95%CI:0.16-0.28); recent immigration (0.12, 95%CI:0.09-0.16); suitable housing (0.21, 95%CI:0.14-0.30); multi-generational households (0.19, 95%CI:0.15-0.23); and essential workers (0.28, 95%CI:0.23-0.34).

Conclusions: There was rapid epidemiologic transition from higher to lower income neighbourhoods with Lorenz curve transitioning from below to above the line of equality across SDOH. Moving forward necessitates integrating programs and policies addressing socioeconomic inequities and structural racism into COVID-19 prevention and vaccination programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.annepidem.2021.07.007DOI Listing
July 2021

A disproportionate epidemic: COVID-19 cases and deaths among essential workers in Toronto, Canada.

Ann Epidemiol 2021 Jul 24;63:63-67. Epub 2021 Jul 24.

St. Michael's Hospital, University of Toronto, Toronto, Canada; Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. Electronic address:

Shelter-in-place mandates and closure of nonessential businesses have been central to COVID19 response strategies including in Toronto, Canada. Approximately half of the working population in Canada are employed in occupations that do not allow for remote work suggesting potentially limited impact of some of the strategies proposed to mitigate COVID-19 acquisition and onward transmission risks and associated morbidity and mortality. We compared per-capita rates of COVID-19 cases and deaths from January 23, 2020 to January 24, 2021, across neighborhoods in Toronto by proportion of the population working in essential services. We used person-level data on laboratory-confirmed COVID-19 community cases and deaths, and census data for neighborhood-level attributes. Cumulative per-capita rates of COVID-19 cases and deaths were 3.3-fold and 2.5-fold higher, respectively, in neighborhoods with the highest versus lowest concentration of essential workers. Findings suggest that the population who continued to serve the essential needs of society throughout COVID-19 shouldered a disproportionate burden of transmission and deaths. Taken together, results signal the need for active intervention strategies to complement restrictive measures to optimize both the equity and effectiveness of COVID-19 responses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.annepidem.2021.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435380PMC
July 2021

The impact of acute pneumococcal disease on health state utility values: a systematic review.

Qual Life Res 2021 Jul 17. Epub 2021 Jul 17.

Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Purpose: Streptococcus pneumoniae infections remain a significant source of morbidity and mortality worldwide. The purpose of this review was to summarize the impact of pneumococcal disease on health state utilities (HSU) in the acute phase of illness.

Methods: We searched MEDLINE, EMBASE, EconLit, the Health Technology Assessment Database, the National Health Economic Evaluation Database, and Tufts Cost-Effectiveness Registry (up to January 2020) for primary studies. Eligible studies elicited HSU estimates using preference-based instruments for the acute phase of infection of pneumococcal syndromes including acute otitis media, pneumonia/lower respiratory tract infections, bacteremia/sepsis, and meningitis. Two reviewers independently conducted screening, data extraction and quality appraisal.

Results: We screened 10,178 studies, of which 26 met our inclusion criteria. Cohort sizes ranged from 8 to 2060 respondents. The most frequently studied syndrome was pneumonia (n = 17), followed by acute otitis media (n = 9), meningitis (n = 7) and bacteremia/sepsis (n = 4). Overall, each syndrome was associated with a substantial impact on HSU. Bacteremia/sepsis (range: - 0.331 to 0.992) and meningitis (range: - 0.330 to 0.977) were generally associated with the lowest HSU, followed by pneumonia (range: - 0.054 to 0.998) and acute otitis media (range: 0.064 to 0.970). HSU estimates varied considerably by treatment setting, elicitation method and type of respondent. The only study to compare pneumococcal infections to non-pneumococcal infections in the same population revealed significantly lower HSU estimates among pneumococcal infections.

Conclusions: Pneumococcal syndromes are associated with decreased HSU estimates. Given the considerable heterogeneity in methods and source populations as well as study quality, care should be taken to select the most appropriate estimates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11136-021-02941-yDOI Listing
July 2021

Clinical manifestations and health outcomes associated with Zika virus infections in adults: A systematic review.

PLoS Negl Trop Dis 2021 Jul 12;15(7):e0009516. Epub 2021 Jul 12.

University of Toronto, Toronto, Ontario, Canada.

Background: Zika virus (ZIKV) has generated global interest in the last five years mostly due to its resurgence in the Americas between 2015 and 2016. It was previously thought to be a self-limiting infection causing febrile illness in less than one quarter of those infected. However, a rise in birth defects amongst children born to infected pregnant women, as well as increases in neurological manifestations in adults has been demonstrated. We systemically reviewed the literature to understand clinical manifestations and health outcomes in adults globally.

Methods: This review was registered prospectively with PROPSERO (CRD 42018096558). We systematically searched for studies in six databases from inception to the end of September 2020. There were no language restrictions. Critical appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools.

Findings: We identified 73 studies globally that reported clinical outcomes in ZIKV-infected adults, of which 55 studies were from the Americas. For further analysis, we considered studies that met 70% of critical appraisal criteria and described subjects with confirmed ZIKV. The most common symptoms included: exanthema (5,456/6,129; 89%), arthralgia (3,809/6,093; 63%), fever (3,787/6,124; 62%), conjunctivitis (2,738/3,283; 45%), myalgia (2,498/5,192; 48%), headache (2,165/4,722; 46%), and diarrhea (337/2,622; 13%). 36/14,335 (0.3%) of infected cases developed neurologic sequelae, of which 75% were Guillain-Barré Syndrome (GBS). Several subjects reported recovery from peak of neurological complications, though some endured chronic disability. Mortality was rare (0.1%) and hospitalization (11%) was often associated with co-morbidities or GBS.

Conclusions: The ZIKV literature in adults was predominantly from the Americas. The most common systemic symptoms were exanthema, fever, arthralgia, and conjunctivitis; GBS was the most prevalent neurological complication. Future ZIKV studies are warranted with standardization of testing and case definitions, consistent co-infection testing, reporting of laboratory abnormalities, separation of adult and pediatric outcomes, and assessing for causation between ZIKV and neurological sequelae.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1371/journal.pntd.0009516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297931PMC
July 2021

Systems thinking in health technology assessment: a scoping review.

Int J Technol Assess Health Care 2021 Jun 24;37(1):e71. Epub 2021 Jun 24.

Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, CanadaM5T 3M6.

Objective: Our objective was to assess how, and to what extent, a systems-level perspective is considered in decision-making processes for health interventions by illustrating how studies define the boundaries of the system in their analyses and by defining the decision-making context in which a systems-level perspective is undertaken.

Method: We conducted a scoping review following the Joanna Briggs Institute methodology. MEDLINE, EMBASE, Cochrane Library, and EconLit were searched and key search concepts included decision making, system, and integration. Studies were classified according to an interpretation of the "system" of analysis used in each study based on a four-level model of the health system (patient, care team, organization, and/or policy environment) and using categories (based on intervention type and system impacts considered) to describe the decision-making context.

Results: A total of 2,664 articles were identified and 29 were included for analysis. Most studies (16/29; 55%) considered multiple levels of the health system (i.e., patient, care team, organization, environment) in their analysis and assessed multiple classes of interventions versus a single class of intervention (e.g., pharmaceuticals, screening programs). Approximately half (15/29; 52%) of the studies assessed the influence of policy options on the system as a whole, and the other half assessed the impact of interventions on other phases of the disease pathway or life trajectory (14/29; 48%).

Conclusions: We found that systems thinking is not common in areas where health technology assessments (HTAs) are typically conducted. Against this background, our study demonstrates the need for future conceptualizations and interpretations of systems thinking in HTA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S0266462321000428DOI Listing
June 2021

Cost-Utility Analysis of Dolutegravir- Versus Efavirenz-Based Regimens as a First-Line Treatment in Adult HIV/AIDS Patients in Ethiopia.

Pharmacoecon Open 2021 Jun 16. Epub 2021 Jun 16.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

Background: In several countries, the dolutegravir (DTG)-based regimen is generally preferred as first-line antiretroviral therapy (ART) over the efavirenz (EFV)-based regimen, but the evidence in low-income countries is limited.

Objective: Our study aimed to evaluate the cost effectiveness of DTG- versus EFV-based first-line human immunodeficiency virus (HIV) treatment in Ethiopia.

Methods: We developed a microsimulation model for the progression of HIV/acquired immune deficiency syndrome (AIDS) to examine the cost effectiveness of DTG-based first-line ART compared with an EFV-based regimen from a healthcare payer perspective. We used a lifetime horizon with a 1-month cycle length and a 3% annual discount rate. The primary outcomes were a lifetime cost in US dollars ($), quality-adjusted life-months (QALMs) that converted to QALYs using the formula QALY = QALM/12, and incremental cost-effectiveness ratio (ICER). Deterministic sensitivity analysis was conducted to account for parameter uncertainty.

Results: Compared with the EFV-based regimen, the DTG-based regimen was associated with an expected lifetime cost of $12,709 (vs. $12,701) and expected QALYs of 15.3 (vs. 14.7 QALYs) per patient, resulting in an ICER value of $13.33 per QALY. From an alternative analysis with a 5-year time horizon, DTG-based ART was found to be dominant, with expected gains of 0.17 QALYs at a lower cost of $1 per patient. The deterministic sensitivity analysis depicted that the maximum increase in ICER value was $72 per QALY, and all ICER values were below the estimated threshold value.

Conclusions: The DTG-based first-line regimen appears to be cost effective compared with the EFV-based regimen for the treatment of HIV/AIDS patients in an Ethiopian setting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41669-021-00275-6DOI Listing
June 2021

Assessing New Technologies in Surgery: Case Example of Acute Primary Repair of the Thumb Ulnar Collateral Ligament.

J Hand Surg Am 2021 08 4;46(8):666-674.e5. Epub 2021 Jun 4.

University of Toronto Faculty of Medicine, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.

Purpose: Health technology assessment provides a means to assess the technical properties, safety, efficacy, cost-effectiveness, and ethical/legal/social impact of a novel technology. An important component of health technology assessment is the cost-effectiveness analysis (CEA), which can be performed using model-based CEA. This study used the CEA model to compare the cost-effectiveness of a novel ligament augmentation device with the standard technique for primary repair of complete ulnar collateral ligament (UCL) tears.

Methods: A model was developed for complete UCL tear requiring acute surgical repair, comparing the cost-effectiveness of standard technique primary repair and repair using a ligament augmentation device from a societal perspective. Primary outcomes included quality-adjusted life years (QALYs), cost, net monetary benefit (NMB) and incremental NMB. A cost-effectiveness threshold of CAD $50,000/QALY was used to compare the 2 techniques. Sensitivity analyses were conducted to assess the parameter uncertainty, specifically the impact of device cost, time off work, probability of complication, and postoperative outcome.

Results: The NMB for the standard technique was CAD $42,598, and the NMB for repair using the ligament augmentation device was CAD $41,818. The standard technique was the preferred strategy for primary repair of complete UCL tears. One-way sensitivity analyses demonstrated that the ligament augmentation device became cost-effective if individuals return to work in <18 days (base case 23 days). The device was also favored when the cost was less than CAD $50 and the difference in time to return to work was at least 1 day.

Conclusions: Our model demonstrates that there may be significant costs associated with the introduction of novel health technologies, and certain conditions, such as an earlier return to work, must be met for some devices to be a cost-effective option. This study provides an example of how model-based CEA is a useful tool to assess the cost-effectiveness of a novel device.

Type Of Study/level Of Evidence: Economic/Decision Analysis II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2021.03.021DOI Listing
August 2021

Simulation-Based Estimation of SARS-CoV-2 Infections Associated With School Closures and Community-Based Nonpharmaceutical Interventions in Ontario, Canada.

JAMA Netw Open 2021 03 1;4(3):e213793. Epub 2021 Mar 1.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.

Importance: Resurgent COVID-19 cases have resulted in the reinstitution of nonpharmaceutical interventions, including school closures, which can have adverse effects on families. Understanding the associations of school closures with the number of incident and cumulative COVID-19 cases is critical for decision-making.

Objective: To estimate the association of schools being open or closed with the number of COVID-19 cases compared with community-based nonpharmaceutical interventions.

Design, Setting, And Participants: This decision analytical modelling study developed an agent-based transmission model using a synthetic population of 1 000 000 individuals based on the characteristics of the population of Ontario, Canada. Members of the synthetic population were clustered into households, neighborhoods, or rural districts, cities or rural regions, day care facilities, classrooms (ie, primary, elementary, or high school), colleges or universities, and workplaces. Data were analyzed between May 5, 2020, and October 20, 2020.

Exposures: School reopening on September 15, 2020, vs schools remaining closed under different scenarios for nonpharmaceutical interventions.

Main Outcomes And Measures: Incident and cumulative COVID-19 cases between September 1, 2020, and October 31, 2020.

Results: Among 1 000 000 simulated individuals, the percentage of infections among students and teachers acquired within schools was less than 5% across modeled scenarios. Incident COVID-19 case numbers on October 31, 2020, were 4414 (95% credible interval [CrI], 3491-5382) cases in the scenario with schools remaining closed and 4740 (95% CrI, 3863-5691) cases in the scenario for schools reopening, with no other community-based nonpharmaceutical intervention. In scenarios with community-based nonpharmaceutical interventions implemented, the incident case numbers on October 31 were 714 (95% CrI, 568-908) cases for schools remaining closed and 780 (95% CrI, 580-993) cases for schools reopening. When scenarios applied the case numbers observed in early October in Ontario, the cumulative case numbers were 777 (95% CrI, 621-993) cases for schools remaining closed and 803 (95% CrI, 617-990) cases for schools reopening. In scenarios with implementation of community-based interventions vs no community-based interventions, there was a mean difference of 39 355 cumulative COVID-19 cases by October 31, 2020, while keeping schools closed vs reopening them yielded a mean difference of 2040 cases.

Conclusions And Relevance: This decision analytical modeling study of a synthetic population of individuals in Ontario, Canada, found that most COVID-19 cases in schools were due to acquisition in the community rather than transmission within schools and that the changes in COVID-19 case numbers associated with school reopenings were relatively small compared with the changes associated with community-based nonpharmaceutical interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2021.3793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013816PMC
March 2021

Demographic characteristics, acute care resource use and mortality by age and sex in patients with COVID-19 in Ontario, Canada: a descriptive analysis.

CMAJ Open 2021 Jan-Mar;9(1):E271-E279. Epub 2021 Mar 22.

Institute of Health Policy, Management and Evaluation (Mac, Barrett, Khan, Naimark, Sander), University of Toronto; Toronto Health Economics and Technology Assessment (THETA) Collaborative (Mac, Ximenes, Sander), University Health Network; University Health Network (Barrett, Khan); Sunnybrook Health Sciences Centre (Naimark); Dalla Lana School of Public Health (Rosella), University of Toronto, Toronto, Ont.; Escola de Matemática Aplicada (Ximenes), Fundação Getúlio Vargas, Rio de Janeiro, Brazil; ICES Central (Rosella, Sander); Public Health Ontario (Rosella), Toronto, Ont.

Background: Understanding resource use for coronavirus disease 2019 (COVID-19) is critical. We conducted a descriptive analysis using public health data to describe age- and sex-specific acute care use, length of stay (LOS) and mortality associated with COVID-19.

Methods: We conducted a descriptive analysis using Ontario's Case and Contact Management Plus database of individuals who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Ontario from Mar. 1 to Sept. 30, 2020, to determine age- and sex-specific hospital admissions, intensive care unit (ICU) admissions, use of invasive mechanical ventilation, LOS and mortality. We stratified analyses by month of infection to study temporal trends and conducted subgroup analyses by long-term care residency.

Results: During the observation period, 56 476 individuals testing positive for SARS-CoV-2 were reported; 41 049 (72.7%) of these were younger than 60 years, and 29 196 (51.7%) were female. Proportion of cases shifted from older populations (> 60 yr) to younger populations (10-39 yr) over time. Overall, 5383 (9.5%) of individuals were admitted to hospital; of these, 1183 (22.0%) were admitted to the ICU, and 712 (60.2%) of these received invasive mechanical ventilation. Mean LOS for individuals in the ward, ICU without invasive mechanical ventilation and ICU with invasive mechanical ventilation was 12.8 (standard deviation [SD] 15.4), 8.5 (SD 7.8) and 20.5 (SD 18.1) days, respectively. Among patients receiving care in the ward, ICU without invasive mechanical ventilation and ICU with invasive mechanical ventilation, 911/3834 (23.8%), 124/418 (29.7%) and 287/635 (45.2%) died, respectively. All outcomes varied by age and decreased over time, overall and within age groups.

Interpretation: This descriptive study shows use of acute care and mortality varying by age and decreasing between March and September 2020 in Ontario. Improvements in clinical practice and changing risk distributions among those infected may contribute to fewer severe outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.9778/cmajo.20200323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096409PMC
April 2021

Health care costs associated with chronic hepatitis C virus infection in Ontario, Canada: a retrospective cohort study.

CMAJ Open 2021 Jan-Mar;9(1):E167-E174. Epub 2021 Mar 8.

School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (Wong, Haines, Bremner, Sander, Thein, Krahn), University Health Network; ICES Central (Wong, Yao, Calzavara, Kwong, Sander); Dalla Lana School of Public Health (Mitsakakis, Kwong, Sander, Thein) and Department of Family and Community Medicine (Kwong), University of Toronto; Public Health Ontario (Kwong, Sander), Toronto, Ont.

Background: High-quality estimates of health care costs are required to understand the burden of illness and to inform economic models. We estimated the costs associated with hepatitis C virus (HCV) infection from the public payer perspective in Ontario, Canada.

Methods: In this population-based retrospective cohort study, we identified patients aged 18-105 years diagnosed with chronic HCV infection in Ontario from 2003 to 2014 using linked administrative data. We allocated the time from diagnosis until death or the end of follow-up (Dec. 31, 2016) to 9 mutually exclusive health states using validated algorithms: no cirrhosis, no cirrhosis (RNA negative) (i.e., cured HCV infection), compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, both decompensated cirrhosis and hepatocellular carcinoma, liver transplantation, terminal (liver-related) and terminal (non-liver-related). We estimated direct medical costs (in 2018 Canadian dollars) per 30 days per health state and used regression models to identify predictors of the costs.

Results: We identified 48 239 patients with chronic hepatitis C, of whom 30 763 (63.8%) were men and 35 891 (74.4%) were aged 30-59 years at diagnosis. The mean 30-day costs were $798 (95% confidence interval [CI] $780-$816) ( = 43 568) for no cirrhosis, $661 (95% CI $630-$692) ( = 6422) for no cirrhosis (RNA negative), $1487 (95% CI $1375-$1599) ( = 4970) for compensated cirrhosis, $3659 (95% CI $3279-$4039) ( = 3151) for decompensated cirrhosis, $4238 (95% CI $3480-$4996) ( = 550) for hepatocellular carcinoma, $8753 (95% CI $7130-$10 377) ( = 485) for both decompensated cirrhosis and hepatocellular carcinoma, $4539 (95% CI $3746-$5333) ( = 372) for liver transplantation, $11 202 (95% CI $10 645-$11 760) ( = 3201) for terminal (liver-related) and $8801 (95% CI $8331-$9271) ( = 5278) for terminal (non-liver-related) health states. Comorbidity was the most significant predictor of total costs for all health states.

Interpretation: Our findings suggest that the financial burden of HCV infection is substantially higher than previously estimated in Canada. Our comprehensive, up-to-date cost estimates for clinically defined health states of HCV infection should be useful for future economic evaluations related to this disorder.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.9778/cmajo.20200162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034296PMC
July 2021

Viral hepatitis C cascade of care: A population-level comparison of immigrant and long-term residents.

Liver Int 2021 08 19;41(8):1775-1788. Epub 2021 Apr 19.

Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background & Aims: Viral hepatitis C represents a major global burden, particularly among immigrant-receiving countries such as Canada, where knowledge of disparities in hepatitis C virus among immigrant groups for micro-elimination efforts is lacking. We quantify the hepatitis C cascades of care among immigrants and long-term residents prior to the introduction of direct-acting antiviral medications.

Methods: Using laboratory and health administrative records, we described the hepatitis C virus cascades of care in terms of diagnosis, engagement with care, treatment initiation, and clearance in Ontario, Canada (1997-2014). We stratified the cascade by immigrant and long-term resident groups and identify drivers at each stage using multivariable Poisson regression.

Results: We included 940 245 individuals in the study with an estimated hepatitis C prevalence of 167 923 (1.4%) overall, 23 759 (0.7%) among all immigrants, and 6019 (1.1%) among immigrants from hepatitis C endemic countries. Overall there were 104 616 individuals with reactive antibody results, 73 861 tested for viral RNA, 52 388 with viral RNA detected, 50 805 genotyped, 13 159 on treatment and 3919 with evidence of viral clearance. Compared to long-term residents, immigrants showed increased nucleic-acid testing (aRR: 1.09 [95%CI: 1.08, 1.10]), treatment initiation (aRR: 1.46 [95%CI: 1.38, 1.54]), and higher clearance rates (aRR: 1.07 [95%CI: 1.03, 1.11]).

Conclusions: Hepatitis C virus is more prevalent among long-term residents compared to immigrants overall, however, immigrants from endemic countries are an important subgroup to consider for future screening and linkage to care initiatives. These findings are prior to the introduction of newer medications and provide a population-based benchmark for follow-up studies and evaluation of treatment programs and surveillance activities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/liv.14840DOI Listing
August 2021

Estimating healthcare resource needs for COVID-19 patients in Nigeria.

Pan Afr Med J 2020 2;37:293. Epub 2020 Dec 2.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Introduction: continuous assessment of healthcare resources during the COVID-19 pandemic will help in proper planning and to prevent an overwhelming of the Nigerian healthcare system. In this study, we aim to predict the effect of COVID-19 on hospital resources in Nigeria.

Methods: we adopted a previously published discrete-time, individual-level, health-state transition model of symptomatic COVID-19 patients to the Nigerian healthcare system and COVID-19 epidemiology in Nigeria by September 2020. We simulated different combined scenarios of epidemic trajectories and acute care capacity. Primary outcomes included the expected cumulative number of cases, days until depletion resources and the number of deaths associated with resource constraints. Outcomes were predicted over a 60-day time horizon.

Results: in our best-case epidemic trajectory, which implies successful implementation of public health measures to control COVID-19 spread, assuming all three resource scenarios, hospital resources would not be expended within the 60-days time horizon. In our worst-case epidemic trajectory, assuming conservative resource scenario, only ventilated ICU beds would be depleted after 39 days and 16 patients were projected to die while waiting for ventilated ICU bed. Acute care resources were only sufficient in the three epidemic trajectory scenarios when combined with a substantial increase in healthcare resources.

Conclusion: substantial increase in hospital resources is required to manage the COVID-19 pandemic in Nigeria, even as the infection growth rate declines. Given Nigeria's limited health resources, it is imperative to focus on maintaining aggressive public health measures as well as increasing hospital resources to reduce COVID-19 transmission further.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.11604/pamj.2020.37.293.26017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881931PMC
March 2021

Comment empêcher le SRAS-CoV-2 d’entrer dans les écoles.

CMAJ 2021 02;193(5):E198-E199

Centre hospitalier pour enfants de l'est de l'Ontario (Thampi); Département de pédiatrie (Thampi), Université d'Ottawa, Ottawa, Ontario; Toronto Health Economics and Technology Assessment Collaborative (Sander), Réseau universitaire de santé; Institut des politiques, de la gestion et de l'évaluation de la santé (Sander), Université de Toronto; Hôpital SickKids (Science); Département de pédiatrie (Science), Université de Toronto, Toronto, Ontario.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.202568-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954569PMC
February 2021

Health-related quality of life of patients with HIV/AIDS at a tertiary care teaching hospital in Ethiopia.

Health Qual Life Outcomes 2021 Jan 19;19(1):24. Epub 2021 Jan 19.

Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Patients' health-related quality of life (HRQoL) and health state utility values are critical inputs in the clinical and economic evaluation of treatments for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). However, information on health state utility values is lacking in the context of Ethiopia. Here, we aimed to assess HRQoL and determine health state utility values and factors that influence the values among HIV/AIDS patients in Ethiopia.

Methods: A cross-sectional study was conducted among 511 HIV/AIDS patients at Tikur Anbessa Specialized Hospital in Ethiopia. Patients aged 18 years or older were eligible for the interview and those who were mentally unstable and with hearing impairment were excluded from the study. We performed face-to-face interviews using EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) in combination with EuroQol-Visual Analog Scales (EQ-VAS). Level-specific disutility coefficients obtained from the general population were used for computing utility values. Patients' health profiles were described using percentages and different statistical analysis were conducted to determine factors associated with the EQ-5D index and EQ-VAS scores.

Results: A total of 511 patients participated in the study. A higher proportion of patients reported slight or more severe problems on the anxiety/depression (55.2%) and pain/discomfort (51.3%) dimensions. The overall median utility value of HIV/AIDS patients was 0.94 (IQR = 0.87, 1) from the EQ-5D index and 80% (IQR = 70%, 90%) from the EQ-VAS scores. Demographic characteristics including age, occupational status, and household monthly income significantly affected patient's utility values. Moreover, statistically significant (p < 0.001) differences were seen between the EQ-5D index values of patients with different CD4 count intervals. Furthermore, number of medicines that the patients were taking at the time of the study and comorbidities were significantly associated with the EQ-5D utility index and EQ-VAS score, p < 0.001.

Conclusions: The anxiety/depression and pain/ discomfort dimensions were identified to have critical influence in reducing the HRQoL of adult HIV/AIDS patients in the context of Ethiopia. The study is also the first to use the EQ-5D-5L tool to identify health state utility values for Ethiopian adult HIV/AIDS patients. Future economic evaluations of HIV/AIDS interventions are encouraged to employ the identified utility values.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12955-021-01670-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816449PMC
January 2021

COVID-19: Adaptation of a model to predicting healthcare resources needs in Valle del Cauca, Colombia.

Colomb Med (Cali) 2020 Sep 30;51(3):e204534. Epub 2020 Sep 30.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.

Background: Valle del Cauca is the region with the fourth-highest number of COVID-19 cases in Colombia (>50,000 on September 7, 2020). Due to the lack of anti-COVID-19 therapies, decision-makers require timely and accurate data to estimate the incidence of disease and the availability of hospital resources to contain the pandemic.

Methods: We adapted an existing model to the local context to forecast COVID-19 incidence and hospital resource use assuming different scenarios: (1) the implementation of quarantine from September 1 to October 15 (average daily growth rate of 2%); (2-3) partial restrictions (at 4% and 8% growth rates); and (4) no restrictions, assuming a 10% growth rate. Previous scenarios with predictions from June to August were also presented. We estimated the number of new cases, diagnostic tests required, and the number of available hospital and intensive care unit (ICU) beds (with and without ventilators) for each scenario.

Results: We estimated 67,700 cases by October 15 when assuming the implementation of a quarantine, 80,400 and 101,500 cases when assuming partial restrictions at 4% and 8% infection rates, respectively, and 208,500 with no restrictions. According to different scenarios, the estimated demand for reverse transcription-polymerase chain reaction tests ranged from 202,000 to 1,610,600 between September 1 and October 15. The model predicted depletion of hospital and ICU beds by September 20 if all restrictions were to be lifted and the infection growth rate increased to 10%.

Conclusion: Slowly lifting social distancing restrictions and reopening the economy is not expected to result in full resource depletion by October if the daily growth rate is maintained below 8%. Increasing the number of available beds provides a safeguard against slightly higher infection rates. Predictive models can be iteratively used to obtain nuanced predictions to aid decision-making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.25100/cm.v51i3.4534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744107PMC
September 2020

Modeling the coronavirus disease 2019 pandemic: A comprehensive guide of infectious disease and decision-analytic models.

J Clin Epidemiol 2021 04 7;132:133-141. Epub 2020 Dec 7.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Canada; Public Health Ontario, Toronto, Canada; ICES, Toronto, Canada. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jclinepi.2020.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837043PMC
April 2021

Fangcang shelter hospitals during the COVID-19 epidemic, Wuhan, China.

Bull World Health Organ 2020 Dec 29;98(12):830-841D. Epub 2020 Sep 29.

Centre for Disease Modelling, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada.

Objective: To design models of the spread of coronavirus disease-2019 (COVID-19) in Wuhan and the effect of Fangcang shelter hospitals (rapidly-built temporary hospitals) on the control of the epidemic.

Methods: We used data on daily reported confirmed cases of COVID-19, recovered cases and deaths from the official website of the Wuhan Municipal Health Commission to build compartmental models for three phases of the COVID-19 epidemic. We incorporated the hospital-bed capacity of both designated and Fangcang shelter hospitals. We used the models to assess the success of the strategy adopted in Wuhan to control the COVID-19 epidemic.

Findings: Based on the 13 348 Fangcang shelter hospitals beds used in practice, our models show that if the Fangcang shelter hospitals had been opened on 6 February (a day after their actual opening), the total number of COVID-19 cases would have reached 7 413 798 (instead of 50 844) with 1 396 017 deaths (instead of 5003), and the epidemic would have lasted for 179 days (instead of 71).

Conclusion: While the designated hospitals saved lives of patients with severe COVID-19, it was the increased hospital-bed capacity of the large number of Fangcang shelter hospitals that helped slow and eventually stop the COVID-19 epidemic in Wuhan. Given the current global pandemic of COVID-19, our study suggests that increasing hospital-bed capacity, especially through temporary hospitals such as Fangcang shelter hospitals, to isolate groups of people with mild symptoms within an affected region could help curb and eventually stop COVID-19 outbreaks in communities where effective household isolation is not possible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2471/BLT.20.258152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716094PMC
December 2020

Economic burden of epilepsy in children: A population-based matched cohort study in Canada.

Epilepsia 2021 01 30;62(1):152-162. Epub 2020 Nov 30.

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.

Objective: The economic burden of childhood epilepsy to the health care system remains poorly understood. This study aimed to determine phase-specific and cumulative long-term health care costs in children with epilepsy (CWE) from the health care payer perspective.

Methods: This cohort study utilized linked health administrative databases in Ontario, Canada. Incident childhood epilepsy cases were identified from January 1, 2003 to June 30, 2017. CWE were matched to children without epilepsy (CWOE) on age, sex, rurality, socioeconomic status, and comorbidities, and assigned prediagnosis, initial, ongoing, and final care phase based on clinical trajectory. Phase-specific, 1-year and 5-year cumulative health care costs, attributable costs of epilepsy, and distribution of costs across different ages were evaluated.

Results: A total of 24 411 CWE were matched to CWOE. The costs were higher for prediagnosis and initial care than ongoing care in CWE. Hospitalization was the main cost component. The costs of prediagnosis, initial, and ongoing care were higher in CWE than CWOE, with the attributable costs at $490 (95% confidence interval [CI] = $352-$616), $1322 (95% CI = $1247-$1402), and $305 (95% CI = $276-$333) per 30 patient-days, respectively. Final care costs were lower in CWE than CWOE, with attributable costs at -$2515 (95% CI = -$6288 to $961) per 30 patient-days. One-year and 5-year cumulative costs were higher in CWE ($14 776 [95% CI = $13 994-$15 546] and $39 261 [95% CI = $37 132-$41 293], respectively) than CWOE ($6152 [95% CI = $5587-$6768] and $15 598 [95% CI = $14 291-$17 006], respectively). The total health care costs were highest in the first year of life in CWE for prediagnosis, initial, and ongoing care.

Significance: Health care costs varied along the continuum of epilepsy care, and were mainly driven by hospitalization costs. The findings identified avenues for remediation, such as enhancing care around the time of epilepsy diagnosis and better care coordination for epilepsy and comorbidities, to reduce hospitalization costs and the economic burden of epilepsy care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/epi.16775DOI Listing
January 2021

Preventing the introduction of SARS-CoV-2 into school settings.

CMAJ 2021 01 24;193(1):E24-E25. Epub 2020 Nov 24.

Children's Hospital of Eastern Ontario (Thampi); Department of Pediatrics (Thampi), University of Ottawa, Ottawa, Ont.; Toronto Health Economics and Technology Assessment Collaborative (Sander), University Health Network; Institute of Health Policy, Management and Evaluation (Sander), University of Toronto; The Hospital for Sick Children (Science); Department of Pediatrics (Science), University of Toronto, Toronto, Ont.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.202568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774472PMC
January 2021

Estimation de l’épuisement des ressources hospitalières attribuable à la COVID-19 en Ontario, au Canada.

CMAJ 2020 11;192(46):E1474-E1481

Institut des politiques, de la gestion et de l'évaluation de la santé (K. Barrett, Y. Khan, S. Mac, D. Naimark, B. Sander), Université de Toronto; Réseau universitaire de santé (K. Barrett, Y. Khan, R. Ximenes); Toronto Health Economics and Technology Assessment (THETA) collaborative (S. Mac, R. Ximenes, B. Sander), Réseau universitaire de santé; Hôpital Sunnybrook (D. Naimark), Toronto, Ont.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.200715-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682993PMC
November 2020

Point-of-care diagnostic tests for influenza in the emergency department: A cost-effectiveness analysis in a high-risk population from a Canadian perspective.

PLoS One 2020 16;15(11):e0242255. Epub 2020 Nov 16.

Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada.

Background: Our objective was to assess the cost-effectiveness of novel rapid diagnostic tests: rapid influenza diagnostic tests (RIDT), digital immunoassays (DIA), rapid nucleic acid amplification tests (NAAT), and other treatment algorithms for influenza in high-risk patients presenting to hospital with influenza-like illness (ILI).

Methods: We developed a decision-analytic model to assess the cost-effectiveness of diagnostic test strategies (RIDT, DIA, NAAT, clinical judgement, batch polymerase chain reaction) preceding treatment; no diagnostic testing and treating everyone; and not treating anyone. We modeled high-risk 65-year old patients from a health payer perspective and accrued outcomes over a patient's lifetime. We reported health outcomes, quality-adjusted life years (QALYs), healthcare costs, and net health benefit (NHB) to measure cost-effectiveness per cohort of 100,000 patients.

Results: Treating everyone with no prior testing was the most cost-effective strategy, at a cost-effectiveness threshold of $50,000/QALY, in over 85% of simulations. This strategy yielded the highest NHB of 15.0344 QALYs, but inappropriately treats all patients without influenza. Of the novel rapid diagnostics, NAAT resulted in the highest NHB (15.0277 QALYs), and the least number of deaths (1,571 per 100,000). Sensitivity analyses determined that results were most impacted by the pretest probability of ILI being influenza, diagnostic test sensitivity, and treatment effectiveness.

Conclusions: Based on our model, treating high-risk patients presenting to hospital with influenza-like illness, without performing a novel rapid diagnostic test, resulted in the highest NHB and was most cost-effective. However, consideration of whether treatment is appropriate in the absence of diagnostic confirmation should be taken into account for decision-making by clinicians and policymakers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242255PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668582PMC
January 2021

Neoadjuvant Versus Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A Microsimulation Model.

Clin Genitourin Cancer 2021 04 13;19(2):e135-e147. Epub 2020 Oct 13.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Background: Upper tract urothelial carcinoma (UTUC) is clinically understudied, and there are no definitive recommendations regarding timing of perioperative chemotherapy. The objective of this study was to compare 3 treatment pathways in UTUC: nephroureterectomy (NU) alone, neoadjuvant chemotherapy (NAC), and adjuvant chemotherapy (AC) using a microsimulation model.

Patients And Methods: An individual-level state transition model was constructed using TreeAgePro software to compare treatment strategies for patients with newly diagnosed UTUC. The base case was that of a 70-year-old patient with a radiographically localized upper tract tumor. Primary outcome was quality-adjusted life expectancy. Secondary outcomes included crude overall survival, rates of adverse events, and bladder cancer diagnoses.

Results: A total of 100,000 patients were simulated. NAC was preferred, with an estimated quality-adjusted life expectancy of 7.50 years versus 6.79 years with NU alone and 7.23 years with AC. Median crude overall survival was 123 months with NAC, 96 months with NU only, and 111 months with AC. Overall, 40.0% of patients in the AC group with invasive pathology completed chemotherapy. In the NAC group, 83.3% of patients completed chemotherapy. In the NAC group, 37.5% of patients experienced an adverse chemotherapy event compared to 15.1% of patients in the AC group. Bladder cancer recurrence rates were 64.9%, 65.9%, and 67.4% over the patient's lifetime for the NU, NAC, and AC strategies, respectively.

Conclusion: This study supports the increased use of NAC in UTUC until robust randomized trials are completed. The ultimate choice should be based on patient and tumor factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clgc.2020.10.001DOI Listing
April 2021

Cost-Effectiveness Analysis of Motion-Preserving Operations for Wrist Arthritis.

Plast Reconstr Surg 2020 11;146(5):588e-598e

From the Division of Plastic and Reconstructive Surgery and the Institute of Health Policy, Management, and Evaluation, University of Toronto; Toronto Health Economics and Technology Assessment Collaborative, Toronto General Hospital; and Sunnybrook Health Sciences Centre.

Background: The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective?

Methods: A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime.

Results: The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion.

Conclusions: The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000007260DOI Listing
November 2020

A Web Application About Herd Immunity Using Personalized Avatars: Development Study.

J Med Internet Res 2020 10 30;22(10):e20113. Epub 2020 Oct 30.

Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada.

Background: Herd immunity or community immunity refers to the reduced risk of infection among susceptible individuals in a population through the presence and proximity of immune individuals. Recent studies suggest that improving the understanding of community immunity may increase intentions to get vaccinated.

Objective: This study aims to design a web application about community immunity and optimize it based on users' cognitive and emotional responses.

Methods: Our multidisciplinary team developed a web application about community immunity to communicate epidemiological evidence in a personalized way. In our application, people build their own community by creating an avatar representing themselves and 8 other avatars representing people around them, for example, their family or coworkers. The application integrates these avatars in a 2-min visualization showing how different parameters (eg, vaccine coverage, and contact within communities) influence community immunity. We predefined communication goals, created prototype visualizations, and tested four iterative versions of our visualization in a university-based human-computer interaction laboratory and community-based settings (a cafeteria, two shopping malls, and a public library). Data included psychophysiological measures (eye tracking, galvanic skin response, facial emotion recognition, and electroencephalogram) to assess participants' cognitive and affective responses to the visualization and verbal feedback to assess their interpretations of the visualization's content and messaging.

Results: Among 110 participants across all four cycles, 68 (61.8%) were women and 38 (34.5%) were men (4/110, 3.6%; not reported), with a mean age of 38 (SD 17) years. More than half (65/110, 59.0%) of participants reported having a university-level education. Iterative changes across the cycles included adding the ability for users to create their own avatars, specific signals about who was represented by the different avatars, using color and movement to indicate protection or lack of protection from infectious disease, and changes to terminology to ensure clarity for people with varying educational backgrounds. Overall, we observed 3 generalizable findings. First, visualization does indeed appear to be a promising medium for conveying what community immunity is and how it works. Second, by involving multiple users in an iterative design process, it is possible to create a short and simple visualization that clearly conveys a complex topic. Finally, evaluating users' emotional responses during the design process, in addition to their cognitive responses, offers insights that help inform the final design of an intervention.

Conclusions: Visualization with personalized avatars may help people understand their individual roles in population health. Our app showed promise as a method of communicating the relationship between individual behavior and community health. The next steps will include assessing the effects of the application on risk perception, knowledge, and vaccination intentions in a randomized controlled trial. This study offers a potential road map for designing health communication materials for complex topics such as community immunity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/20113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665952PMC
October 2020

Prenatal hepatitis B screening, and hepatitis B burden among children, in Ontario: a descriptive study.

CMAJ 2020 Oct;192(43):E1299-E1305

Viral Hepatitis Care Network Study Group/Toronto Centre for Liver Disease (Biondi, Mandel, Shah, Capraru, Janssen, Feld), University Health Network, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Public Health Ontario Laboratory (Marchand-Austin, Cronin, Ravirajan, Goneau, Mazzulli), Toronto, Ont.; National Microbiology Laboratory (Cronin), Public Health Agency of Canada, Winnipeg, Man.; Public Health Ontario (Nanwa, Ravirajan, Sander); ICES Central (Nanwa, Sander); Sinai Health System/University Health Network (Mazzulli); Institute of Medical Sciences (Feld), University of Toronto, Toronto, Ont.

Background: Ontario is 1 of 5 provinces that immunize adolescents for hepatitis B virus (HBV), despite the World Health Organization recommendation for universal birth dose vaccination. One rationale for not vaccinating at birth is that universal prenatal screening and related interventions prevent vertical transmission. The aims of our study were to evaluate the uptake and epidemiology of prenatal HBV screening, and to determine the number of children in Ontario with a diagnosis of HBV before adolescent vaccination.

Methods: We extracted data from ICES, Public Health Ontario and Better Outcomes & Registry Network (BORN) Ontario databases. We assessed prenatal screening uptake and prevalence of prenatal hepatitis B surface antigen (HBsAg) from 2012 to 2016, as well as subsequent hepatitis B e-antigen (HBeAg) and HBV DNA testing and percent positivity. We used age and region to subcategorize the results. In a separate unlinked analysis, we evaluated the number of children positive for HBV aged 0-11 years who were born in Ontario from 2003 to 2013.

Results: From 2012 to 2016, 93% of pregnant women were screened for HBV, with an HBsAg prevalence of 0.6%. Prevalence of HBsAg increased with age, peaking at older than 45 years at 3%. North Toronto had the highest overall prevalence of 1.5%, whereas northern Ontario had the lowest. Of women who were HBsAg positive, HBeAg and HBV DNA tests were subsequently ordered in 13% and 38%, respectively. Of children born in Ontario between 2003 and 2013, 139 of 23 759 tested positive for HBV.

Interpretation: Prenatal HBV screening is not universal and subsequent evaluation is poor, limiting optimal intervention and possibly contributing to some Ontario-born children being given a diagnosis of HBV before age 12 years. These findings underscore the limitations of the province's adolescent vaccination strategy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.200290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577574PMC
October 2020

Peri-complication diagnosis of hepatitis C infection: Risk factors and trends over time.

Liver Int 2021 01;41(1):33-47

Department of Medicine, University of Toronto, Toronto, ON, Canada.

Background & Aims: Hepatitis C virus (HCV) is a common and treatable cause of cirrhosis and its complications, yet many chronically infected individuals remain undiagnosed until a late stage. We sought to identify the frequency of and risk factors for HCV diagnosis peri-complication, that is within six months of an advanced liver disease complication.

Methods: This was a retrospective cohort study of Ontario residents diagnosed with chronic HCV infection between 2003 and 2014. HCV diagnosis peri-complication was defined as the occurrence of decompensated cirrhosis, hepatocellular carcinoma or liver transplant within ±6 months of HCV diagnosis. Multivariable logistic regression was used to identify risk factors for peri-complication diagnosis among all those diagnosed with HCV infection.

Results: Our cohort included 39,515 patients with chronic HCV infection, of whom 4.2% (n = 1645) were diagnosed peri-complication; these represented 31.6% of the 5,202 patients who developed complications in the follow-up period. Peri-complication diagnosis became more common over the study period and was associated with increasing age among baby boomers, alcohol use, diabetes mellitus, chronic HBV co-infection and moderate to high levels of morbidity. Female sex, immigrant status, having more previous outpatient physician visits, a previous emergency department visit, a history of drug use or mental health visits were associated with reduced risk of peri-complication diagnosis.

Conclusions: Over a quarter of HCV-infected patients with complications were diagnosed peri-complication. This problem increased over time, suggesting a need to further expand HCV screening.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/liv.14670DOI Listing
January 2021

Diagnosis of Chronic Hepatitis B Pericomplication: Risk factors and Trends Over Time.

Hepatology 2021 Jun 15;73(6):2141-2154. Epub 2021 Jun 15.

Department of Medicine, University of Toronto, Toronto, ON, Canada.

Background And Aims: Hepatitis B virus (HBV) is a major cause of chronic liver disease, which can progress to cirrhosis, hepatocellular carcinoma, and death. A timely diagnosis allows for antiviral treatment, which can prevent liver-related complications. Conversely, a late diagnosis signals a missed opportunity for earlier care and treatment. Our objective was to measure the proportion of chronic HBV diagnoses that are made within 6 months of presentation with a liver disease-related complication and examine associated factors and trends over time.

Approach And Results: We used provincial laboratory data to identify patients with chronic HBV diagnosed from 2003 to 2014. We measured the proportion who experienced a liver disease complication (decompensated cirrhosis, hepatocellular carcinoma, or liver transplant) within ±6 months of their HBV diagnosis date. A multivariable logistic regression model was used to identify factors associated with HBV diagnosis pericomplication. Of 18,434 patients with chronic HBV, 1,279 (6.9%) developed an HBV-related complication during the follow-up period. Among these, 570 (44.6%) had a first diagnosis pericomplication. HBV diagnosis pericomplication did not decrease over time and was independently associated with older age at HBV diagnosis, rural residence, alcohol use, and moderate to high levels of comorbidity. Female patients, immigrants, and those with more outpatient physician visits were less likely to have an HBV diagnosis pericomplication.

Conclusions: A high proportion of patients with HBV-related complications are first diagnosed with HBV pericomplication. These signal missed opportunities for earlier detection and treatment. Our findings support expansion of HBV screening.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hep.31557DOI Listing
June 2021

Costs Associated with Nontuberculous Mycobacteria Infection, Ontario, Canada, 2001-2012.

Emerg Infect Dis 2020 09;26(9):2097-2107

To determine incidence-based healthcare costs attributable to nontuberculous mycobacterial (NTM) pulmonary disease (PD) and NTM pulmonary isolation (PI), from the healthcare payer perspective, we conducted a population-based matched cohort study in Ontario, Canada. We established cohorts of patients with incident NTM-PD and NTM-PI during 2001-2012 by using individually linked laboratory data and health administrative data, matched to unexposed persons from the general population. To estimate attributable costs for acute and long-term illness, we used a phase-of-care approach. Costs were stratified by age, sex, and healthcare resource, and reported in 2018 Canadian dollars (CAD) and US dollars (USD), standardized to 10 days. Costs were highest during the before-death phase (NTM-PD CAD $1,352 [USD $1,044]; NTM-PI CAD $731 [USD $565]). The cumulative mean attributable 1-year costs were CAD $14,953 (USD $11,541) for NTM-PD and CAD $8,729 (USD $6,737) for NTM-PI. Costs for patients with NTM-PD and NTM-PI were higher than those for unexposed persons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3201/eid2609.190524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454113PMC
September 2020
-->