Publications by authors named "John Matelski"

41 Publications

A Protocol for a Pan-Canadian Prospective Observational Study on Active Surveillance or Surgery for Very Low Risk Papillary Thyroid Cancer.

Front Endocrinol (Lausanne) 2021 10;12:686996. Epub 2021 Jun 10.

Department of Otolaryngology and Head and Neck Surgery, University Health Network and University of Toronto, Toronto, ON, Canada.

Background: The traditional management of papillary thyroid cancer (PTC) is thyroidectomy (total or partial removal of the thyroid). Active surveillance (AS) may be considered as an alternative option for small, low risk PTC. AS involves close follow-up (including regularly scheduled clinical and radiological assessments), with the intention of intervening with surgery for disease progression or patient preference.

Methods: This is a protocol for a prospective, observational, long-term follow-up multi-centre Canadian cohort study. Consenting eligible adults with small, low risk PTC (< 2cm in maximal diameter, confined to the thyroid, and not immediately adjacent to critical structures in the neck) are offered the choice of AS or surgery for management of PTC. Patient participants are free to choose either option (AS or surgery) and the disease management course is thus not assigned by the investigators. Surgery is provided as usual care by a surgeon in an institution of the patient's choice. Our primary objective is to determine the rate of 'failure' of disease management in respective AS and surgical arms as defined by: i) AS arm - surgery for progression of PTC, and ii) surgical arm - surgery or other treatment for disease persistence or progression after completing initial treatment. Secondary outcomes include long-term thyroid oncologic and treatment outcomes, as well as patient-reported outcomes.

Discussion: The results from this study will provide long-term clinical and patient reported outcome evidence regarding active surveillance or immediate surgery for management of small, low risk PTC. This will inform future clinical trials in disease management of small, low risk papillary thyroid cancer.

Registration Details: This prospective observational cohort study is registered on clinicaltrials.gov (NCT04624477), but it should not be considered a clinical trial as there is no assigned intervention and patients are free to choose either AS or surgery.
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http://dx.doi.org/10.3389/fendo.2021.686996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237853PMC
June 2021

Impact of Minimally Invasive Gynaecology Fellowship Training on Quality Performance Metrics for Hysterectomy.

J Obstet Gynaecol Can 2021 Jun 18. Epub 2021 Jun 18.

Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON.

Objective: To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists.

Methods: Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH).

Results: Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P < 0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P < 0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P < 0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits.

Conclusion: Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.
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http://dx.doi.org/10.1016/j.jogc.2021.05.017DOI Listing
June 2021

Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis.

Fertil Steril 2021 Jun 12. Epub 2021 Jun 12.

Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada. Electronic address:

Objective: To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management.

Design: Systematic review and meta-analysis.

Setting: Not applicable.

Patient(s): Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references.

Intervention(s): Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above.

Main Outcome Measure(s): Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion).

Result(s): The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%-90.4%), GnRH-a (89.3%; 99% CI, 71.4%-96.5%) and methotrexate (90.0%; 99% CI, 55.8%-98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%-26.8%) and GnRH-a (10.7%; 99% CI, 3.5%-28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM.

Conclusion(s): Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.
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http://dx.doi.org/10.1016/j.fertnstert.2021.05.095DOI Listing
June 2021

Developing a business case for a regional anesthesia block room: up with efficiency, down with costs.

Reg Anesth Pain Med 2021 May 12. Epub 2021 May 12.

Anesthesiology and Pain Medicine, Sinai Health, Toronto, Ontario, Canada

Background: Regional anesthesia techniques offer many benefits for total joint arthroplasty (TJA) patients. However, they require personnel and equipment resources, as well as valuable operating room (OR) time. A block room offers a dedicated environment to perform regional anesthesia procedures while potentially offsetting costs.

Methods: The goal of this prospective quality improvement study was to develop a business case for implementation of a regional anesthesia block room and to demonstrate the cost-effectiveness of this program in decreasing OR time for TJA. All elective TJA patients presenting between January 2019 and March 2020 were included in our analysis.

Results: Our detailed business plan was approved by the hospital leadership. 561 patients in the preintervention group and 432 in the postintervention group were included for data analysis. Mean total OR time per surgical case decreased from 166 to 143 min for a difference of 23 min (95% CI 17 to 29). Similarly, anesthesia controlled OR time decreased from 46 min to 26 min for a difference of 20 min (95% CI 17 to 22). The block room resulted in an additional primary TJA case per daily OR list. The percentage of TJA patients receiving a peripheral nerve block increased from 63.1% to 87.0% (p<0.001). No safety events or block room associated OR delays were observed.

Conclusion: Implementing a regional anesthesia block room required a comprehensive business plan for securing the necessary resources to support the program. The regional anesthesia block room is a cost-effective method to improve patient care and OR efficiency.
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http://dx.doi.org/10.1136/rapm-2021-102545DOI Listing
May 2021

Utilization Rates of Pancreatectomy, Radical Prostatectomy, and Nephrectomy in New York, Ontario, and New South Wales, 2011 to 2018.

JAMA Netw Open 2021 04 1;4(4):e215477. Epub 2021 Apr 1.

Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Importance: Few studies have compared surgical utilization between countries or how rates may differ according to patients' socioeconomic status.

Objective: To compare population-level utilization of 3 common nonemergent surgical procedures in New York State (US), Ontario (Canada), and New South Wales (Australia) and how utilization differs for residents of lower- and higher-income neighborhoods.

Design, Setting, And Participants: This cohort study included all adults aged 18 years and older who were hospitalized for pancreatectomy, radical prostatectomy, or nephrectomy between 2011 and 2016 in New York, between 2011 and 2018 in Ontario, and between 2013 and 2018 in New South Wales. Each patient's address of residence was linked to 2016 census data to ascertain neighborhood income. Data were analyzed from August 2019 to November 2020.

Main Outcomes And Measures: Primary outcomes were (1) each jurisdiction's per capita age- and sex-standardized utilization rates (procedures per 100 000 residents per year) for each surgery and (2) utilization rates among residents of lower- and higher-income neighborhoods.

Results: This study included 115 428 surgical patients (25 780 [22.3%] women); 5717, 21 752, and 24 617 patients in New York were hospitalized for pancreatectomy, radical prostatectomy, and nephrectomy, respectively; 4929, 19 125, and 16 916 patients in Ontario, respectively; and 2069, 13 499, and 6804 patients in New South Wales, respectively. Patients in New South Wales were older for all procedures (eg, radical prostatectomy, mean [SD] age in New South Wales, 64.8 [7.3] years; in New York, 62.7 [8.4] years; in Ontario, 62.8 [6.7] years; P < .001); patients in New York were more likely than those in other locations to be women for pancreatectomy (New York: 2926 [51.2%]; Ontario: 2372 [48.1%]; New South Wales, 1003 [48.5%]; P = .004) and nephrectomy (New York: 10 645 [43.2%]; Ontario: 6529 [38.6%]; 2605 [38.3%]; P < .001). With the exception of nephrectomy in Ontario, there was a higher annual utilization rate for all procedures in all jurisdictions among patients residing in affluent neighborhoods (quintile 5) compared with poorer neighborhoods (quintile 1). This difference was largest in New South Wales for pancreatectomy (4.65 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and radical prostatectomy (73.46 additional procedures per 100 000 residents [SE, 1.20]; P < .001); largest in New York for nephrectomy (8.43 additional procedures per 100 000 residents [SE, 0.85]; P < .001) and smallest in New York for radical prostatectomy (19.70 additional procedures per 100 000 residents [SE, 2.63]; P < .001); and smallest in Ontario for pancreatectomy (1.15 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and nephrectomy (-1.10 additional procedures per 100 000 residents [SE, 0.52]; P < .001). New York had the highest utilization of nephrectomy (28.93 procedures per 100 000 residents per year [SE, 0.18]) and New South Wales for had the highest utilization of pancreatectomy and radical prostatectomy (6.94 procedures per 100 000 residents per year [SE, 0.15] and 94.37 procedures per 100 000 residents per year [SE, 0.81], respectively; all P < .001). Utilization was lowest in Ontario for all procedures (pancreatectomy, 6.18 procedures per 100 000 residents per year [SE, 0.09]; radical prostatectomy, 49.24 procedures per 100 000 residents per year [SE, 0.36]; nephrectomy, 21.40 procedures per 100 000 residents per year [SE, 0.16]; all P < .001).

Conclusions And Relevance: In this study, New York and New South Wales had higher per capita surgical utilization and larger neighborhood income-utilization gradients than Ontario. These findings suggest that income-based disparities are larger in the United States and Australia and smaller in Canada and highlight trade-offs inherent in the health care systems of different countries.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.5477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056282PMC
April 2021

Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation.

BMC Health Serv Res 2021 Apr 17;21(1):361. Epub 2021 Apr 17.

Toronto General Hospital Research Institute, University Health Network, Toronto, Canada.

Background: Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process.

Methods: Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations.

Results: Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p < 0.001) and discussion of help needed (6% increase, p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant.

Conclusions: This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.
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http://dx.doi.org/10.1186/s12913-021-06374-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052788PMC
April 2021

Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study.

J Arthroplasty 2021 03 8;36(3):837-844. Epub 2020 Oct 8.

Granovsky Gluskin Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Background: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle.

Methods: This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education.

Results: The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030).

Conclusion: Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.arth.2020.09.054DOI Listing
March 2021

Utilisation and outcomes of allogeneic hematopoietic cell transplantation in Ontario, Canada, and New York State, USA: a population-based retrospective cohort study.

BMJ Open 2020 10 31;10(10):e039293. Epub 2020 Oct 31.

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Objective: Allogeneic haematopoietic cell transplantation (HCT) is a potentially curative treatment for haematologic and oncologic diseases. There is a perception that the United States of America (USA) offers greater access to expensive therapies such as HCT. Alternatively, Canada is thought to suffer from protracted wait times, but lower spending. Our objective was to compare HCT utilisation and short-term outcomes in Ontario (ON), Canada, and New York State (NY), USA.

Design, Setting And Participants: We conducted a population-based cohort study using administrative health data to identify all residents of ON and NY who underwent allogeneic HCT between 2012 and 2015.

Primary And Secondary Outcome Measures: The primary outcome measures were age and sex standardised HCT utilisation rates, in-hospital mortality, hospital length of stay (LOS) and readmission rates in ON and NY. Secondary outcomes included comparing ON and NY HCT recipients with respect to demographic characteristics and patient wealth (using neighbourhood income quintile).

Results: We identified 547 HCT procedures in ON and 1361 HCT procedures performed in NY. HCT recipients in ON were younger than NY (mean age 49.0 vs 51.6 years; p<0.001) and a lower percentage of ON recipients resided in affluent neighbourhoods compared with NY (47.2% vs 52.6%; p=0.026). Utilisation of HCT was 14.4 per 1 million population per year in ON and 26.7 per 1 million per year in NY (p<0.001). The magnitude of the ON-NY difference in utilisation was larger for older patients. In-hospital mortality, LOS and readmission rates were lower in ON than NY in both unadjusted and adjusted analyses.

Conclusions: We found significantly lower utilisation of HCT in ON compared with NY, particularly among older patients. Higher in-hospital mortality in NY relative to ON requires further study. These differences are thought provoking for patients, healthcare providers and policy-makers in both jurisdictions.
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http://dx.doi.org/10.1136/bmjopen-2020-039293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783612PMC
October 2020

Retrograde Bladder Filling after Laparoscopic Gynecologic Surgery: A Double-blind Randomized Controlled Trial.

J Minim Invasive Gynecol 2021 05 3;28(5):1006-1012.e1. Epub 2020 Oct 3.

Department of Obstetrics and Gynecology, Mount Sinai Hospital (Drs. Zakhari, Paek, Chan, Edwards, Solnik, and Murji); Department of Obstetrics & Gynecology, University of Toronto (Drs. Zakhari, Paek, Chan, Edwards, Solnik, and Murji). Electronic address:

Study Objective: To evaluate whether retrofilling the bladder on completion of elective laparoscopic gynecologic surgery for benign indications has an effect on the timing of the first postoperative void and the timing of discharge from the hospital.

Design: Double-blind randomized controlled trial.

Setting: Single academic surgical day hospital.

Patients: Patients undergoing outpatient laparoscopic gynecologic surgery, excluding hysterectomy or pelvic reconstructive surgery.

Interventions: On completion of surgery, patients were randomized to either retrograde filling of the bladder with 200 mL of saline before catheter removal or standard care (immediate catheter removal). Patients and postanesthesia care unit nurses (outcome assessors) were both blinded.

Measurements And Main Results: The primary outcome was the time to first void. The secondary outcomes were time to hospital discharge, postoperative urinary tract infection, and patient satisfaction. Over a 3-month period, 47 patients were approached on the day of surgery, 42 consented and were randomized (21 to intervention and 21 to control). There were no significant differences in baseline demographics between the groups. The median time to first void was significantly shorter for patients in the intervention arm than controls (104 ± 75 minutes vs 162 ± 76 minutes, p <.001). Patients who had retrofilled bladders were discharged faster from post-anesthesia care unit compared to controls (155.0 ± 74 minutes vs 227 ± 58 minutes, p = .001). There were no urinary tract infections in either group, and the proportion of satisfied or very satisfied patients was high (93.8% vs 88.2%, p = .512).

Conclusion: Retrograde filling of the bladder after outpatient laparoscopic gynecologic surgery is a safe, effective method that significantly reduces the length of hospital stay.
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http://dx.doi.org/10.1016/j.jmig.2020.09.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532349PMC
May 2021

Comparing the Effects of Tidal Volume, Driving Pressure, and Mechanical Power on Mortality in Trials of Lung-Protective Mechanical Ventilation.

Respir Care 2021 Feb 25;66(2):221-227. Epub 2020 Aug 25.

Interdepartmenal Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.

Background: The unifying goal of lung-protective ventilation strategies in ARDS is to minimize the strain and stress applied by mechanical ventilation to the lung to reduce ventilator-induced lung injury (VILI). The relative contributions of the magnitude and frequency of mechanical stress and the end-expiratory pressure to the development of VILI is unknown. Consequently, it is uncertain whether the risk of VILI is best quantified in terms of tidal volume (V), driving pressure (ΔP), or mechanical power.

Methods: The correlation between differences in V, ΔP, and mechanical power and the magnitude of mortality benefit in trials of lung-protective ventilation strategies in adult subjects with ARDS was assessed by meta-regression. Modified mechanical power was computed including PEEP (Power), excluding PEEP (Power), and using ΔP (Power). The primary analysis incorporated all included trials. A secondary subgroup analysis was restricted to trials of lower versus higher PEEP strategies.

Results: We included 9 trials involving 4,731 subjects in the analysis. Odds ratios for moderation derived from meta-regression showed that variations in V, ΔP, and Power were associated with increased mortality with odds ratios of 1.24 (95% CI 1.03-1.49), 1.31 (95% CI 1.03-1.66), and 1.37 (95% CI 1.05-1.78), respectively. In trials comparing higher versus lower PEEP strategies, Power was increased in the higher PEEP arm (24 ± 1.7 vs 20 ± 1.5 J/min, respectively), whereas the other parameters were not affected on average by a higher PEEP ventilation strategy.

Conclusions: In trials of lung-protective ventilation strategies, V, ΔP, Power, Power, and Power exhibited similar moderation of treatment effect on mortality. In this study, modified mechanical power did not add important information on the risk of death from VILI in comparison to V or ΔP.
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http://dx.doi.org/10.4187/respcare.07876DOI Listing
February 2021

Tacrolimus Impairs Kupffer Cell Capacity to Control Bacteremia: Why Transplant Recipients Are Susceptible to Infection.

Hepatology 2021 May 30;73(5):1967-1984. Epub 2021 Mar 30.

Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada.

Background And Aims: Kupffer cells (KCs) are the resident intravascular phagocyte population of the liver and critical to the capture and killing of bacteria. Calcineurin/nuclear factor of activated T cells (NFAT) inhibitors (CNIs) such as tacrolimus are used to prevent rejection in solid organ transplant recipients. Although their effect on lymphocytes has been studied extensively, there are limited experimental data about if and how CNIs shape innate immunity, and whether this contributes to the higher rates of infection observed in patients taking CNIs.

Approach And Results: Here, we investigated the impact of tacrolimus treatment on innate immunity and, more specifically, on the capability of Kupffer cells (KCs) to fight infections. Retrospective analysis of data of >2,700 liver transplant recipients showed that taking calcineurin inhibitors such as tacrolimus significantly increased the likelihood of Staphylococcus aureus infection. Using a mouse model of acute methicillin-resistant S. aureus (MRSA) bacteremia, most bacteria were sequestered in the liver and we found that bacteria were more likely to disseminate and kill the host in tacrolimus-treated mice. Using imaging, we unveiled the mechanism underlying this observation: the reduced capability of KCs to capture, phagocytose, and destroy bacteria in tacrolimus-treated animals. Furthermore, in a gene expression analysis of infected KCs, the triggering receptor expressed on myeloid cells 1 (TREM1) pathway was the one with the most significant down-regulation after tacrolimus treatment. TREM1 inhibition likewise inhibited KC bacteria capture. TREM1 levels on neutrophils as well as the overall neutrophil response after infection were unaffected by tacrolimus treatment.

Conclusions: Our results indicate that tacrolimus treatment has a significant impact directly on KCs and on TREM1, thereby compromising their capacity to fend off infections.
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http://dx.doi.org/10.1002/hep.31499DOI Listing
May 2021

Dienogest and the Risk of Endometriosis Recurrence Following Surgery: A Systematic Review and Meta-analysis.

J Minim Invasive Gynecol 2020 Nov - Dec;27(7):1503-1510. Epub 2020 May 16.

Department of Obstetrics and Gynecology, McGill University Health Center, Montreal, QC, Canada (Drs. Zakhari, Edwards, and Murji). Electronic address:

Study Objective: To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management.

Data Sources: Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials.

Methods Of Study Selection: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as "dienogest," "endometriosis," and "recurrence" were used to identify relevant studies.

Tabulation, Integration, And Results: The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43-3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66-31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds -1.96, CI, -2.53 to -1.38, p <.001).

Conclusion: Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.
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http://dx.doi.org/10.1016/j.jmig.2020.05.007DOI Listing
February 2021

Peer outreach point-of-care testing as a bridge to hepatitis C care for people who inject drugs in Toronto, Canada.

Int J Drug Policy 2020 06 14;80:102755. Epub 2020 May 14.

Michael Garron Hospital, 825 Coxwell Ave, Toronto, ON M4C 3E7, Canada. Electronic address:

Background: People who inject drugs have high rates of hepatitis C (HCV) and yet many remain undiagnosed and untreated. HCV treatment guidelines and elimination strategies recommend task-shifting to expand where, and by whom, HCV testing and care is delivered.

Methods: A randomized controlled trial design was used to evaluate if point-of-care (POC) HCV antibody testing by peer outreach workers outside of health and social service spaces would improve engagement in HCV care. People with a lifetime history of injection drug use without prior knowledge of HCV antibody status were randomized to receive HCV outreach plus either POC or referral to community-based HCV program for testing as usual. The study was co-designed by people with lived experience of HCV.

Results: 920 people were approached to participate over 14 weeks. After refusals, withdrawals and removal of duplicates, there were 380 study participants. Outreach took place primarily in public spaces (66%) such as parks, coffee shops and apartment lobbies. Participants reported very high rates of poverty, housing instability and recent injection drug use. Despite being at high risk for HCV, 61% had no history or knowledge of past HCV testing (n = 230). Of those who received a POC test 77/195 (39%) were positive for HCV antibodies. There was no change in rates of engagement in HCV care among those who received the POC (n = 6; 3%) compared to those who did not (n = 5; 3%).

Conclusion: Peer outreach workers were able to efficiently reach a marginalized group of individuals who had a high HCV antibody prevalence and low rates of prior HCV testing. This improved participants' knowledge of their HCV antibody status, but that knowledge in itself did not lead to any change in participant's subsequent engagement in HCV care. Future work is required to evaluate strategies such as incentives or peer navigators to improve linkage to HCV care after diagnosis.
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http://dx.doi.org/10.1016/j.drugpo.2020.102755DOI Listing
June 2020

Association Between Web-Based Physician Ratings and Physician Disciplinary Convictions: Retrospective Observational Study.

J Med Internet Res 2020 05 14;22(5):e16708. Epub 2020 May 14.

Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.

Background: Physician rating websites are commonly used by the public, yet the relationship between web-based physician ratings and health care quality is not well understood.

Objective: The objective of our study was to use physician disciplinary convictions as an extreme marker for poor physician quality and to investigate whether disciplined physicians have lower ratings than nondisciplined matched controls.

Methods: This was a retrospective national observational study of all disciplined physicians in Canada (751 physicians, 2000 to 2013). We searched ratings (2005-2015) from the country's leading online physician rating website for this group, and for 751 matched controls according to gender, specialty, practice years, and location. We compared overall ratings (out of a score of 5) as well as mean ratings by the type of misconduct. We also compared ratings for each type of misconduct and punishment.

Results: There were 62.7% (471/751) of convicted and disciplined physicians (cases) with web-based ratings and 64.6% (485/751) of nondisciplined physicians (controls) with ratings. Of 312 matched case-control pairs, disciplined physicians were rated lower than controls overall (3.62 vs 4.00; P<.001). Disciplined physicians had lower ratings for all types of misconduct and punishment-except for physicians disciplined for sexual offenses (n=90 pairs; 3.83 vs 3.86; P=.81). Sexual misconduct was the only category in which mean ratings for physicians were higher than those for other disciplined physicians (3.63 vs 3.35; P=.003).

Conclusions: Physicians convicted for disciplinary misconduct generally had lower web-based ratings. Physicians convicted of sexual misconduct did not have lower ratings and were rated higher than other disciplined physicians. These findings may have future implications for the identification of physicians providing poor-quality care.
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http://dx.doi.org/10.2196/16708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256745PMC
May 2020

Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events.

BMJ Qual Saf 2020 11 9;29(11):932-938. Epub 2020 Mar 9.

Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada.

Background: Human auditing has been the gold standard for evaluating hand hygiene (HH) compliance but is subject to the Hawthorne effect (HE), the change in subjects' behaviour due to their awareness of being observed. For the first time, we used electronic HH monitoring to characterise the duration of the HE on HH events after human auditors have left the ward.

Methods: Observations were prospectively conducted on two transplant wards at a tertiary centre between May 2018 and January 2019. HH events were measured using the electronic GOJO Smartlink Activity Monitoring System located throughout the ward. Non-covert human auditing was conducted in 1-hour intervals at random locations on both wards on varying days of the week. Two adjusted negative binomial regression models were fit in order to estimate an overall auditor effect and a graded auditor effect.

Results: In total, 365 674 HH dispensing events were observed out of a possible 911 791 opportunities. In the adjusted model, the presence of an auditor increased electronic HH events by approximately 2.5-fold in the room closest to where the auditor was standing (9.86 events per hour/3.98 events per hour; p<0.01), an effect sustained across only the partial hour before and after the auditor was present but not beyond the first hour after the auditor left. This effect persisted but was attenuated in areas distal from the auditor (total ward events of 6.91*6.32-7.55, p<0.01). Additionally, there was significant variability in the magnitude of the HE based on temporal and geographic distribution of audits.

Conclusion: The HE on HH events appears to last for a limited time on inpatient wards and is highly dynamic across time and auditor location. These findings further challenge the validity and value of human auditing and support the need for alternative and complementary monitoring methods.
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http://dx.doi.org/10.1136/bmjqs-2019-010310DOI Listing
November 2020

Airway Oscillometry Detects Spirometric-Silent Episodes of Acute Cellular Rejection.

Am J Respir Crit Care Med 2020 06;201(12):1536-1544

Division of Respirology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Acute cellular rejection (ACR) is common during the initial 3 months after lung transplant. Patients are monitored with spirometry and routine surveillance transbronchial biopsies. However, many centers monitor patients with spirometry only because of the risks and insensitivity of transbronchial biopsy for detecting ACR. Airway oscillometry is a lung function test that detects peripheral airway inhomogeneity with greater sensitivity than spirometry. Little is known about the role of oscillometry in patient monitoring after a transplant. To characterize oscillometry measurements in biopsy-proven clinically significant (grade ≥2 ACR) in the first 3 months after a transplant. We enrolled 156 of the 209 double lung transplant recipients between December 2017 and March 2019. Weekly outpatient oscillometry and spirometry and surveillance biopsies at Weeks 6 and 12 were conducted at our center. Of the 138 patients followed for 3 or more months, 15 patients had 16 episodes of grade 2 ACR (AR2) and 44 patients had 64 episodes of grade 0 ACR (AR0) rejection associated with stable and/or improving spirometry. In 15/16 episodes of AR2, spirometry was stable or improving in the weeks leading to transbronchial biopsy. However, oscillometry was markedly abnormal and significantly different from AR0 ( < 0.05), particularly in integrated area of reactance and the resistance between 5 and 19 Hz, the indices of peripheral airway obstruction. By 2 weeks after biopsy, after treatment for AR2, oscillometry in the AR2 group improved and was similar to the AR0 group. Oscillometry identified physiological changes associated with AR2 that were not discernible by spirometry and is useful for graft monitoring after a lung transplant.
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http://dx.doi.org/10.1164/rccm.201908-1539OCDOI Listing
June 2020

Utilization of Advanced Cardiovascular Therapies in the United States and Canada: An Observational Study of New York and Ontario Administrative Data.

Circ Cardiovasc Qual Outcomes 2020 01 20;13(1):e006037. Epub 2020 Jan 20.

Department of Medicine (P.C., D.S.L., D.T.K.), University of Toronto, ON.

Background: Endovascular aortic aneurysm repair (EVAR), left ventricular assist device (LVAD), and transcatheter aortic valve replacement (TAVR) are expensive cardiovascular technologies with potential to benefit large numbers of patients. There are few population-based studies comparing utilization between countries. Our objective was to compare patient characteristics and utilization patterns of EVAR, LVAD, and TAVR in Ontario, Canada, and New York State, United States.

Methods And Results: We performed a retrospective cohort study using administrative data to identify all adults who received EVAR, LVAD, or TAVR in Ontario and New York between 2012 and 2015. We compared socio-demographics of EVAR, LVAD, and TAVR recipients in Ontario and New York. We compared standardized utilization rates between jurisdictions for each procedure. We identified 3295 EVAR recipients from Ontario and 6236 from New York (mean age 74.6 versus 74.5 years; =0.61): 136 LVAD recipients from Ontario and 686 from New York (age, 57.4 versus 57.7 years; =0.80): 1708 TAVR recipients from Ontario and 4838 from New York (age, 83.1 versus 83.1; =1.0). A significantly smaller percentage of EVAR and TAVR recipients in Ontario were female compared to New York (EVAR, 15.8% versus 22.1% female; <0.001; TAVR, 45.9% versus 51.8%; <0.001), but for LVAD the percentage female was similar (21.3% versus 20.8%; =0.99). Utilization was significantly higher in New York for all procedures: EVAR (12.8 procedures per-100 000 adults per-year in Ontario, 20.2 in New York; <0.001); LVAD (0.3 in Ontario versus 1.3 in New York; <0.001); and TAVR (6.6 in Ontario, 14.3 in New York; <0.001). Higher utilization of EVAR and TAVR in New York relative to Ontario increased substantially with increasing age.

Conclusions: We observed significantly higher utilization of EVAR, LVAD, and TAVR in New York compared to Ontario. Our results highlight important differences in how 2 different countries are using advanced cardiovascular therapies.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.006037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006709PMC
January 2020

Self-reported test ordering practices among Canadian internal medicine physicians and trainees: a multicenter cross-sectional survey.

BMC Health Serv Res 2019 Nov 8;19(1):820. Epub 2019 Nov 8.

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

Background: Over-testing is a recognized problem, but clinicians usually lack information about their personal test ordering volumes. In the absence of data, clinicians rely on self-perception to inform their test ordering practices. In this study we explore clinician self-perception of diagnostic test ordering intensity.

Methods: We conducted a cross-sectional survey of inpatient General Internal Medicine (GIM) attending physicians and trainees at three Canadian teaching hospitals. We collected information about: self-reported test ordering intensity, perception of colleagues test ordering intensity, and importance of clinical utility, patient comfort, and cost when ordering tests. We compared responses of clinicians who self-identified as high vs low utilizers of diagnostic tests, and attending physicians vs trainees.

Results: Only 15% of inpatient GIM clinicians self-identified as high utilizers of diagnostic tests, while 73% felt that GIM clinicians in aggregate ("others") order too many tests. Survey respondents identified clinical utility as important when choosing to order tests (selected by 94%), followed by patient comfort (48%) and cost (23%). Self-identified low/average utilizers of diagnostic tests were more likely to report considering cost compared to high utilizers (27% vs 5%, P = 0.04). Attending physicians were more likely to consider patient comfort (70% vs 41%, p = 0.01) and cost (42% vs 17%, p = 0.003) than trainees.

Conclusions: In the absence of data, providers seem to recognize that over investigation is a problem, but few self-identify as being high test utilizers. Moreover, a significant percentage of respondents did not consider cost or patient discomfort when ordering tests. Our findings highlight challenges in reducing over-testing in the current era.
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http://dx.doi.org/10.1186/s12913-019-4639-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842191PMC
November 2019

Utilization and Outcomes for Spine Surgery in the United States and Canada.

Spine (Phila Pa 1976) 2019 Oct;44(19):1371-1380

Healthcare & Outcomes Research, Arthritis Program, Krembil Research Institute, University Health Network, Toronto, ON.

Study Design: A retrospective cohort study.

Objective: The aim of this study was to examine variation in spine surgery utilization between the province of Ontario and state of New York among all patients and pre-specified patient subgroups.

Summary Of Background Data: Spine surgery is common and costly. Within-country variation in utilization is well studied, but there has been little exploration of variation in spine surgery utilization between countries.

Methods: We used population-level administrative data from Ontario (years 2011-2015) and New York (2011-2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery using relevant procedure codes. Patients were stratified according to age and surgical urgency (elective vs. emergent). We calculated standardized utilization rates (procedures per-10,000 population per year) for each jurisdiction. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared utilization rates of spinal decompression and fusion surgery in Ontario and New York among all patients and after stratifying by surgical urgency and patient age.

Results: Patients in Ontario were older than patients in New York for both decompression (mean age 58.8 vs. 51.3 years; P < 0.001) and fusion (58.1 vs. 54.9; P < 0.001). A smaller percentage of hospitals in Ontario than New York performed decompression (26.1% vs. 54.9%; P < 0.001) or fusion (15.2% vs. 56.7%; P < 0.001). Overall, utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 16.5 per-10,000 per-year (P < 0.001). Ontario-New York differences in utilization were smaller for emergent cases (2.0 per 10,000 in Ontario vs. 2.5 in New York; P < 0.001), but larger for elective cases (4.6 vs. 13.9; P < 0.001). The lower utilization in Ontario was particularly large among younger patients (age <60 years).

Conclusion: We found significantly lower utilization of spine surgery in Ontario than in New York. These differences should inform policy reforms in both jurisdictions.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746582PMC
October 2019

Age-related cytokine effects on cancer-related fatigue and quality of life in acute myeloid leukemia.

J Geriatr Oncol 2020 04 10;11(3):402-409. Epub 2019 May 10.

Department of Psychiatry, University Health Network, Toronto, Canada.

Objectives: We determined whether cytokines are a potential target to improve cancer-related fatigue (CRF) and quality of life (QOL) in acute myeloid leukemia (AML).

Methods: 219 patients age 18+ undergoing intensive chemotherapy for AML were assessed at up to 4 time points (pre-treatment, 1 month, 6 months, 12 months). CRF and QOL were assessed with validated patient-reported outcome measures with minimum clinically important differences (MCID) of 4 and 10 points, respectively. A panel of 31 plasma cytokines was measured. CRF and QOL were regressed against scaled cytokine values, adjusting for age, gender, time, remission status, and hemoglobin in linear models.

Results: 498 cytokine samples were available. For CRF, the model R was 25.3%, with cytokines explaining 6.9% of the variance. For QOL, corresponding values were 27.9% and 7.4%, respectively. A shift from the 30th to 70th centile distribution of all cytokines was associated with an improvement in CRF by 5.2 points and a 10.2-point improvement in QOL. A shift from 5th to 95th centile in TNF-α but no other single cytokine was associated with a change of >MCID in CRF, but there was no similar association with QOL. Cytokines had greater explanatory power for CRF in older versus younger adults and the most influential cytokines differed by age, particularly TNF-α.

Conclusion: Cytokines explain a relatively small amount of CRF and QOL scores in patients with AML and effects differ by age group. For cytokine-targeted therapies to improve either outcome, multiple cytokines may need to be substantially altered and therapeutic targets may vary with age.
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http://dx.doi.org/10.1016/j.jgo.2019.04.009DOI Listing
April 2020

Hip fracture care in Manitoba, Canada and New York State, United States: an analysis of administrative data.

CMAJ Open 2019 Jan-Mar;7(1):E55-E62. Epub 2019 Feb 11.

North American Observatory on Health Systems and Policies (Cram), Institute for Health Policy, Management and Evaluation, University of Toronto; Departments of Medicine (Cram) and Surgery (Gandhi), University of Toronto; Division of General Internal Medicine and Geriatrics (Cram), Sinai Health System and University Health Network, Toronto, Ont.; Departments of Community Health Sciences (Lix, Bohm, Yan, Roos), Surgery (Bohm) and Medicine (Leslie), University of Manitoba, Winnipeg, Man.; Biostatistics Research Unit (Matelski) and Arthritis Program (Gandhi), University Health Network, Toronto, Ont.; Department of Health Care Policy (Landon), Harvard Medical School; Division of General Medicine and Primary Care (Landon), Beth Israel Deaconess Medical Center, Boston, Mass.

Background: Nearly 30 years ago, a series of studies showed increased hip fracture mortality in Manitoba compared to the United States, but these data have not been updated. Our objective was to compare the organization of hip fracture care and short-term outcomes in Manitoba and New York State using contemporary data.

Methods: This was a retrospective cohort study of administrative data for all adults aged 50 years or more admitted to hospital with hip fracture between Jan. 1, 2011, and Oct. 31, 2013 in Manitoba and New York State. We compared the 2 jurisdictions with respect to: 1) the proportion of hospitals treating hip fracture and annual hip fracture volume, 2) hospital length of stay, 3) death and 4) hospital readmission. We used descriptive statistics, univariate methods and regression models to compare differences in care between jurisdictions.

Results: We identified 2845 patients (mean age 82.2 yr, 2061 women [72.4%]) with hip fracture in Manitoba and 31 524 patients (mean age 81.9 yr, 22 973 women [72.9%]) with hip fracture in New York. A smaller proportion of hospitals in Manitoba than in New York treated hip fracture (7/30 [23%] v. 180/239 [75.3%]) ( < 0.001); the mean annual hospital hip fracture volume was higher in Manitoba (140.0) than in New York (68.9), but the difference did not reach statistical significance ( = 0.2). For patients with femoral neck fractures, the median hospital length of stay was longer in Manitoba than in New York (13 d v. 7 d). The rate of death within 7 days of admission was similar in Manitoba and New York (1.3% v. 2.0%, = 0.07), although the rate of in-hospital death was higher in Manitoba (5.7% v. 3.5%, < 0.001). Readmission within 30 days of discharge was less frequent in Manitoba than in New York (9.8% v. 12.0%, = 0.02). Results were similar for patients with intertrochanteric fractures.

Interpretation: Poor short-term outcomes for patients with hip fracture in Manitoba that were documented in the 1980s seem to have been eliminated. Our results should provide optimism that reengineering of clinical care can produce substantive improvements in quality.
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http://dx.doi.org/10.9778/cmajo.20180126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404962PMC
February 2019

Factors associated with attendance at primary care appointments after discharge from hospital: a retrospective cohort study.

CMAJ Open 2018 Oct-Dec;6(4):E587-E593. Epub 2018 Dec 3.

Department of Medicine (Lam, Abrams, Okrainec), University of Toronto; Division of General Internal Medicine (Abrams, Okrainec), University Health Network; Biostatistics Research Unit (Matelski), University Health Network, Toronto, Ont.

Background: Follow-up with a primary care provider within 1-2 weeks of discharge from hospital has been associated with reduced readmissions. We sought to determine appointment attendance with primary care providers postdischarge and identify factors associated with attendance.

Methods: We conducted a retrospective cohort study involving general medicine patients who had been discharged from hospital between Sept. 1, 2014, and Dec. 30, 2015, from 2 Ontario academic hospitals, and who had been supported by a transitional care specialist and advised to see a primary care provider within 1 week. Attendance was determined by self-report during follow-up by telephone. We used multivariable logistic regression to assess whether patient factors (e.g., comorbidity) or system factors (e.g., booking the appointment before discharge) predicted attendance. We used Cox proportional hazards modelling to assess whether attendance predicted readmission within 30 days.

Results: Of the 214 patients included in our study, 35% ( = 75) attended a primary care appointment within 1 week of discharge; 52% ( = 124) of patients attended an appointment within 2 weeks. After adjusting for age, sex and comorbidity, significant predictors of attendance were booking the appointment before discharge (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.07-4.40), familiarity with the primary care provider (OR 5.43, 95% CI 2.25-14.1) and inclusion of a reminder, callback number and appointment time in the discharge summary (OR 15.3, 95% CI 2.09-326). Predictors of nonattendance were the presence of a home support worker (OR 0.38, 95% CI 0.17-0.80) and a booked specialist appointment before discharge (OR 0.37, 95% CI 0.18-0.73). Attendance was not associated with reduced readmissions (hazard ratio 0.66, 95% CI 0.40-1.09).

Interpretation: Timely follow-up with PCPs postdischarge remains challenging. Efforts to improve attendance should focus on reinforcing need for follow-up and coordinating follow-up before discharge, particularly for those poorly connected with the health care system.
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http://dx.doi.org/10.9778/cmajo.20180069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277252PMC
December 2018

Long-Term Effects of Phased Implementation of Antimicrobial Stewardship in Academic ICUs: 2007-2015.

Crit Care Med 2019 02;47(2):159-166

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

Objectives: Antimicrobial stewardship is advocated to reduce antimicrobial resistance in ICUs by reducing unnecessary antimicrobial consumption. Evidence has been limited to short, single-center studies. We evaluated whether antimicrobial stewardship in ICUs could reduce antimicrobial consumption and costs.

Design: We conducted a phased, multisite cohort study of a quality improvement initiative.

Setting: Antimicrobial stewardship was implemented in four academic ICUs in Toronto, Canada beginning in February 2009 and ending in July 2012.

Patients: All patients admitted to each ICU from January 1, 2007, to December 31, 2015, were included.

Interventions: Antimicrobial stewardship was delivered using in-person coaching by pharmacists and physicians three to five times weekly, and supplemented with unit-based performance reports. Total monthly antimicrobial consumption (measured by defined daily doses/100 patient-days) and costs (Canadian dollars/100 patient-days) before and after antimicrobial stewardship implementation were measured.

Measurements And Main Results: A total of 239,123 patient-days (57,195 patients) were analyzed, with 148,832 patient-days following introduction of antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50 defined daily dose/100 patient-days following introduction of antimicrobial stewardship (adjusted intervention effect -12.12 defined daily dose/100 patient-days; 95% CI, -16.75 to -7.49; p < 0.001) and total antifungal use decreased from 30.53 to 27.37 defined daily doses/100 patient-days (adjusted intervention effect -3.16 defined daily dose/100 patient-days; 95% CI, -8.33 to 0.04; p = 0.05). Monthly antimicrobial costs decreased from $3195.56 to $1998.59 (adjusted intervention effect -$642.35; 95% CI, -$905.85 to -$378.84; p < 0.001) and total antifungal costs were unchanged from $1771.86 to $2027.54 (adjusted intervention effect -$355.27; 95% CI, -$837.88 to $127.33; p = 0.15). Mortality remained unchanged, with no consistent effects on antimicrobial resistance and candidemia.

Conclusions: Antimicrobial stewardship in ICUs with coaching plus audit and feedback is associated with sustained improvements in antimicrobial consumption and cost. ICUs with high antimicrobial consumption or expenditure should consider implementing antimicrobial stewardship programs.
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http://dx.doi.org/10.1097/CCM.0000000000003514DOI Listing
February 2019

Test Result Management Practices of Canadian Internal Medicine Physicians and Trainees.

J Gen Intern Med 2019 01 8;34(1):118-124. Epub 2018 Oct 8.

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

Background: Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting.

Objective: To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up.

Design: Cross-sectional survey.

Participants: General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals.

Main Measures: Methods used to track test results; satisfaction with these methods; personal encounters with results respondents "wish they had known about sooner."

Key Results: We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic "inbox") (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they "wish they had known about sooner" in the past 2 months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001).

Conclusions: Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.
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http://dx.doi.org/10.1007/s11606-018-4656-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318178PMC
January 2019

Changes in Ability of Hospitals to Provide Pricing for Total Hip Arthroplasty From 2012 to 2016.

JAMA Intern Med 2018 Aug;178(8):1132-1133

Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Mount Sinai, New York, New York.

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http://dx.doi.org/10.1001/jamainternmed.2018.1473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143109PMC
August 2018

The Characteristics of Physicians Who are Re-Disciplined by Medical Boards: A Retrospective Cohort Study.

Jt Comm J Qual Patient Saf 2018 Jun 18;44(6):361-365. Epub 2018 Apr 18.

Background: Physician misconduct adversely affects patient safety and is therefore of societal importance. Little work has specifically examined re-disciplined physicians. A study was conducted to compare the characteristics of re-disciplined to first-time disciplined physicians.

Methods: A retrospective review of Canadian physicians disciplined by medical boards between 2000 and 2015 was conducted. Physicians were divided into those disciplined once and those disciplined more than once. Differences in demographics, transgressions, and penalties were evaluated.

Results: There were 938 disciplinary events for 810 disciplined physicians with 1 in 8 (n = 101, 12.5%) being re-disciplined. Re-disciplined physicians had up to six disciplinary events in the study period and 4 (4.0%) had events in more than one jurisdiction. Among those re-disciplined, 94 (93.1%) were male, 34 (33.7%) were international medical graduates, and 88 (87.1%) practiced family medicine (n = 59, 58.4%), psychiatry (n = 11, 10.9%), surgery (n = 9, 8.9%), or obstetrics/gynecology (n = 9, 8.9%). The proportion of obstetrician/gynecologists was higher among re-disciplined physicians (8.9% vs. 4.2%, p = 0.048). Re-disciplined physicians had more mental illness (1.7% vs. 0.1%, p = 0.01), unlicensed activity (19.2% vs. 7.2%, p <0.01), and less sexual misconduct (20.1% vs. 27.9%, p = 0.02). License suspension occurred more frequently among those re-disciplined (56.8% vs. 48.0%, p = 0.02) as did license restriction (38.4% vs. 26.7%, p <0.01). License revocation was not different between cohorts (10.9% vs. 13.5%, p = 0.36).

Conclusion: Re-discipline is not uncommon and underscores the need for better identification of at-risk individuals and optimization of remediation and penalties. The distribution of transgression argues for a national disciplinary database that could improve communication between jurisdictional medical boards.
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http://dx.doi.org/10.1016/j.jcjq.2017.12.003DOI Listing
June 2018

Scope, Breadth, and Differences in Online Physician Ratings Related to Geography, Specialty, and Year: Observational Retrospective Study.

J Med Internet Res 2018 03 7;20(3):e76. Epub 2018 Mar 7.

Sinai Health System, Department of Medicine, University of Toronto, Toronto, ON, Canada.

Background: Physician ratings websites have emerged as a novel forum for consumers to comment on their health care experiences. Little is known about such ratings in Canada.

Objective: We investigated the scope and trends for specialty, geographic region, and time for online physician ratings in Canada using a national data source from the country's leading physician-rating website.

Methods: This observational retrospective study used online ratings data from Canadian physicians (January 2005-September 2013; N=640,603). For specialty, province, and year of rating, we assessed whether physicians were likely to be rated favorably by using the proportion of ratings greater than the overall median rating.

Results: In total, 57,412 unique physicians had 640,603 individual ratings. Overall, ratings were positive (mean 3.9, SD 1.3). On average, each physician had 11.2 (SD 10.1) ratings. By comparing specialties with Canadian Institute of Health Information physician population numbers over our study period, we inferred that certain specialties (obstetrics and gynecology, family practice, surgery, and dermatology) were more commonly rated, whereas others (pathology, radiology, genetics, and anesthesia) were less represented. Ratings varied by specialty; cardiac surgery, nephrology, genetics, and radiology were more likely to be rated in the top 50th percentile, whereas addiction medicine, dermatology, neurology, and psychiatry were more often rated in the lower 50th percentile of ratings. Regarding geographic practice location, ratings were more likely to be favorable for physicians practicing in eastern provinces compared with western and central Canada. Regarding year, the absolute number of ratings peaked in 2007 before stabilizing and decreasing by 2013. Moreover, ratings were most likely to be positive in 2007 and again in 2013.

Conclusions: Physician-rating websites are a relatively novel source of provider-level patient satisfaction and are a valuable source of the patient experience. It is important to understand the breadth and scope of such ratings, particularly regarding specialty, geographic practice location, and changes over time.
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http://dx.doi.org/10.2196/jmir.7475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5863010PMC
March 2018

Can Patient Selection Explain the Obesity Paradox in Orthopaedic Hip Surgery? An Analysis of the ACS-NSQIP Registry.

Clin Orthop Relat Res 2018 05;476(5):964-973

J. C. Zhang, Department of Medicine, University of Toronto, Toronto, Ontario, Canada J. Matelski, Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada R. Gandhi, Division of Orthopaedic Surgery and Krembil Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada T. Jackson, Department of Surgery, University Heath Network, University of Toronto, Toronto, Ontario, Canada R. Gandhi, T. Jackson, D. Urbach, Department of Surgery, University of Toronto, Toronto, Ontario, Canada D. Urbach, Department of Surgery, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada P. Cram, Division of General Internal Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada.

Background: The "obesity paradox" is a phenomenon described in prior research in which patients who are obese have been shown to have lower postoperative mortality and morbidity compared with normal-weight individuals. The paradox is that clinical experience suggests that obesity is a risk factor for difficult wound healing and adverse cardiovascular outcomes. We suspect that the obesity paradox may reflect selection bias in which only the healthiest patients who are obese are offered surgery, whereas nonobese surgical patients are comprised of both healthy and unhealthy individuals. We questioned whether the obesity paradox (decreased mortality for patients who are obese) would be present in nonurgent hip surgery in which patients can be carefully selected for surgery but absent in urgent hip surgery where patient selection is minimized.

Questions/purposes: (1) What is the association between obesity and postoperative mortality in urgent and nonurgent hip surgery? (2) How is obesity associated with individual postoperative complications in urgent and nonurgent hip surgery? (3) How is underweight status associated with postoperative mortality and complications in urgent and nonurgent hip surgery?

Methods: We used 2011 to 2014 data from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) to identify all adults who underwent nonurgent hip surgery (n = 63,148) and urgent hip surgery (n = 29,047). We used logistic regression models, controlling for covariants including age, sex, anesthesia risk, and comorbidities, to examine the relationship between body mass _index (BMI) category (classified as underweight < 18.5 kg/m, normal 18.5-24.9 kg/m, overweight 25-29.9 kg/m, obese 30-39.9 kg/m, and morbidly obese > 40 kg/m) and adverse outcomes including 30-day mortality and surgical complications including wound complications and cardiovascular events.

Results: For patients undergoing nonurgent hip surgery, regression models demonstrate that patients who are morbidly obese were less likely to die within 30 days after surgery (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01-0.57; p = 0.038) compared with patients with normal BMI, consistent with the obesity paradox. For patients undergoing urgent hip surgery, patients who are morbidly obese had similar odds of death within 30 days compared with patients with normal BMI (OR, 1.18; 95% CI, 0.76-1.76; p = 0.54). Patients who are morbidly obese had higher odds of wound complications in both nonurgent (OR, 4.93; 95% CI, 3.68-6.65; p < 0.001) and urgent cohorts (OR, 4.85; 95% CI, 3.27-7.01; p < 0.001) compared with normal-weight patients. Underweight patients were more likely to die within 30 days in both nonurgent (OR, 3.79; 95% CI, 1.10-9.97; p = 0.015) and urgent cohorts (OR, 1.47; 95% CI, 1.23-1.75; p < 0.001) compared with normal-weight patients.

Conclusions: Patients who are morbidly obese appear to have a reduced risk of death in 30 days after nonurgent hip surgery, but not for urgent hip surgery. Our results suggest that the obesity paradox may be an artifact of selection bias introduced by careful selection of the healthiest patients who are obese for elective hip surgery. Surgeons should continue to consider obesity a risk factor for postoperative mortality and complications such as wound infections for both urgent and nonurgent surgery.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1007/s11999.0000000000000218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916618PMC
May 2018

Utilization and Short-Term Outcomes of Primary Total Hip and Knee Arthroplasty in the United States and Canada: An Analysis of New York and Ontario Administrative Data.

Arthritis Rheumatol 2018 04 26;70(4):547-554. Epub 2018 Feb 26.

University of Toronto and Canada Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.

Objective: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are common and effective surgical procedures. This study sought to compare utilization and short-term outcomes of primary TKA and THA in adjacent regions of Canada and the United States.

Methods: The study was designed as a retrospective cohort study of patients who underwent primary TKA or THA, comparing administrative data from New York and Ontario in 2012-2013. Demographic features of the TKA and THA patients, per capita utilization rates, and short-term outcomes were compared between the jurisdictions.

Results: A higher percentage of New York hospitals performed TKA compared to Ontario hospitals (75.7% versus 42.1%; P < 0.001), and the mean annual procedural volume for TKAs was lower in New York hospitals (mean 179 versus 327 in Ontario hospitals; P < 0.001). After direct standardization, utilization was significantly lower in New York compared to Ontario, both for TKA (16.1 TKAs versus 21.4 TKAs per 10,000 population per year; P < 0.001) and for THA (10.5 THAs versus 11.5 THAs per 10,000 population per year; P < 0.001). For those who underwent TKA, the length of stay in Ontario hospitals was significantly longer (mean 3.7 days versus 3.4 days in New York hospitals; P < 0.001). A smaller percentage of New York patients were discharged directly home (46.2% versus 90.9% of Ontario patients; P < 0.001), but 30-day and 90-day readmission rates were higher in New York compared to Ontario (30-day rates, 4.6% versus 3.9% [P < 0.001]; 90-day rates, 8.4% versus 6.7% [P < 0.001]). For the THA cohorts, the results with regard to length of stay, discharge disposition, and readmission rates were similar to those for TKA.

Conclusion: Ontario has higher utilization of total joint arthroplasty than New York but has a smaller percentage of hospitals performing these procedures. Patients are more likely to be discharged home and less likely to be readmitted in Ontario. Our results suggest areas where each jurisdiction could improve.
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http://dx.doi.org/10.1002/art.40407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5876109PMC
April 2018
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