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Biomedical subjects

A Laupacis

Publications and source records attributed to A Laupacis.

At least 19 recordsLinked to original sources
PubMed1995

Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group.

OBJECTIVE: To assess the feasibility and impact of introducing the Ottawa ankle rules to a large number of physicians in a wide variety of hospital and community settings over a prolonged period of time. DESIGN: Multicentre before and after controlled clinical trial. SETTING: Emergency departments of eight teaching and community hospitals in Canadian communities (population 10,000 to 3,000,000). SUBJECTS: All 12,777 adults (6288 control, 6489 intervention) seen with acute ankle injuries during two 12 month periods before and after the intervention. INTERVENTION: More than 200 physicians of varying experience were taught to order radiography according to the Ottawa ankle rules. MAIN OUTCOME MEASURES: Referral for ankle and foot radiography. RESULTS: There were significant reductions in use of ankle radiography at all eight hospitals and within a priori subgroups: for all hospitals combined 82.8% control v 60.9% intervention(P < 0.001); for community hospitals 86.7% v 61.7%; (P < 0.001); for teaching hospitals 77.9% v 59.9%; (P < 0.001); for emergency physicians 82.1% v 61.6%; (P < 0.001); for family physicians 84.3% v 60.1%; (P < 0.001); and for housestaff 82.3% v 60.1%; (P < 0.001). Compared with patients without fracture who had radiography during the intervention period those who had no radiography spent less time in the emergency department (54.0 v 86.9 minutes; P < 0.001) and had lower medical charges ($70.20 v $161.60; P < 0.001). There was no difference in the rate of fractures diagnosed after discharge from the emergency department (0.5 v 0.4%). CONCLUSIONS: Introduction of the Ottawa ankle rules proved to be feasible in a large variety of hospital and community settings. Use of the rules over a prolonged period of time by many physicians of varying experience led to a decrease in ankle radiography, waiting times, and costs without an increased rate of missed fractures. The multiphase methodological approach used to develop and implement these rules may be applied to other clinical problems.

Ankle Injuries↗
PubMed1995

Research by collaboration.

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Antineoplastic Combined Chemotherapy Protocols↗
PubMed1995

Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications.

The prevalence of atrial fibrillation (AF) is related to age. Anticoagulation is highly effective in preventing stroke in patients with AF, but the risk of hemorrhage may be increased in older patients. We reviewed the available epidemiologic data to define the age and sex distribution of people with AF. From four large recent population-based surveys, we estimated the overall age- and gender-specific prevalence of AF. These estimates were applied to the recent US census data to calculate the number of men and women with AF in each age group. There are an estimated 2.2 million people in the United States with AF, with a median age of about 75 years. The prevalence of AF is 2.3% in people older than 40 years and 5.9% in those older than 65 years. Approximately 70% of individuals with AF are between 65 and 85 years of age. The absolute number of men and women with AF is about equal. After age 75 years, about 60% of the people with AF are women. In contrast to people with AF in the general population, patients with AF in recent anticoagulation trials had a mean age of 69 years, and only 20% were older than 75 years. The risks and benefits of antithrombotic therapy in older individuals are important considerations in stroke prevention in AF.

Adult↗
PubMed1995

Cost-effectiveness analysis of the Ottawa Ankle Rules.

STUDY OBJECTIVE: To conduct an incremental cost-effectiveness analysis of implementation of the Ottawa Ankle Rules in emergency departments in the United States and Canada. DESIGN: A decision analytic approach to technology assessment. Clinical decision rules that allow physicians to be more selective in their use of radiography were compared with current practice in a decision analytic model. SETTING: A university hospital adult ED. PARTICIPANTS: ED physicians instructed in the use of the Ottawa Ankle Rules for adult patients with ankle injury. RESULTS: Radiography, waiting time, lost productivity, and medicolegal costs were calculated. In the United States, the savings varied between US$614,226 and US$3,145,910 per 100,000 patients, depending on the charge rate for radiography. In Ontario, Canada, the total savings were CAN$730,145 per 100,000 patients. One- and two-way sensitivity analyses that varied the rate of missed fractures, cost of radiography, probability of lawsuits, and cost of lawsuits did not change the results substantially. CONCLUSION: Implementation of the Ottawa Ankle Rules would result in significant savings of health care dollars despite the cost of missed fractures including litigation costs.

Adult↗
PubMed1995

The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation.

PURPOSE: To develop a conceptual tool for the systematic development of cancer treatment practice guidelines. MATERIALS AND METHODS: The guidelines development tool, the Practice Guidelines Development Cycle, was derived from observing an evidence-based practice guidelines initiative at a comprehensive cancer center in Ontario, Canada, and from a literature review that uncovered barriers to guidelines development and implementation. Based on the literature findings and direct observations of how clinicians struggled with evidence-based guidelines development, we evolved a framework to incorporate clinical and administrative factors (eg, costs) into evidence-based guidelines. Use of the Practice Guidelines Development Cycle is illustrated with a clinical example (the use of adjuvant systemic therapy in good-risk, node-negative premenopausal breast cancer patients). RESULTS: The result is the Practice Guidelines Development Cycle, which consists of eight sequential steps, from topic selection to policy formulation. Independent validation of guidelines is included. The cycle products are the evidence-based recommendation, the practice guideline, and the practice policy. The main features of the cycle are emphasis on scientific evidence, acknowledgment of the roles of clinical experience and nonclinical (administrative) factors through consensus, and explicit separation of clinical and cost considerations in guidelines development. Twenty guidelines are currently in development. CONCLUSION: Attention to the barriers of guidelines development and the sociocultural nature of clinical practice, and respect for clinical experience, can lead to improved strategies for guidelines development.

Cancer Care Facilities↗
PubMed1995

Total hip replacement: the case for noncemented femoral fixation because of age.

Both noncemented fixation and improved cemented fixation of total hip replacements emerged to counteract the clinical and radiographic failures of early cemented procedures. A randomized clinical trial comparing a second-generation cemented with a second-generation noncemented total hip replacement demonstrated that in the medium term both implants allow excellent, disease-specific, global and functional capacity outcome measures. No significant differences existed between the cemented and noncemented implants in terms of these parameters or revision rate. Cost-to-utility analyses of both types of replacements revealed that total hip replacement is one of the most cost-effective medical interventions. Noncemented total hip replacements seem as efficacious as cemented devices in patients younger than 70 years.

Adolescent↗
PubMed1994

Low-dose cyclosporine for the treatment of Crohn's disease. The Canadian Crohn's Relapse Prevention Trial Investigators.

BACKGROUND: Long-term corticosteroid therapy for Crohn's disease is associated with important types of morbidity, such as osteoporosis. Safe and effective alternative treatments are required. Although a short-term benefit of cyclosporine in active Crohn's disease has been suggested, the long-term safety and efficacy of this treatment have not been established. METHODS: We conducted a randomized, double-blind, placebo-controlled evaluation of the effect of 18 months of low-dose cyclosporine treatment on the course of Crohn's disease. Adult patients whose disease had been active within the previous two years were randomly assigned to receive cyclosporine (151 patients) or placebo (154 patients) in addition to their usual therapy. Randomization was stratified according to center and score on the Crohn's Disease Activity Index (193 patients had scores of 150 or less, and 112 had scores greater than 150). The primary outcome measure was clinically important worsening of Crohn's disease, defined as a 100-point increase in the Crohn's Disease Activity Index from the patient's base-line value. Secondary outcomes were the use of prednisone and 5-amino-salicylates, mean score on the Crohn's Disease Activity Index and mean quality-of-life score, and the need for surgery. RESULTS: The condition of more patients worsened with cyclosporine than with placebo (91 of 151, or 60.3 percent, vs. 80 of 154, or 51.9 percent; P = 0.10). The median time to worsening of disease in patients receiving cyclosporine was 338 days, as compared with 492 days in patients receiving placebo (P = 0.25; relative risk, 1.22; 95 percent confidence interval, 0.86 to 1.72). Analyses of the mean Crohn's Disease Activity Index and quality-of-life scores and of the use of prednisone and 5-aminosalicylates also failed to demonstrate benefit. CONCLUSIONS: In our patient population, the addition of low-dose cyclosporine to conventional treatment for Crohn's disease did not improve symptoms or reduce requirements for other forms of therapy.

Adult↗
PubMed1994

Hard to swallow test.

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Cerebrovascular Disorders↗
PubMed1994

Costs of elective total hip arthroplasty during the first year. Cemented versus noncemented.

The cost-effectiveness of the Mallory Head (Biomet, Warsaw, IN) cemented versus noncemented total hip arthroplasty was determined as part of a randomized trial. Costs were assessed during the first postoperative year. In-hospital resource use was determined using a chart review of 60 randomly selected patients. Costs were determined using a fully allocated costing model. Outpatient resource use was determined using patient diaries, and appropriate costs were allocated for outpatient visits, admissions to hospital, and patient-borne costs. There was no difference in costs between the cemented and noncemented prostheses. The average cost of the initial hospitalization was $9,990 (1988 Canadian dollars), and outpatient costs during the first year were $1,137 (total cost during the first year was $11,127). The cost per quality adjusted life year was $27,139 during the first year and $8,031 during the first 3 years.

Ambulatory Care↗
PubMed1994

A meta-analysis of prophylactic endoscopic sclerotherapy for esophageal varices.

OBJECTIVES: A number of randomized clinical trials of prophylactic sclerotherapy have been carried out with different results. The main objective of this study was to determine if the literature provides evidence that prophylactic sclerotherapy increases the survival rate of patients with esophageal varices. METHODS: Meta-analysis was used to evaluate the effect of prophylactic sclerotherapy on the survival of patients with esophageal varices. Only randomized controlled trials that compared prophylactic sclerotherapy to placebo were included. RESULTS: Fourteen fully published randomized controlled trials, as well as six trials published as abstracts, were identified in the English literature. Pooling of the 14 fully published trials yielded an odds ratio of death in the treatment group compared with the control group of 0.74 (95% confidence interval, 0.60-0.93) in favor of prophylactic sclerotherapy. There was statistically significant heterogeneity that resolved when the trials were pooled in subgroups based on the sclerosant used. Pooling of trials using polidocanol showed a highly significant benefit for prophylactic sclerotherapy in terms of overall mortality, particularly when those trials that selected subjects at high risk of bleeding were pooled, yielding an odds ratio of 0.51 (95% confidence interval, 0.36-0.73). When trials using sodium tetradecyl sulfate were pooled, a detrimental effect for prophylactic sclerotherapy was seen, with an odds ratio of 1.86 (95% confidence interval, 1.15-3.00). Subgroup analysis by Child's class showed no benefit for patients in Child's class A. CONCLUSION: These results suggest that prophylactic sclerotherapy with polidocanol is effective, particularly in high-risk patients.

Endoscopy, Gastrointestinal↗
PubMed1994

A double-blind study of 250 cases comparing cemented with cementless total hip arthroplasty. Cost-effectiveness and its impact on health-related quality of life.

The success of a total hip arthroplasty (THA) is dependent on many more parameters than simply the prosthesis used. This study has demonstrated that a randomized controlled clinical trial of 250 patients comparing two types of hip prostheses (cemented versus cementless) with virtually complete follow-up examination is feasible. It also demonstrates that patients are willing to answer extensive quality-of-life questionnaires that allow complete assessment of the impact of hip arthroplasty on the patient's overall health-related quality of life. This study has also demonstrated that THA is an extremely effective intervention when one assesses its ability to impact on patients health-related quality of life with no difference between cement versus cementless at two years' follow-up examination.

Activities of Daily Living↗