Dealing with alcoholism.
Explore the source record for details and available documents.
Alcohol Drinking↗
Biomedical subjects
Doug Coyle
Publications and source records attributed to Doug Coyle.
Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care.
PURPOSE: Most women with breast cancer are diagnosed at an early stage and more than 80% will be long-term survivors. Routine follow-up marks the transition from intensive treatment to survivorship. It is usual practice for routine follow-up to take place in specialist clinics. This study tested the hypothesis that follow-up by the patient's family physician is a safe and acceptable alternative to specialist follow-up. PATIENTS AND METHODS: A multicenter, randomized, controlled trial was conducted involving 968 patients with early-stage breast cancer who had completed adjuvant treatment, were disease free, and were between 9 and 15 months after diagnosis. Patients may have continued receiving adjuvant hormonal therapy. Patients were randomly allocated to follow-up in the cancer center according to usual practice (CC group) or follow-up from their own family physician (FP group). The primary outcome was the rate of recurrence-related serious clinical events (SCEs). The secondary outcome was health-related quality of life (HRQL). RESULTS: In the FP group, there were 54 recurrences (11.2%) and 29 deaths (6.0%). In the CC group, there were 64 recurrences (13.2%) and 30 deaths (6.2%). In the FP group, 17 patients (3.5%) compared with 18 patients (3.7%) in the CC group experienced an SCE (0.19% difference; 95% CI, -2.26% to 2.65%). No statistically significant differences (P < .05) were detected between groups on any of the HRQL questionnaires. CONCLUSION: Breast cancer patients can be offered follow-up by their family physician without concern that important recurrence-related SCEs will occur more frequently or that HRQL will be negatively affected.
Adult↗
Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.
BACKGROUND: People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle. METHODS: Subjects enrolled in MAP were dispensed alcohol on an hourly basis. Hospital charts were reviewed for all emergency department (ED) visits and admissions during the 3 years before and up to 2 years after program enrollment, and the police database was accessed for all encounters during the same periods. The results of blood tests were analyzed for trends. A questionnaire was administered to MAP participants and staff about alcohol use, health and activities of daily living before and during the program. Direct program costs were also recorded. RESULTS: Seventeen adults with an average age of 51 years and a mean duration of alcoholism of 35 years were enrolled in MAP for an average of 16 months. Their monthly mean group total of ED visits decreased from 13.5 to 8 (p = 0.004); police encounters, from 18.1 to 8.8 (p = 0.018). Changes in blood test findings were nonsignificant. All program participants reported less alcohol consumption during MAP, and subjects and staff alike reported improved hygiene, compliance with medical care and health. INTERPRETATION: A managed alcohol program for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters.
Alcoholism↗
Shelter-based palliative care for the homeless terminally ill.
BACKGROUND: The homeless have high rates of mortality, but live in environments not conducive to terminal care. Traditional palliative care hospitals may be reluctant to accept such patients, due to behavior or lifestyle concerns. The Ottawa Inner City Health Project (OICHP) is a pilot study to improve health care delivery to homeless adults. This is a retrospective analysis of a cohort of terminally ill homeless individuals and the effectiveness of shelter-based palliative care. As proof of principle, a cost comparison was performed. METHODS: 28 consecutive homeless terminally ill patients were admitted and died at a shelter-based palliative care hospice. Demographics, diagnoses at admission and course were recorded. Burden of illness was assessed by medical and psychiatric diagnoses, addictions, Karnofsky scale and symptom management. An expert panel was convened to identify alternate care locations. Using standard costing scales, direct versus alternate care costs were compared. RESULTS: 28 patients had a mean age 49 years; average length of stay 120 days. DIAGNOSES: liver disease 43%, HIV/AIDS 25%, malignancy 25% and other 8%. Addiction to drugs or alcohol and mental illness in 82% of patients. Karnofsky performance score mean 40 +/- 16.8. Pain management with continuous opiates in 71%. The majority reunited with family. Compared to alternate care locations, the hospice projected 1.39 million dollars savings for the patients described. CONCLUSION: The homeless terminally ill have a heavy burden of disease including physical illness, psychiatric conditions and addictions. Shelter-based palliative care can provide effective end-of-life care to terminally ill homeless individuals at potentially substantial cost savings.
Adult↗
Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.
STUDY OBJECTIVE: We have previously described a prospective, randomized, multicenter, clinical trial comparing the hair apposition technique, a new technique of treating scalp lacerations with tissue adhesives, with standard suturing. We found the hair apposition technique to be a better technique for closing suitable scalp lacerations. In this study, we aim to compare the cost-effectiveness of the hair apposition technique and standard suturing. METHODS: All costs related to each method were calculated, including equipment and staff time. On the basis of the previous randomized controlled trial, differential costs caused by complications were also calculated. The incremental effectiveness of the hair apposition technique was assessed in terms of complications avoided. Expected values of costs and outcomes were obtained through Monte Carlo simulation. RESULTS: The hair apposition technique was dominant over standard suturing in that it was more effective and resulted in a cost savings of USD 28.50 (95% confidence interval USD 16.30 to USD 43.40) per patient compared with standard suturing because of reduced equipment needs, shorter medical staff time required, no need for another visit to remove sutures, and lower complication rates. The probability of the hair apposition technique being both cost saving and more effective was 98.9%. CONCLUSION: The hair apposition technique is more cost-effective compared with standard suturing and could lead to large cost savings, given the common occurrence of scalp lacerations in most health systems.
Cost-Benefit Analysis↗
International Master's Program in health technology assessment and management: assessment of the first edition (2001--2003).
BACKGROUND: Despite a clear call for greater input from health technology assessment (HTA) in the areas of clinical practice and policy making, there are currently very few formal training programs. The objectives of our Consortium were to (i) develop a master's level program in HTA, (ii) test its content with a group of Canadian and European students, and (iii) evaluate the Program's strengths and weaknesses. OBJECTIVES: This study presents the results of our evaluation of the first edition of the Master's Program (2001--2003). METHODS: The evaluation relied on (i) a self-administered student questionnaire for each course (n = 142), (ii) interviews with students (n = 10), and (iii) interviews with internship supervisors (n = 5). RESULTS: A vast majority of students were satisfied with the course content and particularly appreciated the exercises and materials presented in an intensive format. However, they needed more systematic feedback from faculty members and recommended increasing the methodology content. The six key characteristics of the program are (i) flexible format adapted to the needs of skilled professionals, (ii) continuous interaction between HTA users and producers, (iii) international academic and professional collaboration, (iv) partnership with HTA agencies, (v) global approach to evidence-based methods and practices, and (vi) multidisciplinary approach. CONCLUSIONS: Despite the numerous organizational barriers inherent to creating an international program and several areas for improvement in the Program itself, the Ulysses Project was successful in attaining its objectives. Because there is a growing need for human resources with special training in HTA, further efforts need to be devoted to strengthening the international research capacity in HTA.
Canada↗
Economic evaluation of cardiac rehabilitation: a systematic review.
BACKGROUND: Economic evaluation is an important tool in the evaluation of competing healthcare interventions. Little is known about the economic benefits of different cardiac rehabilitation program delivery models. DESIGN: The goal of this study was to review and evaluate the methodological quality of published economic evaluations of cardiac rehabilitation services. METHODS: Electronic databases were searched for English language evaluations (trials, modeling studies) of the economic impact of cardiac rehabilitation. A review of study characteristics and methodological quality was completed using standardized tools. All costs are adjusted to 2004 US dollars. RESULTS: Fifteen economic evaluations were identified which met eligibility criteria but which displayed wide variation in the use of comparators, evaluation type, perspective and design. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation in myocardial infarction and heart failure patients was identified. The range of cost per life year gained was estimated as from 2193 dollars to 28,193 dollars and from - 668 dollars to 16,118 dollars per quality adjusted life year gained. The level of evidence supporting the economic value of home-based cardiac rehabilitation interventions is limited to partial economic analyses. CONCLUSIONS: Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. Further trials are required to support the cost-effectiveness of cardiac rehabilitation in cardiac patients who have under gone revascularization. The literature evaluating home-based and alternative delivery models of cardiac rehabilitation was insufficient to draw conclusions about their relative cost-effectiveness. The overall quality of published economic evaluations of cardiac rehabilitation is poor and further well-designed trials are required.
Cost-Benefit Analysis↗
Costs associated with infant bronchiolitis in the Baffin region of Nunavut.
UNLABELLED: OBJECTIVE. Although infants living in the north of Canada have been reported to have one of the highest rates of hospital admission for bronchiolitis in the world, the economic effects of this condition have not been reported. Passive immunization against the Respiratory Syncytial Virus, the most common causative agent of infant bronchiolitis, is available. METHODS: We tabulated transportation, in-hospital care and family accommodation costs for infants of less than 12 months of age residing in the Baffin Region of Nunavut aged who were admitted to Baffin Regional Hospital in Iqaluit, Nunavut, and the Children's Hospital of Eastern Ontario in Ottawa, Ontario, with a primary diagnosis of bronchiolitis or viral pneumonia, over a 36-month period, between April 1999 and March 2002. RESULTS: One hundred fifty-nine infants were admitted a total of 210 times, with 196 admissions to Baffin Regional Hospital, and 14 to the Children's Hospital of Eastern Ontario, during the study period. The overall, annual, population-based admission rate for the Baffin Region of Nunavut was 197 admissions per thousand infants per year. Total costs were $2,997,373 ($2,357,747 for Baffin Regional Hospital, $639,625 for the Children's Hospital of Eastern Ontario). Overall average costs were $14,273 per admission, $12,029 for infants admitted to Baffin Regional Hospital and $45,688 for infants admitted to the Children's Hospital of Eastern Ontario. CONCLUSIONS: Infant bronchiolitis in the Baffin Region of Nunavut represents a significant burden on the territorial health care system.
Bronchiolitis, Viral↗
Family caregiver burden: results of a longitudinal study of breast cancer patients and their principal caregivers.
BACKGROUND: The vital role played by family caregivers in supporting dying cancer patients is well recognized, but the burden and economic impact on caregivers is poorly understood. We prospectively examined the psychosocial, occupational and economic impact of caring for a person with a terminal illness. METHODS: We studied 89 caregivers of women with advanced breast cancer receiving care at either the Ottawa or Hamilton regional cancer centres in Ontario. Patients were followed until their death or study completion at 3 years. Patients identified a principal caregiver to participate in the study. The Karnofsky Performance Status (KPS) index, the Medical Outcomes Study 36-item Short Form (SF-36), the Hospital Anxiety and Depression Scale, the Zarit Burden Inventory, FAMCARE and the Medical Outcomes Study Social Support Survey were administered during follow-up. Economic data were collected by means of a questionnaire administered by an interviewer. Assessments were conducted every 3 months during the palliative period (KPS score > 50) and every 2 weeks during the terminal period (KPS score < or = 50). RESULTS: Over half of the caregivers were male (55%) and the patient's spouse or partner (52%), with a mean age of 53 years. At the start of the palliative period, the caregivers' mean physical functioning score was better than the patients' (51.3 v. 35.1, 95% confidence interval [CI] 13.3-20.0); there were similar mean mental functioning scores (46.6 and 47.1 respectively); similar proportions were depressed (11% and 12%); and significantly more caregivers than patients were anxious (35% v. 19%, p = 0.009). More caregivers were depressed (30% v. 9%, p = 0.02) and had a higher level of perceived burden (26.2 v. 19.4, p = 0.02) at the start of the terminal period than at the start of the palliative period. Burden was the most important predictor of both anxiety and depression. Of employed caregivers, 69% reported some form of adverse impact on work. In the terminal period 77% reported missing work because of caregiving responsibilities. Prescription drugs were the most important component of financial burden. INTERPRETATION: Caregivers' depression and perceived burden increase as patients' functional status declines. Strategies are needed to help reduce the psychosocial, occupational and economic burden associated with caregiving.
Adult↗
The societal unit cost of allogenic red blood cells and red blood cell transfusion in Canada.
BACKGROUND: There is a dearth of information about the cost of allogenic red blood cells (RBCs) and RBC transfusion in Canada in the aftermath of the Canadian blood system reorganization and the introduction of various safety measures. The unit cost of allogenic RBCs and RBC transfusion in Canada in 1994 was estimated at 152.17 US dollars. The objective of this study was to determine the unit cost of allogenic RBC transfusion in Canada from a societal perspective. STUDY DESIGN AND METHODS: A cost-structure analysis using the cost information from 2001 through 2002 was used. Costs of blood collection, production, distribution, delivery (hospital transfusion service processing and patient administration), transfusion reaction management, and opportunity cost of donor's time were included in the analysis. Canadian Blood Services and Héma-Québec supplied the data for collection, production, and distribution stages. Delivery and transfusion reaction costs were collected from eight hospitals across six Canadian provinces. In-patient costs were assessed for the intensive care unit, emergency, general medicine ward, and operating room. RESULTS: The aggregate mean societal unit cost of RBCs transfused on an inpatient basis in 2002 was 264.81 US dollars (95% confidence interval [CI], 256.29 dollars-275.65 dollars). The mean cost of blood collection, production, and distribution was 202.74 US dollars (95% CI, 199.63 dollars-204.31 dollars), the mean opportunity cost of donor time was 18.21 US dollars (95% CI, 17.11 dollars-21.63 dollars), the mean cost of hospital transfusion service processing was 16.65 US dollars (95% CI, 13.50 dollars-19.79 dollars), of RBC transfusion was 26.92 US dollars (95% CI, 25.33 dollars-28.52 dollars), and of transfusion reaction management was 0.29 US dollars(95% CI, 0.22 dollars-0.36 dollars). There were substantial variations in hospital transfusion service processing and RBC transfusion costs across hospitals. CONCLUSION: The societal unit cost of RBC transfusion has doubled since 1994 to 1995. Further increases in unit costs would be expected as additional safety measures are introduced. This will have important financial implications for treating patient populations that require a high level of RBC transfusions.
Blood Banks↗
Clinical outcomes following institution of the Canadian universal leukoreduction program for red blood cell transfusions.
CONTEXT: A number of countries have implemented a policy of universal leukoreduction of their blood supply, but the potential role of leukoreduction in decreasing postoperative mortality and infection is unclear. OBJECTIVE: To evaluate clinical outcomes following adoption of a national universal prestorage leukoreduction program for blood transfusions. DESIGN, SETTING, AND POPULATION: Retrospective before-and-after cohort study conducted from August 1998 to August 2000 in 23 academic and community hospitals throughout Canada, enrolling 14 786 patients who received red blood cell transfusions following cardiac surgery or repair of hip fracture, or who required intensive care following a surgical intervention or multiple trauma. INTERVENTION: Universal prestorage leukoreduction program introduced by 2 Canadian blood agencies. A total of 6982 patients were enrolled during the control period and 7804 patients were enrolled following prestorage leukoreduction. MAIN OUTCOME MEASURES: All-cause in-hospital mortality and serious nosocomial infections (pneumonia, bacteremia, septic shock, all surgical site infections) occurring after first transfusion and at least 2 days after index procedure or intensive care unit admission. Secondary outcomes included rates of posttransfusion fever and antibiotic use. RESULTS: Unadjusted in-hospital mortality rates were significantly lower following the introduction of leukoreduction compared with the control period (6.19% vs 7.03%, respectively; P =.04). Compared with the control period, the adjusted odds of death following leukoreduction were reduced (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.75-0.99), but serious nosocomial infections did not decrease (adjusted OR, 0.97; 95% CI, 0.87-1.09). The frequency of posttransfusion fevers decreased significantly following leukoreduction (adjusted OR, 0.86; 95% CI, 0.79-0.94), as did antibiotic use (adjusted OR, 0.90; 95% CI, 0.82-0.99). CONCLUSION: A national universal leukoreduction program is potentially associated with decreased mortality as well as decreased fever episodes and antibiotic use after red blood cell transfusion in high-risk patients.
Adult↗
Cost-effectiveness of hip protectors in institutional dwelling elderly.
OBJECTIVE: To assess the effectiveness and cost-effectiveness of hip protectors in the prevention of hip fracture in an elderly population living in institutions. DESIGN AND SETTING: Meta-analysis followed by economic analysis. METHODS: The meta-analysis of randomized controlled clinical trials was based on the recommendations of the Cochrane Collaboration. Model-based economic analysis was conducted using estimates of transition probabilities, costs, and utilities relevant to Canada. RESULTS: The results indicate that hip protectors compared with control results in a relative risk of hip fracture of 0.40 (95% Confidence Interval 0.23-0.70). The economic analysis found that the use of hip protectors is expected to be both effective and cost saving. Results were robust to a range of analysis exploring the uncertainty of input parameters. CONCLUSIONS: There is sufficient clinical and economic evidence to support the use of hip protectors for institutional dwelling elderly.
Aged↗
The outpatient treatment of deep vein thrombosis delivers cost savings to patients and their families, compared to inpatient therapy.
BACKGROUND: The outpatient treatment of deep vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) has been shown to be cost-effective from the perspective of a third party payer. The aim of this study is to determine if some or all of these cost savings to third party payers are shifted to patients and their families. METHODS: A prospective cohort study with micro-costing of patient/family costs was conducted at the thrombosis units of The Ottawa Hospital. Costs were determined by administering a questionnaire at the end of the patients' heparin therapy. Over a period of 4 months, consecutive patients presenting at the thrombosis units were approached at the initiation of their heparin therapy; 44 patients consented to participate and completed questionnaires were obtained for 41. RESULTS: The mean patient/family costs associated with outpatient therapy were significantly less than those associated with inpatient therapy (219.42 dollars versus 402.93 dollars, p=0.003); a savings of 190.91 dollars per patient. Even when lost income to patients/families was ignored, mean patient/family costs remained significantly less for outpatient therapy (72.00 dollars versus 134.29 dollars, p=0.004); a savings of 62.30 dollars per patient. Furthermore, patients preferred outpatient to inpatient therapy by almost 3:1 (30 versus 11, respectively). INTERPRETATION: The outpatient treatment of DVT does not result in any net shifting of costs to patients and their families, and further, brings about cost savings. Given the cost savings associated with and the preference of patients for outpatient care, this study further supports the shift of DVT therapy from the inpatient unit to the outpatient clinic.
Adult↗
Program evaluation of hospital-based antenatal home care for high-risk women.
In light of the emphasis on increased efficiency in the delivery of hospital-based healthcare services in Canada, healthcare administrators need to advocate for greater care in the community. The implementation of an antenatal home-care program for women with high-risk pregnancies at the Ottawa Hospital presented the opportunity to develop a comprehensive framework to evaluate the value and outcomes of the new community-based program.
Community Health Nursing↗
OMERACT 6 Economics Working Group report: a proposal for a reference case for economic evaluation in rheumatoid arthritis.
Standardization of methods for economic evaluation is essential for defining the methodological research agenda that will advance the discipline. Standardization also greatly facilitates the interpretation and comparison of the results of economic analyses. For these reasons, several jurisdictions now require economic evaluation, conducted according to standardized methodological guidelines, as a key ingredient in decision making for reimbursement of health treatments and technologies. The application of these general guidelines, however, can be difficult in the absence of disease-specific information. In the case of rheumatoid arthritis (RA), the recent emergence of innovative, highly effective, but also expensive treatments has created an immediate need to more fully understand the economic implications of RA treatments. With this background, the OMERACT Economics Working Group set out in 1994 to develop an RA-specific reference case for economic evaluation. This report summarizes the OMERACT process leading to specific recommendations on the 12 key elements of a proposed "reference case" for economic evaluation in RA. These elements include: study horizon, duration of therapy, extrapolation beyond trial duration, modeling beyond therapy, synthesis of comparisons where head-to-head trials do not exist, clinical outcome measures, mortality, valuation of health states, resource utilization, discontinuation of therapy, therapeutic sequence, and population risk stratification. Through these efforts, the OMERACT Economics Working Group aims to expedite and enhance the conduct and dissemination of methodological research in economic analyses in the rheumatic diseases.
Arthritis, Rheumatoid↗
Economic evaluation of programs or interventions in the management of rheumatoid arthritis: defining a consensus-based reference case.
Improvement in the quality of economic evaluation could be documented as a consequence of international and national standardization efforts. One such effort is the recommendation that all economic evaluations in a given field produce findings in a standard format using a reference case. A reference case-based economic evaluation would adhere to specific settings with regard to outcomes, comparators, modeling techniques, and use of costs to facilitate comparisons among economic evaluations performed with the same objective. In the past, the Outcome Measures in Rheumatology Clinical Trials (OMERACT) consensus conference has successfully developed widely used, consensus-based outcome criteria for clinical improvement in rheumatoid arthritis (RA). Present efforts are being directed at the development of recommendations for the type and format of a reference case economic evaluation for newly developed disease modifying antirheumatic drugs (DMARD). This document discusses 13 important elements that experts considered to be relevant for the development of a reference case recommendation for economic evaluations in RA. We provide the rationale for each element and discuss how each element has been addressed in published economic evaluations of DMARD.
Antirheumatic Agents↗