Míriam Garrido Clua

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Comparison of the Management and Short-Term Outcomes between Patients with Advanced Cancer and Other End-of-Life Conditions Presenting to Two Canadian Emergency Departments

Journal of Palliative Medicine (2022)

Scott W. Kirkland Esther H. Yang Míriam Garrido Clua M. Kruhlak Cristina Villa‐Roel

Background: An increasing number of patients with end-of-life (EOL) conditions, particularly those with advanced cancer, are presenting to the emergency department (ED). Objectives: To assess the characteristics, management and short-term outcomes of ED patients with advanced cancer compared to patients with other EOL conditions. Methodology/Design: A secondary analysis of a prospective cohort study. Setting/Participants: Volunteer emergency physicians in two Canadian EDs identified presentations for advanced cancer and other EOL conditions with the aid of a modified screening tool March–August 2018. Results: Among the 663 presentations by patients with EOL conditions, 272 (41%) presented with advanced cancer. The majority of presentations for advanced cancer (81%) or other EOL conditions (77%) were by patients with unmet palliative care (PC) needs. Patients with advanced cancer were significantly less likely to have active goals of care (GOC) documented on their charts (53% vs. 75%; p < 0.001). While no significant differences were found between the groups, the majority of presentations involved imaging, investigations, consultations, and hospitalization. Presentations for advanced cancer were more likely to receive a postdischarge referral (38% vs. 23%; p < 0.001). Referrals to PC consultations or postdischarge referrals were infrequent. Regression analysis found that patients with advanced cancer were associated with shorter length of stay (LOS). Conclusions: The majority of presentations for advanced cancer or other EOL conditions involved significant resource use. Patients with cancer experienced shorter LOS; however, had less documentation of GOC and gaps in referrals to PC services were identified. Interventions should be explored to promote early GOC discussions and PC referrals in this patient group.

End-of-Life Care

10.1089/jpm.2021.0519

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Citations (2)

A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol

Pilot and Feasibility Studies (2022)

Moin Khan Asheesh Bedi Ryan M. Degen Jon J.P. Warner Mohit Bhandari

Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied.The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively.This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability.This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&draw=2&rank=1 .This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability.

Latarjet procedure

Bankart repair

10.1186/s40814-022-00987-4

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Citations (7)

P072: Preventing emergency department visits among patients with cancer: a scoping review

Canadian Journal of Emergency Medicine (2020)

Scott W. Kirkland Míriam Garrido Clua Daniela R. Junqueira S. Campbell BH Rowe

Outpatient clinic

10.1017/cem.2020.278

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Citations (0)

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

The Lancet (2020)

Flávia K. Borges Mohit Bhandari Ernesto Guerra-Farfán Ameen Patel Alben Sigamani

Hip Fracture

Stroke

Gold standard (test)

10.1016/s0140-6736(20)30058-1

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Citations (275)

Accelerated Surgery Versus Standard Care in Hip Fracture (HIP ATTACK-1): A Kidney Substudy of a Randomized Clinical Trial

American Journal of Kidney Diseases (2022)

Flávia K. Borges P.J. Devereaux Meaghan S. Cuerden Jessica M. Sontrop Mohit Bhandari

Hip Fracture

10.1053/j.ajkd.2022.01.431

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Citations (2)

An Assessment of the Management of Patients with Advanced End-Stage Illness in the Emergency Department: An Observational Cohort Study

Journal of Palliative Medicine (2021)

M. Kruhlak Scott W. Kirkland Míriam Garrido Clua Cristina Villa‐Roel Adam Elwi

Background: Presentations to the emergency department (ED) by patients with end-of-life (EOL) conditions for their acute care needs are common. Objectives: The objective of this study was to identify and describe the ED management across presentations to the ED for EOL conditions. Design: Prospective observational cohort study. Settings/Subjects: Emergency physicians in two Canadian ED's were asked to identify presentations by adult patients with EOL conditions using a modified screening tool. Measurements: Patient characteristics and ED management for each presentation were collected through chart review by trained research assistants. Descriptive analyses were conducted as appropriate and bivariate comparisons of dichotomous and continuous variables were completed using χ2 tests and using t test or Wilcoxon rank-sum test, respectively. Results: Physicians identified 663 ED presentations for EOL conditions, with advanced cancer (41%), dementia (23%), and chronic obstructive pulmonary disease (16%) being the most common EOL conditions. The majority of presentations involved consultations (77%), hospitalization (65%), and numerous investigations (97%), including blood work (97%) and imaging (92%). The majority of patients with EOL conditions had a history of ED visits (68%). Using a modified screening tool, 78% of presentations involved patients with unmet palliative care needs, but only 1% of presentations involved a palliative consultation or admission to a palliative care unit. Conclusion: Presentations to the ED for EOL conditions involve significant ED resources; however, only a handful of patients are referred to palliative services. Patients with EOL conditions are appropriate targets for palliative services and community support outside the ED.

10.1089/jpm.2021.0004

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Citations (6)

MP08: The frequency of emergency departments visits for patients with end-of-life conditions: a call for action

Canadian Journal of Emergency Medicine (2019)

Scott W. Kirkland M. Kruhlak Míriam Garrido Clua Cristina Villa‐Roel S. Couperthwaite

End-of-Life Care

10.1017/cem.2019.143

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Citations (1)

Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs

PLoS ONE (2021)

Scott W. Kirkland Míriam Garrido Clua M. Kruhlak Cristina Villa‐Roel S. Couperthwaite

Introduction This study examined emergency department (ED) presentations of patients with end of life (EOL) conditions and patients having met and unmet palliative care needs were compared. Methods Presentations for EOL conditions were prospectively identified and screened for palliative care needs. Descriptive data were reported as proportions, means or medians. Bi-variable analysis for dichotomous and continuous variables were performed by chi-squared and T-tests (p≤0.01), respectively. A multivariable logistic regression model identified factors associated with having unmet palliative needs and reported adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Overall, 663 presentations for EOL conditions were identified; 518 (78%) involved patients with unmet palliative care needs. Presentations by patients with unmet palliative needs were more likely to involve consultations (80% vs. 67%, p = 0.001) and result in hospitalization (69% vs. 51%, p<0.001) compared to patients whose palliative needs were met. Patients with unmet palliative care needs were more likely to have previous ED visits (73% unmet vs. 48% met; p<0.001). While medication, procedures, investigations and imaging ordering were high across all patients with EOL conditions, there were no significant differences between the groups. Consultations with palliative specialists in the ED (6% unmet vs. 1% met) and following discharge (29% unmet vs. 18% met) were similarly uncommon. Patients having two or more EOL conditions (aOR = 2.41; 95% CI: 1.16, 5.00), requiring hospitalization (aOR = 1.93; 95% CI: 1.30, 2.87), and dying during the ED visit (aOR = 2.15; 95% CI: 1.02, 4.53) were strongly associated with having unmet palliative care needs. Conclusions Most ED presentations for EOL conditions were made by patients with unmet palliative care needs, who were significantly more likely to require consultation, hospitalization, and to die. Referrals to palliative care services during and after the ED visit were infrequent, indicating important opportunities to promote these services.

Advance Care Planning

10.1371/journal.pone.0257501

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Citations (9)

Correction to: A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol

Pilot and Feasibility Studies (2022)

Moin Khan Asheesh Bedi Ryan M. Degen Jon J.P. Warner Mohit Bhandari

Latarjet procedure

10.1186/s40814-022-01020-4

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Citations (1)

Health Economic Evaluation of Antimicrobial Stewardship, Procalcitonin Testing, and Rapid Blood Culture Identification in Sepsis Care: A 90-Day Model-Based, Cost-Utility Analysis

PharmacoEconomics - Open (2024)

Wendy Sligl Charles Yan Jeff Round Xioaming Wang Justin Z. Chen

We evaluated the cost-effectiveness of a bundled intervention including an antimicrobial stewardship program (ASP), procalcitonin (PCT) testing, and rapid blood culture identification (BCID), compared with pre-implementation standard care in critically ill adult patients with sepsis. We conducted a decision tree model-based cost-effectiveness analysis alongside a previously published pre- and post-implementation quality improvement study. We adopted a public Canadian healthcare payer's perspective. Two intensive care units in Alberta with 727 adult critically ill patients were included. Our bundled intervention was compared with pre-implementation standard care. We collected healthcare resource use and estimated unit costs in 2022 Canadian dollars (CAD) over a time horizon from study entry to hospital discharge or death. We calculated the incremental net monetary benefit (iNMB) of the intervention group compared with the pre-intervention group. The primary outcome was cost per sepsis case. Secondary outcomes included readmission rates, Clostridioides difficile infections, mortality, and lengths of stay. Uncertainty was investigated using cost-effectiveness acceptability curves, cost-effectiveness plane scatterplots, and sensitivity analyses. Mean (standard deviation [SD]) cost per index hospital admission was CAD $83,251 ($107,926) for patients in the intervention group and CAD $87,044 ($104,406) for the pre-intervention group, though the difference ($3,793 [$7,897]) was not statistically significant. Costs were higher in the pre-intervention group for antibiotics, readmissions, and C. difficile infections. The intervention group had a lower mean expected cost; $110,580 ($108,917) compared with pre-intervention ($125,745 [$113,210]), with a difference of $15,165 ($8278). There were no statistically significant differences in quality adjusted life years (QALYs) between groups. The iNMB of the intervention group compared with pre-intervention was greater than $15,000 for willingness-to-pay (WTP) per QALY values of between $0 and $100,000. In our sensitivity analysis, the intervention was most likely to be cost-effective in roughly 56% of simulations at all WTP thresholds. Our bundled intervention of ASP, PCT, and BCID among adult critically ill patients with sepsis was potentially cost-effective, but with substantial decision uncertainty.

Antimicrobial Stewardship

Procalcitonin

Blood Culture

10.1007/s41669-024-00538-y

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Citations (0)