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The Evidence Speaks (December 2017)

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The Evidence Speaks Series is a recurring feature highlighting the latest in CHÉOS research. This series features summaries of select publications as well as in-depth features on the latest work from our investigators.

In the early days of CHÉOS, the Centre had a series known as “The Evidence Speaks,” a monograph series to keep media and the research community up-to-date with CHÉOS’ current research results in the health outcomes field.

Laratta CR, Ayas NT, Povitz M, Pendharkar SR. Diagnosis and treatment of obstructive sleep apnea in adults. CMAJ. 2017 Dec 4;189(48):E1481-8.

Obstructive sleep apnea (OSA), which refers to a recurring reduction or blockage in airflow during sleep, can have serious implications. Specifically, moderate or severe OSA is associated with increased risk of heart attack, heart failure, ischemic stroke, insulin resistance, and hypertension, as well as maternal and fetal complications. Although over one quarter of Canadians report symptoms and risk factors associated with OSA, only 3% report receiving a formal diagnosis. In a recent review paper, CHÉOS’ Dr. Najib Ayas, with colleagues from UBC, University of Calgary, and Western University, outlined the signs, symptoms, associated morbidity, and treatment and diagnosis options for OSA. Polysomnography, a sleep study that collects seven distinct measurements, remains the gold standard for diagnosing OSA. The accuracy of other home testing can be affected by false negatives and technical failures meaning polysomnography should be used in those who have a high likelihood of OSA. Although its benefit has not been clearly shown in all indications, the review suggests that continuous positive airway pressure be offered to those with moderate to severe OSA due to its benefits for health, quality of life, and productivity. The evidence for the use of oral appliances is unclear and alternative treatments such as surgical interventions should be implemented on a case-by-case basis; decision aids for such treatments are under development. Given the prevalence and potential impact of this disorder, the authors state that more attention needs to be paid to the research, diagnosis, treatment, and ongoing care for Canadians with OSA.

Howard M, Bansback N, Tan A, Klein D, Bernard C, Barwich D, Dodek P, Nijjar A, Heyland DK. Recognizing difficult trade-offs: values and treatment preferences for end-of-life care in a multi-site survey of adult patients in family practices. BMC Med Inform Decis Mak. 2017 Dec 6;17(1):164.

CHÉOS Scientists Drs. Nick Bansback and Peter Dodek contributed to a recently published study about advanced care planning in serious illness. During end-of-life care, treatment preferences and patient values often shift towards increasing quality versus quantity of life. However, this is not always clear to care providers and communication can be inadequate — current decision aids for these situations may not capture patient values and treatment goals. In light of this, the research group examined how patients’ values and preferences were associated and whether these values could be used to guide treatment decisions. Over 800 patients in 20 family practices in Ontario, Alberta, and British Columbia completed a series of questionnaires. In the values questionnaire, patients rated the importance of such things as “How important is it that I have more time with my family?” and “How important is it that I avoid being attached to machines and tubes?”. Another questionnaire had patients rate their preference for varying degrees of life-sustaining interventions. The researchers found that, when compared to each other, value statements were rated inconsistently or illogically and that these statements did not mesh well with treatment preferences. In general, patients did not recognize that necessity of trade-offs when it came to receiving treatment congruent with their values. This research reveals the need for tools to assist patients in recognizing trade-offs and close the gap between values and treatment preferences in order to improve advanced care planning.

Hetrick SE, Bailey AP, Smith KE, Malla A, Mathias S, Singh SP, O’Reilly A, Verma SK, Benoit L, Fleming TM, Moro MR, Rickwood DJ, Duffy J, Eriksen T, Illback R, Fisher CA, McGorry PD. Integrated (one-stop shop) youth health care: best available evidence and future directions. Med J Aust. 2017 Nov 20;207(10):S5-18.

Mental health problems are the largest burden of disease in young people; integrated care, a practice that combines mental, physical, and social care into one centre, has been lauded as a solution to this pervasive issue. Together with researchers from around the world, Dr. Steve Mathias, CHÉOS Scientist and Executive Director of Foundry, reviewed the evidence for integrated youth services and identified areas for improvement. Evaluations of 18 service networks and 10 single centres in Ireland, Australia, France, New Zealand, the United Kingdom, Singapore, the United States, Israel, and Canada were analyzed. In general, young people were satisfied with care and benefitted from the services. Positive aspects of the evaluated centres included accessibility, welcoming environment, privacy, and being staffed by young people. Long waiting lists and restricted opening hours were identified as areas of potential dissatisfaction. A proportion of young people that accessed these centres did not benefit and, in some cases, experienced a worsening of their symptoms. This finding highlights the necessity of integrating specialist care into these centres and increasing engagement and outreach for these more severely affected individuals. Although a model of best practice was not identified in this review, the findings highlight both the strengths and weakness of different approaches to integrated youth services and will guide future development and delivery of this type of care.

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