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The Evidence Speaks (July 2018)


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.

Shuster C, Hurlburt A, Yung T, Wan T, Staples JA, Tam P. Preventability of 28-day hospital readmissions in general internal medicine patients: A retrospective analysis at a quaternary hospital. Qual Manag Health Care. 2018 Jul/Sep;27(3):151-6.

Unplanned hospital readmissions are associated with higher patient mortality and up to billions of dollars health care costs and can be used as a metric of health care quality. Some readmissions are preventable and there is a growing base of research to determine whether it is possible to reliably reduce hospital readmission rates. Physicians from the division of General Internal Medicine in UBC’s Department of Medicine, including CHÉOS Scientist Dr. John Staples, set out to identify preventable hospital readmissions of general internal medicine patients and their common causes in an effort to inform future interventions that can reduce readmission. For patients discharged from general internal medicine teaching service at Vancouver General Hospital and readmitted within 28 days to general internal medicine or family practice from 2015 to 2016, the research team gathered data on their admissions from patient charts and electronic medical records and through interviews with patients or family member. What made this study unique was its formation of a multidisciplinary panel of physicians, nurses, and hospital administrators to adjudicate the preventability and cause of readmission. After reviewing the information available for each case, the panel made a decision by consensus on its preventability. A readmission was determined to be preventable if the patient’s care could have reasonably been altered at any point between the initial hospitalization and readmission to avoid the readmission. Thematic analysis was used to categorize preventable readmissions according to major themes and sub-themes. Factors considered included the quality of care during the initial admission, discharge planning, post-discharge follow-up and coordination between inpatient and outpatient healthcare providers. Two hospital readmission prediction tools were also applied for each patient. Roughly 7 per cent of all general internal medicine patients during the study period were readmitted within 28 days. Among the 55 hospital re-admissions identified, 53 per cent were deemed to be preventable. The preventable and non-preventable cases were comparable on demographic and hospitalization characteristics and readmission prediction scores. While patients attributed readmission to symptom recurrence and the onset of new medical issues, the panel determined inadequate coordination of community services on discharge, insufficient follow-up, and suboptimal end-of-life care to be the most common causes of preventable hospital admission. Though the rate of preventable readmission in this study was higher, the findings were otherwise consistent with previous research. The major themes that emerged through this study may be valuable for informing quality improvement efforts and interventions to reduce preventable hospital readmissions.

Muraca GM, Lisonkova S, Skoll A, Brant R, Cundiff GW, Sabr Y, Joseph KS. Ecological association between operative vaginal delivery and obstetric and birth traumaCMAJ. 2018 Jun 18;190(24):E734-41.

Over the past several decades caesarean delivery rates have increased while rates of operative vaginal delivery—deliveries using forceps, vacuum, and other devices—have declined. Increasing operative vaginal deliveries has been recommended as a means of reducing rates of caesarean delivery, but recent research has shown that operative vaginal delivery is associated with higher rates of severe perinatal and maternal adverse outcomes. Researchers from UBC, with contributions from CHÉOS Scientist Dr. Geoffrey Cundiff, sought to build on this body of work and examine the population-level impact of increasing rates of operative vaginal delivery on perinatal and maternal outcomes. They ran an ecological analysis on data from Canadian Institute for Health Information for all term, singleton deliveries in Alberta, Manitoba, Ontario, and Saskatchewan during the 2004 to 2014 fiscal years to characterize temporal trends in maternal and new-born morbidity in Canada. In total, 1,938,913 deliveries were included in the study population, which was subdivided into women with no previous births (nulliparous), women with previous caesarean delivery, and women without caesarean delivery. Operative vaginal delivery was the less common mode of delivery compared with caesarean among all women, and especially women with a previous caesarean delivery. The rate of obstetric trauma was 7.2 per cent for nulliparous women and 2.2 per cent and 2.7 per cent in women without and with previous caesarean delivery, respectively, and a similar distribution was found among rates of severe trauma to the newborn. The majority of obstetric trauma cases were the result of severe perineal lacerations among operative vaginal deliveries and injury to bladder or urethra for caesarean deliveries. Most cases of neonatal trauma, for both modes of delivery, were the result of brachial plexus injury (damage to the network of nerves running to the chest, shoulder, arm, and hand). Over the study period the rate of trauma to the mother increased, especially among operative vaginal deliveries. For operative vaginal deliveries, the rate of severe neonatal trauma increased as well. The study showed that at a population level an increased rate of operative vaginal delivery was associated with higher rates of obstetric trauma and, in nulliparous women, is also associated with severe neonatal trauma. The findings of this study highlight the potential consequences that increasing the rate of operative vaginal delivery may have through impairments to quality of life and in further medical complications to mother and child and ultimately put into question the recommendations to increase operative vaginal delivery as a means for reducing rates of caesarean delivery.

Mezei AK, Pedersen HN, Sy S, Regan C, Mitchell-Foster SM, … Singer J, et al. Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: A cost-effectiveness analysis of the ASPIRE trial.BMJ Open. 2018 Jun 12;8(6):e020484.

In high-income countries like Canada, the impacts of cervical cancer have been mitigated through screening programs and prophylactic HPV vaccination. However, the benefits of these advances have yet to reach low- and middle-income countries and visual inspection of the cervix with acetic acid (VIA) and HPV DNA testing have been proposed as screening methods that are better suited to these settings. In order to expand population coverage and increase effectiveness, self-collection of samples for testing, rather than provider-collection, can reduce some of the barriers to screening in low- and middle-income countries. CHÉOS Scientist Dr. Joel Singer along with research team from Vancouver, Boston, and Kampala, Uganda evaluated the cost-effectiveness of a randomized trial comparing community-based self-collected HPV testing to clinic-based VIA run by the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) Project in Kampala. The trial involved 500 women between the ages of 30 and 65 who were randomised to either clinic-based via screening (VIA) or self-collected HPV testing with subsequent VIA triage for women with positive HPV tests (HPV-VIA). If the women screened positive for HPV, they were offered cryotherapy or sent for further diagnosis and treatment as required. Using a Monte Carlo simulation model of HPV infection and cervical cancer, the researchers were able to estimate the effectiveness and cost-effectiveness of the two ASPIRE screening strategies and a strategy where women that screen positive from the self-collected test are sent directly for treatment (HPV-ST). A variety of scenarios where women undergo screening once, three times, or five times between the ages of 30 and 50 in a lifetime were assessed for reductions in cervical cancer risk and incremental cost-effectiveness ratios, expressed in 2014 US dollars per life saved. The costs were calculated from a societal perspective, including direct medical costs, women’s time costs, and programmatic costs. Strategies were considered cost-effective if the incremental cost-effectiveness ratio was under $730, Uganda’s GDP per capita in 2014. Under all scenarios HPV-ST led to the largest reduction in lifetime risk of cervical cancer, followed by HPV-VIA, then VIA. The reduction in cancer risk was increased as women were screened an increasing number of times. HPV-ST was also the most cost-effective strategy, both less costly and more effective than all other screening strategies. Although self-collected testing is not as good at identifying cases of HPV, higher screening uptake made it the most effective strategy. However, implementation of HPV-ST on a larger scale comes with caveats. One concern raised by the researchers was the strain that providing cryotherapy for all women with positive HPV tests—for some of whom treatment may not be required—would have on under-resourced health systems in low- and middle-income countries. Another potential drawback stems from the association between cryotherapy and increased risk of HIV, which could be problematic in communities where HIV prevalence is already high. The findings of this cost-effectiveness analysis run counter to current World Health Organisation recommendations for HPV testing with VIA but demonstrate that community-based self-collected HPV testing could help reduce morbidity and mortality in low-resource settings where the burden of cervical cancer remains significant.

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