Browsing by Author "Bhutani, Mohit"

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    Canadian multidisciplinary expert consensus on the use of biologics in upper airways: a Delphi study
    (2023-04-24) Thamboo, Andrew V.; Lee, Melissa; Bhutani, Mohit; Chan, Charles; Chan, Yvonne; Chapman, Ken R.; Chin, Christopher J.; Connors, Lori; Dorscheid, Del; Ellis, Anne K.; Gall, Richard M.; Godbout, Krystelle; Janjua, Arif; Javer, Amin; Kilty, Shaun; Kim, Harold; Kirkpatrick, Gordon; Lee, John M.; Leigh, Richard; Lemiere, Catherine; Monteiro, Eric; Neighbour, Helen; Keith, Paul K.; Philteos, George; Quirt, Jaclyn; Rotenberg, Brian; Ruiz, Juan C.; Scott, John R.; Sommer, Doron D.; Sowerby, Leigh; Tewfik, Marc; Waserman, Susan; Witterick, Ian; Wright, Erin D.; Yamashita, Cory; Desrosiers, Martin
    Abstract Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective. Methods A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1–9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures—kappa coefficient ( $$\kappa$$ κ ) value > 0.61. Results After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease. Conclusion This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years. Graphical abstract
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    Cost Analysis of a Transition Care Bundle Compared with Usual Care for COPD Patients Being Discharged from Hospital: Evaluation of a Randomized Controlled Trial
    (2023-03-11) Yan, Charles; Round, Jeff; Akpinar, Ilke; Atwood, Chantal E.; Deuchar, Lesly; Bhutani, Mohit; Leigh, Richard; Stickland, Michael K.
    Abstract Background Appropriate management of chronic obstructive pulmonary disease (COPD) patients following acute exacerbations can reduce the risk of future exacerbations, improve health status, and lower care costs. While a transition care bundle (TCB) was associated with lower readmissions to hospitals than usual care (UC), it remains unclear whether the TCB was associated with cost savings. Objective The aim of this study was to evaluate how this TCB was associated with future Emergency Department (ED)/outpatient visits, hospital readmissions, and costs in Alberta, Canada. Methods Patients who were aged 35 years or older, who were admitted to hospital for a COPD exacerbation, and had not been treated with a care bundle received either TCB or UC. Those who received the TCB were then randomized to either TCB alone or TCB enhanced with a care coordinator. Data collected were ED/outpatient visits, hospital admissions and associated resources used for index admissions, and 7-, 30- and 90-day post-index discharge. A decision model with a 90-day time horizon was developed to estimate the cost. A generalized linear regression was conducted to adjust for imbalance in patient characteristics and comorbidities, and a sensitivity analysis was conducted on the proportion of patients’ combined ED/outpatient visits and inpatient admissions as well as the use of a care coordinator. Results Differences in length of stay (LOS) and costs between groups were statistically significant, although with some exceptions. Inpatient LOS and costs were 7.1 days (95% confidence interval [CI] 6.9–7.3) and Canadian dollars (CAN$) 13,131 (95% CI CAN$12,969–CAN$13,294) in UC, 6.1 days (95% CI 5.8–6.5) and CAN$7634 (95% CI CAN$7546–CAN$7722) in TCB with a coordinator, and 5.9 days (95% CI 5.6–6.2) and CAN$8080 (95% CI CAN$7975–CAN$8184) in TCB without a coordinator. Decision modelling indicated TCB was less costly than UC, with a mean (standard deviation [SD]) of CAN$10,172 (40) versus CAN$15,588 (85), and TCB with a coordinator was slightly less costly than without a coordinator (CAN$10,109 [49] versus CAN$10,244 [57]). Conclusion This study suggests that the use of the TCB, with or without a care coordinator, appears to be an economically attractive intervention compared with UC.
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    Effectiveness of a standardized electronic admission order set for acute exacerbation of chronic obstructive pulmonary disease
    (BMC Pulmonary Medicine, 2018-05-30) Pendharkar, Sachin R.; Ospina, Maria B.; Gadotti, D. A.; Hirani, Naushad; Graham, Jim Allen; Faris, Peter D.; Bhutani, Mohit; Leigh, Richard A.; Mody, Christopher H.; Strickland, Michael K.
    Background: Variation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay. Methods: The order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits. Results: There were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval − 0.5, − 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions. Conclusions: Use of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care. Keywords: Length of stay, Clinical decision support, Chronic obstructive pulmonary disease, Quality improvement
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    Effectiveness of a standardized electronic admission order set for acute exacerbation of chronic obstructive pulmonary disease
    (2018-05-30) Pendharkar, Sachin R; Ospina, Maria B; Southern, Danielle A; Hirani, Naushad; Graham, Jim; Faris, Peter; Bhutani, Mohit; Leigh, Richard; Mody, Christopher H; Stickland, Michael K
    Abstract Background Variation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay. Methods The order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits. Results There were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval − 0.5, − 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions. Conclusions Use of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care.
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    Empowering Family Physicians to Impart Proper Inhaler Teaching to Patients with Chronic Obstructive Pulmonary Disease and Asthma
    (2015-01-01) Leung, Janice M; Bhutani, Mohit; Leigh, Richard; Pelletier, Dan; Good, Cathy; Sin, Don D
    BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) and asthma depend on inhalers for management, but critical errors committed during inhaler use can limit drug effectiveness. Outpatient education in inhaler technique remains inconsistent due to limited resources and inadequate provider knowledge.OBJECTIVE: To determine whether a simple, two-session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice.METHODS: An inhaler education program with small-group hands-on device training was instituted for family physicians (FP) in British Columbia and Alberta. Sessions were spaced one to three months apart. All critical errors were corrected in the first session. Questionnaires surveying current inhaler teaching practices and attitudes toward inhaler teaching were distributed to physicians before and after the program.RESULTS: Forty-one (60%) of a total 68 participating FPs completed both before and after program questionnaires. Before the program, only 20 (49%) reported providing some form of inhaler teaching in their practices, and only four (10%) felt fully competent to teach patients inhaler technique. After the program, 40 (98%) rated their inhaler teaching as good to excellent. Thirty-four (83%) reported providing inhaler teaching in their practices, either by themselves or by an allied health care professional they had personally trained. All stated they could teach inhaler technique within 5 min. Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique.CONCLUSION: A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practices.
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    Factors influencing the implementation and uptake of a discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease: a qualitative focus group study
    (2020-02-25) Michas, Marta; Deuchar, Lesly; Leigh, Richard; Bhutani, Mohit; Rowe, Brian H; Stickland, Michael K; Ospina, Maria B
    Abstract Background Chronic obstructive pulmonary disease (COPD) is one of the most common causes of mortality and morbidity in high-income countries. In addition to the high costs of initial hospitalization, COPD patients frequently return to the emergency department (ED) and are readmitted to hospital within 30 days of discharge. A COPD acute care discharge care bundle focused on optimizing care for patients with an acute exacerbation of COPD has been shown to reduce ED revisits and hospital readmissions. The aim of this study was to explore and understand factors influencing implementation and uptake of COPD discharge care bundle items in acute care facilities from the perspective of health care providers and patients. Methods Qualitative methodology was adopted. Nine focus groups were conducted using a semi-structured guide: seven with acute and primary/community health care providers and two with patients/family members. Focus groups were audiotaped, transcribed verbatim, and coded and analyzed using a thematic approach. Results Forty-six health care providers and 14 patients/family members participated in the focus groups. Health care providers and patients identified four factors that can challenge the implementation of COPD discharge care bundles: process of care complexities, human capacity in care settings, communication and engagement, and attitudes and perceptions towards change. Both health care providers and patients recognized process of care complexity as the most important determinant of the COPD discharge bundle uptake. Processes of care complexity include patient activities in seeking and receiving care, as well as practitioner activities in making a diagnosis and recommending or implementing treatment. Important issues linked to human capacity in care settings included time constraints, high patient volume, and limited staffing. Communication during transitions in care across settings and patient engagement were also broadly discussed. Other important issues were linked to patients’, providers’, and system attitudes towards change and level of involvement in COPD discharge bundle implementation. Conclusions Complexities in the process of care were perceived as the most important determinant of COPD discharge bundle implementation. Early engagement of health providers and patients in the uptake of COPD discharge bundle items as well as clear communication between acute and post-acute settings can contribute positively to bundle uptake and implementation success.