Browsing by Author "Doig, Christopher J."

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    A cost-utility analysis of decompressive hemicraniectomy in patients with malignant middle cerebral artery (mca) infarction
    (2009) Berthiaume, Luc Roger; Doig, Christopher J.; Manns, Braden
    Decompressive hemicraniectomy improves survival in patients with large hemispheric strokes and cerebral edema, but a significant proportion of these survivors have moderate to severe disability. Given that decompressive hemicraniectomy is a very resource intensive therapy, whether it offers good value for money is an important question that has not been addressed previously. Our objective was to determine the costs and benefits of decompressive hemicraniectomy in adults with hemispheric strokes associated with cerebral edema and compare these with medical therapy as an alternative treatment strategy. Cost-utility and cost-effectiveness analyses were performed. The performance of decompressive hemicraniectomy in patients with malignant MCA infarction was associated a gain of 2.77 quality adjusted life years (QAL Ys) compared to 0.84 QAL Ys for standard care. The expected cost of a surgical strategy was CAN$ 225 931 compared to CAN$ 101 826 for standard care. The incremental cost per QAL Y gained (ICER) of treating patients with decompressive hemicraniectomy was CAN$ 64 220. When the measure of effectiveness was life years gained, the incremental cost per life year gained was CAN$ 32,180. ii Sensitivity and scenario suggest a likely ICER range of 50,000 to 100,000 dollars per QAL Y gained in appropriately selected patients. Sensitivity analyses suggest that delayed surgery (beyond 48 hours) and surgery performed in older patients could be associated with a much higher ICER. We feel that decompressive hemicraniectomy should be offered to patients with large strokes complicated by cerebral edema as it is a potentially life-saving procedure in a young patient population and it has a similar ICER when compared to therapies that are already funded within the Canadian health care system. Our study results suggest that directing this surgery towards younger patients who can be operated in within 48 hours might optimize use of resources. However, it is associated with an incremental cost and decision makers will need to weight its costs and benefits with other therapies being considered for funding. iii
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    A longitudinal analysis of health-related quality of life in survivors of intensive care
    (2003) Juzwishin, Kelsey Dawn Moore; Doig, Christopher J.
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    Can Failure of Vascular Access for Hemodialysis be Predicted by the Initial Blood Flow Measurement?
    (2008) Monroy-Cuadros, Felix Mauricio; Doig, Christopher J.
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    Effect of socioeconomic status on mortality and care provision among critically ill adult patients
    (2010) Hennessy, Deirdre Ann; Doig, Christopher J.
    Background: Socioeconomic status (SES) has been recognized as an important determinant of health outcomes and healthcare utilization across a variety of chronic and infectious diseases in Canada and internationally. However, the effect of SES on mortality and care provision among critically ill patients has been little investigated. Most importantly, no Canadian study has been completed to date to investigate the distribution and effects of SES in the critically ill. Broadly, the objectives of this study were to investigate whether differences exist in mortality and care provision by SES among adult critically ill patients in a Canadian health region. Methods: This was a population-based retrospective cohort study of patients admitted to intensive care (ICU) in the Calgary Health Region (CHR) between January 2002 and December 2006. The primary outcome measures were hospital and I-year mortality. Median household income, obtained from the 2001 Canadian census, was the primary exposure variable. Receipt of welfare or healthcare premium subsidy and Aboriginal status were the secondary exposure measures. The eventual study sample consisted of 6,822 critically ill CHR residents. ICU and hospital clinical data were linked with the primary exposure data using the Postal Code Conversion File, available from Statistics Canada through the Academic Data Centre at the University of Calgary. Clinical data were linked with secondary exposure data through the CHR population registry file. Descriptive and adjusted analyses of mortality, access to care and intensity of care was undertaken by median household income, welfare/subsidy receipt and Aboriginal status. Results: This study demonstrated a lack of association between SES and hospital mortality or mortality up to 1-year after critical illness. Further, low income, defined by receipt of welfare/subsidy, and Aboriginal status was not associated with increased mortality among critically ill patients. Importantly, these data also show that lower SES is associated with greater use of/access to critical care services; however no differences in intensity of care in ICU or hospital existed by SES. Discussion: The results of this study provide reassurance that hospital and 1-year outcomes after critical illness in the CHR do not differ by SES and highlight the increased need for critical care among individuals oflower SES. Further research is required to investigate whether longer-term outcomes are influenced by SES and to examine the exact nature of the relationship between SES and incidence of critical illness. These results have implications for ICU clinicians interested in optimizing long-term outcomes and for health policy makers interested in evidence-based resource allocation.
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    Endotyping in ARDS: one step forward in precision medicine
    (2024-05-14) Côté, Andréanne; Lee, Chel H.; Metwaly, Sayed M.; Doig, Christopher J.; Andonegui, Graciela; Yipp, Bryan G.; Parhar, Ken K. S.; Winston, Brent W.
    Abstract Background The Berlin definition of acute respiratory distress syndrome (ARDS) includes only clinical characteristics. Understanding unique patient pathobiology may allow personalized treatment. We aimed to define and describe ARDS phenotypes/endotypes combining clinical and pathophysiologic parameters from a Canadian ARDS cohort. Methods A cohort of adult ARDS patients from multiple sites in Calgary, Canada, had plasma cytokine levels and clinical parameters measured in the first 24 h of ICU admission. We used a latent class model (LCM) to group the patients into several ARDS subgroups and identified the features differentiating those subgroups. We then discuss the subgroup effect on 30 day mortality. Results The LCM suggested three subgroups (n1 = 64, n2 = 86, and n3 = 30), and 23 out of 69 features made these subgroups distinct. The top five discriminating features were IL-8, IL-6, IL-10, TNF-a, and serum lactate. Mortality distinctively varied between subgroups. Individual clinical characteristics within the subgroup associated with mortality included mean PaO2/FiO2 ratio, pneumonia, platelet count, and bicarbonate negatively associated with mortality, while lactate, creatinine, shock, chronic kidney disease, vasopressor/ionotropic use, low GCS at admission, and sepsis were positively associated. IL-8 and Apache II were individual markers strongly associated with mortality (Area Under the Curve = 0.84). Perspective ARDS subgrouping using biomarkers and clinical characteristics is useful for categorizing a heterogeneous condition into several homogenous patient groups. This study found three ARDS subgroups using LCM; each subgroup has a different level of mortality. This model may also apply to developing further trial design, prognostication, and treatment selection.
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    Health Economic Evaluation of Antimicrobial Stewardship, Procalcitonin Testing, and Rapid Blood Culture Identification in Sepsis Care: A 90-Day Model-Based, Cost-Utility Analysis
    (2024-11-19) Sligl, Wendy I.; Yan, Charles; Round, Jeff; Wang, Xiaoming; Chen, Justin Z.; Boehm, Cheyanne; Fong, Karen; Crick, Katelynn; Clua, Míriam G.; Codan, Cassidy; Dingle, Tanis C.; Prosser, Connie; Chen, Guanmin; Tse-Chang, Alena; Garros, Daniel; Zygun, David; Opgenorth, Dawn; Conly, John M.; Doig, Christopher J.; Lau, Vincent I.; Bagshaw, Sean M.
    Abstract Objective 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. Methods 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. Results 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. Conclusions Our bundled intervention of ASP, PCT, and BCID among adult critically ill patients with sepsis was potentially cost-effective, but with substantial decision uncertainty.
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    Intravenous immunoglobulin in leukocyte recruitment
    (2005) Gill, Varinder; Doig, Christopher J.; Kubes, Paul
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    Non-neurological organ dysfunction in sever traumatic brain injury
    (2004) Zygun, David Andrew; Doig, Christopher J.
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    Organ and tissue donation in the Calgary Health Region: a population based study on intensive care unit practices
    (2004) Barnieh, Lianne Josephine; Doig, Christopher J.
    Organ and tissue donation are part of quality end-of-life decisions in the intensive care unit. The efficacy of any organ and tissue donation process lies on the efficiency of individual steps in the process and not on reporting crude statistics. An examination of these individual steps allows not only for the identification of any possible shortcomings within a process, but provides a base on which comparisons to other systems can be made. The results of this study demonstrate that a process whereby organ and tissue donation is viewed as a measure of quality end-of-life care, and a process that is inherent to critical care, is efficient and could be adopted by other critical care groups. Further, if an efficient process exists, the ethical propriety of increasing organ supply using alternative sources can be examined.
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    Restricted visitation policies in acute care settings during the COVID-19 pandemic: a scoping review
    (2021-09-25) Moss, Stephana J.; Krewulak, Karla D.; Stelfox, Henry T.; Ahmed, Sofia B.; Anglin, Melanie C.; Bagshaw, Sean M.; Burns, Karen E. A.; Cook, Deborah J.; Doig, Christopher J.; Fox-Robichaud, Alison; Fowler, Robert; Hernández, Laura; Kho, Michelle E.; Kredentser, Maia; Makuk, Kira; Murthy, Srinivas; Niven, Daniel J.; Olafson, Kendiss; Parhar, Ken K. S.; Patten, Scott B.; Rewa, Oleksa G.; Rochwerg, Bram; Sept, Bonnie; Soo, Andrea; Spence, Krista; Spence, Sean; Straus, Sharon; West, Andrew; Parsons Leigh, Jeanna; Fiest, Kirsten M.
    Abstract Background Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals. Methods We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate. Results Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (n = 31, 20%) and mental health outcomes (n = 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (n = 107, 69%), connection and communication (n = 107, 69%), and awareness of state of well-being (n = 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (n = 61, 70%), patients (n = 51, 59%), and healthcare professionals (n = 40, 46%). Conclusions Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals. Trial registration: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.
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    The unrestricted global effort to complete the COOL trial
    (2023-05-11) Kirkpatrick, Andrew W.; Coccolini, Federico; Tolonen, Matti; Minor, Samuel; Catena, Fausto; Gois, Emanuel; Doig, Christopher J.; Hill, Michael D.; Ansaloni, Luca; Chiarugi, Massimo; Tartaglia, Dario; Ioannidis, Orestis; Sugrue, Michael; Colak, Elif; Hameed, S. M.; Lampela, Hanna; Agnoletti, Vanni; McKee, Jessica L.; Garraway, Naisan; Sartelli, Massimo; Ball, Chad G.; Parry, Neil G.; Voght, Kelly; Julien, Lisa; Kroeker, Jenna; Roberts, Derek J.; Faris, Peter; Tiruta, Corina; Moore, Ernest E.; Ammons, Lee A.; Anestiadou, Elissavet; Bendinelli, Cino; Bouliaris, Konstantinos; Carroll, Rosemarry; Ceresoli, Marco; Favi, Francesco; Gurrado, Angela; Rezende-Neto, Joao; Isik, Arda; Cremonini, Camilla; Strambi, Silivia; Koukoulis, Georgios; Testini, Mario; Trpcic, Sandy; Pasculli, Alessandro; Picariello, Erika; Abu-Zidan, Fikri; Adeyeye, Ademola; Augustin, Goran; Alconchel, Felipe; Altinel, Yuksel; Hernandez Amin, Luz A.; Aranda-Narváez, José M.; Baraket, Oussama; Biffl, Walter L.; Baiocchi, Gian L.; Bonavina, Luigi; Brisinda, Giuseppe; Cardinali, Luca; Celotti, Andrea; Chaouch, Mohamed; Chiarello, Maria; Costa, Gianluca; de’Angelis, Nicola; De Manzini, Nicolo; Delibegovic, Samir; Di Saverio, Salomone; De Simone, Belinda; Dubuisson, Vincent; Fransvea, Pietro; Garulli, Gianluca; Giordano, Alessio; Gomes, Carlos; Hayati, Firdaus; Huang, Jinjian; Ibrahim, Aini F.; Huei, Tan J.; Jailani, Ruhi F.; Khan, Mansoor; Luna, Alfonso P.; Malbrain, Manu L. N. G.; Marwah, Sanjay; McBeth, Paul; Mihailescu, Andrei; Morello, Alessia; Mulita, Francesk; Murzi, Valentina; Mohammad, Ahmad T.; Parmar, Simran; Pak, Ajay; Wong, Michael P.; Pantalone, Desire; Podda, Mauro; Puccioni, Caterina; Rasa, Kemal; Ren, Jianan; Roscio, Francesco; Gonzalez-Sanchez, Antonio; Sganga, Gabriele; Scheiterle, Maximilian; Slavchev, Mihail; Smirnov, Dmitry; Tosi, Lorenzo; Trivedi, Anand; Vega, Jaime A. G.; Waledziak, Maciej; Xenaki, Sofia; Winter, Desmond; Wu, Xiuwen; Zakaria, Andee D.; Zakaria, Zaidi
    Abstract Background Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. Methods The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. Discussion OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of “damage control”; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).