Browsing by Author "Richer, Lawrence"

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    Analgesic Use Among Adults with a Trauma-Related Emergency Department Visit: A Retrospective Cohort Study from Alberta, Canada
    (2023-06-03) Sevcik, Bill; Lobay, Kevin; Luu, Huong; Martins, Karen J. B.; Vu, Khanh; Nguyen, Phuong U.; Bohlouli, Solmaz; Eurich, Dean T.; Lester, Erica L. W.; Williamson, Tyler; Richer, Lawrence; Klarenbach, Scott W.
    Abstract Introduction A better understanding of current acute pain-driven analgesic practices within the emergency department (ED) and upon discharge will provide foundational information in this area, as few studies have been conducted in Canada. Methods Administrative data were used to identify adults with a trauma-related ED visit in the Edmonton area in 2017/2018. Characteristics of the ED visit included time from initial contact to analgesic administration, type of analgesics dispensed during and upon being discharged home directly from the ED (≤ 7 days after), and patient characteristics. Results A total of 50,950 ED visits by 40,505 adults with trauma were included. Analgesics were administered in 24.2% of visits, of which non-opioids were dispensed in 77.0% and opioids were dispensed in 49.0%. Time to analgesic initiation occurred more than 2 h after first contact. Upon discharge, 11.5% received a non-opioid and 15.2% received an opioid analgesic, among whom 18.5% received a daily dose ≥ 50 morphine milligram equivalents (MME) and 30.2% received > 7 days of supply. Three hundred and seventeen adults newly met criteria for chronic opioid use after the ED visit, among whom 43.5% received an opioid dispensation upon discharge; of these individuals, 26.8% had a daily dose ≥ 50 MME and 65.9% received > 7 days of supply. Conclusions Findings can be used to inform optimization of analgesic pharmacotherapy practices for the treatment of acute pain, which may include reducing the time to initiation of analgesics in the ED, as well as close consideration of recommendations for acute pain management upon discharge to provide ideal patient-centered, evidence-informed care.
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    Clinical Prediction of Perinatal Arterial Ischemic Stroke
    (2022-06) Srivastava, Ratika; Kirton, Adam; Hill, Michael D; Richer, Lawrence; Samuel, Susan; Hagel, Brent
    Perinatal stroke is a well-defined but heterogenous group of disorders involving a focal disruption of cerebral blood flow between 20 weeks gestation and 28 days of life. At a combined incidence of 1:1000 live births, stroke in the perinatal period is more common than at any other time in childhood. Morbidity of perinatal stroke is high, and it is the most common cause of hemiparetic cerebral palsy. Years living with disability are amplified with deficits lasting a lifetime. Perinatal arterial ischemic stroke (PAIS) is the most common type of perinatal stroke. Advances in neuroimaging have allowed for exceptional growth in stroke diagnosis. However, etiology is poorly understood. Many pregnancy, delivery, and fetal risk factors have been considered, but targeted treatment and prevention efforts are still not possible. This thesis reviewed perinatal stroke and developed a diagnostic risk prediction model for PAIS. Pathophysiology, strategies for diagnosis, investigations, management, and outcomes were broken down by perinatal stroke disease, with an additional focus on family mental health and active trials for acute intervention. A diagnostic prediction model was then developed using novel, multisource data and multivariable logistic regression. Clinical pregnancy, delivery, and neonatal risk factors were collected from four registries including the Alberta Perinatal Stroke Project, Canadian Cerebral Palsy Registry, International Pediatric Stroke Study, and Alberta Pregnancy Outcomes and Nutrition study. Variable selection was based on peer-reviewed literature. The final model included nine clinical factors – maternal age, tobacco exposure, substance exposure, pre-eclampsia, chorioamnionitis, intrapartum maternal fever, emergency c-section, low 5-minute Apgar score, and male sex – to predict the risk of PAIS in a term neonate with good discrimination between cases and controls (C-statistic 0.73). This work highlights the lifelong effects of perinatal stroke on patients and families, and the potential for early perinatal stroke diagnosis. Findings suggest that clinical prediction and early, accurate diagnosis of PAIS may be possible using common clinical variables. Future research is needed to optimize risk prediction by better understanding perinatal stroke pathophysiology, including the role of the placenta, and identifying high-risk groups.
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    Health resource utilization and cost before versus after initiation of second-generation long-acting injectable antipsychotics among adults with schizophrenia in Alberta, Canada: a retrospective, observational single-arm study
    (2022-07-02) Wong, Kai O.; Klarenbach, Scott W.; Martins, Karen J. B.; Chue, Pierre; Dursun, Serdar M.; Snaterse, Mark; Guigue, Alexis; So, Helen; Luu, Huong; Vu, Khanh; Richer, Lawrence
    Abstract Background Long-acting injectable (LAI) antipsychotics, along with community treatment orders (CTOs), are used to improve treatment effectiveness through adherence among individuals with schizophrenia. Understanding real-world medication adherence, and healthcare resource utilization (HRU) and costs in individuals with schizophrenia overall and by CTO status before and after second generation antipsychotic (SGA)-LAI initiation may guide strategies to optimize treatment among those with schizophrenia. Methods This retrospective observational single-arm study utilized administrative health data from Alberta, Canada. Adults (≥ 18 years) with schizophrenia who initiated a SGA-LAI (no use in the previous 2-years) between April 1, 2014 and March 31, 2016, and had ≥ 1 additional dispensation of a SGA-LAI were included; index date was the date of SGA-LAI initiation. Medication possession ratio (MPR) was determined, and paired t-tests were used to examine mean differences in all-cause and mental health-related HRU and costs (Canadian dollars), comprised of hospitalizations, physician visits, emergency department visits, and total visits, over the 2-year post-index and 2-year pre-index periods. Analyses were stratified by presence or absence of an active CTO during the pre-index and/or post-index periods. Results Among 1,211 adults with schizophrenia who initiated SGA-LAIs, 64% were males with a mean age of 38 (standard deviation [SD] 14) years. The mean overall antipsychotic MPR was 0.39 (95% confidence interval [CI] 0.36, 0.41) greater during the 2-year post-index period (0.84 [SD 0.26]) compared with the 2-year pre-index period (0.45 [SD 0.40]). All-cause and mental health-related HRU and costs were lower post-index versus pre-index (p < 0.001) for hospitalizations, physician visits, emergency department visits, and total visits; mean total all-cause HRU costs were $33,788 (95% CI -$38,993, -$28,583) lower post- versus pre-index ($40,343 [SD $68,887] versus $74,131 [SD $75,941]), and total mental health-related HRU costs were $34,198 (95%CI -$39,098, -$29,297) lower post- versus pre-index ($34,205 [SD $63,428] versus $68,403 [SD $72,088]) per-patient. Forty-three percent had ≥ 1 active CTO during the study period; HRU and costs varied according to CTO status. Conclusions SGA-LAIs are associated with greater medication adherence, and lower HRU and costs however the latter vary according to CTO status.
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    Siloed mentality, health system suboptimization and the healthcare symphony: a Canadian perspective
    (2024-07-17) Lau, Robin S.; Boesen, Mari E.; Richer, Lawrence; Hill, Michael D.
    Abstract Measuring and optimizing a health system is challenging when patient care is split between many independent organizations. For example, patients receive care from their primary care provider, outpatient specialist clinics, hospitals, private providers and, in some instances, family members. These silos are maintained through different funding sources (or lack of funding) which incentivize siloed service delivery. A shift towards prioritizing patient outcomes and keeping the patient at the centre of care is emerging. However, competing philosophies on patient needs, how health is defined and how health is produced and funded is creating and engraining silos in the delivery of health services. Healthcare and health outcomes are produced through a series of activities conducted by diverse teams of health professionals working in concert. Health professionals are continually learning from each patient interaction; however, silos are barriers to information exchange, collaborative evidence generation and health system improvement. This paper presents a systems view of healthcare and provides a systems lens to approach current challenges in health systems. The first part of the paper provides a background on the current state and challenges to healthcare in Canada. The second part presents potential reasons for continued health system underperformance. The paper concludes with a system perspective for addressing these challenges.
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    The Clinical Utility of a Novel Multi-Modal Assessment Battery for Acute Sport-Related Concussion
    (2024-04-19) Bertagnolli, Jalena Ashley; Benson, Brian; Dukelow, Sean; Smith, David; Richer, Lawrence
    Objective: To determine the clinical utility of a novel, multimodal, assessment battery in detecting acute post-concussion impairment relative to baseline performance. Study Design: Prospective observational cohort study. Subjects: Four hundred thirty-one elite ice hockey, alpine and freestyle ski, artistic swimming and luge athletes (mean age: 15.7 years (range: 14-36 years), male: 349, female: 82) over one athletic season (2022-2023). Observation Technique: Standardized multimodal baseline assessments including electroencephalography (EEG) utilizing the NeuroCatch® 1.0 device, postural sway using the tri-axial accelerometer Protxx® device, cardiovascular exercise from a bicycle ergometer and sustained handgrip strength were completed in the pre-season and then repeated for any athlete sustaining a sport-related concussion within seven days of injury. Outcome Measures: Directional bootstrap paired t-tests and binomial tests adjusting for multiplicity using Bonferroni correction were used to assess changes in performance between baseline and post-concussion test results for the following four primary assessments of interest: 1) quantitative EEG event-related potentials (N100, P300, and N400 amplitude and latency) (NeuroCatch), 2) quantitative assessment of postural sway with eyes open and eyes closed using a physiological vibration acceleration (phybrata) sensor (Protxx), 3) concussion symptom exacerbation (≥1 on a 10-point visual analogue rating scale) during a submaximal bicycle ergometer assessment, and 4) change in heart rate during a 30-second, 30% maximal handgrip strength contraction. Results: Forty-six athletes were diagnosed with a concussion by a sport medicine physician during the study period. Neither amplitude nor latency for N100, P300 or N400 event-related potentials demonstrated a significant group difference between baseline and post-concussion assessments. Athletes demonstrated a significant group difference in postural sway between baseline and post-concussion timepoints using the phybrata sensor for sway power ratio, with a moderate effect size (dav= 0.491) (baseline: 1.4 ±0.5W, post-concussion: 1.9 ±1.4W, p=0.005). Fifteen (68.2%) of the 22 athletes completing post-concussion exercise assessments experienced worsening symptoms, with two additional athletes unable to initiate exercise due to significant symptom burden (p<0.001, large effect size PR= 0.972). Furthermore, no significant difference was observed for change in heart rate during the handgrip strength task. Conclusions: A novel phybrata motion sensor objectively evaluating postural sway and standardized submaximal cardiovascular assessment evaluating symptom exacerbation demonstrated significant clinical utility in detecting impairment within seven days of an acute sport-related concussion, while event-related potentials (N100, P300, N400) and heart rate change during a sustained handgrip task did not.