Poster Presentations

Presenting author: Dr. Mireille Goetghebeur, Vice-President, Operations, , BioMedCom Consultants Inc.

Co-authors: Ms. Michéle Tony (Research Application Associate) and Dr. Monika Wagner (Director, Research Application), BioMedCom Consultants Inc.; Dr. Cheri L. Deal (Professor of Pediatrics and Program Director, Pediatric Endocrinology and Diabetes) and Dr. Renaldo Battista (Professeur titulaire), University of Montreal/CHU Sainte-Justine Research Center

Background: Prader-Willi syndrome (PWS) is a rare and complex multisystem disorder with serious long-term consequences. Use and coverage of growth hormone (GH) in patients with PWS varies widely across Canada and there is a need to clarify its benefits.

Objective: To test a pragmatic framework (EVIDEM) to: 1) clarify the state of knowledge regarding GH therapy in PWS; and 2) facilitate compliance with the recommendations of the AGREE collaboration in developing evidence-based clinical practice guidelines (CPGs).

Methods: An extensive literature review was performed to identify and synthesize available evidence on GH for PWS for each criterion of the EVIDEM framework. The framework was adapted to include a CPGs module, complying with AGREE requirements, which was used to identify questions for CPGs development. Experts were involved in the process for validation.

Results: Evidence was synthesized and validated for 13 scientific criteria covering disease impact, therapeutic context, treatment outcomes (efficacy and effectiveness, safety, and patient-reported outcomes), type of benefits, and economic impact. The efficacy criterion was subdivided into subcriteria for each type of outcome measured, including growth, body composition, exercise tolerance, metabolic effects, bone health, cardiovascular health, psychomotor development, and behavioural outcomes. Relevance and validity of evidence were assessed. Data for six contextual criteria was synthesized, including for ethical considerations. Identified CPGs questions were aligned with each decision criterion, using the CPGs module, which will be used to develop international CPGs during a consensus workshop.

Conclusion: The framework provides a pragmatic means for systematic assessment of evidence and identification of questions to guide clinical practice.

 Presenting authors: Ms. Michelle Clark (Clinical Research Assistant) and Ms. Brendalynn Ens (Liaison Officer), Canadian Agency for Drugs and Technologies in Health

Evidence was requested in response to three incidents of unexplained respiratory arrest during an anesthetic procedure for cataract surgery at a tertiary hospital. The time from adverse events to required presentation of the information during a peer review session was less than 10 days. 

High-risk incidents are required to be reviewed and reported by hospital-based clinical departments promptly. Besides the circumstances of an incident, knowledge of current best practices for improvement is also required for discussion and documentation. Multidisciplinary teams must demonstrate evidence-informed plans for change or prevention. A rapid review of evidence (Reference List) was invaluable to the multidisciplinary Operating Room team to quickly determine consistencies in care between available research and common practices. With ready access to this information, there was wide-spread acceptance and valued appreciation for the rapid review service.

Information was used to inform best practices for multidisciplinary teams. The rapid review document was shared with all team members to inform the issue and support collaborative education, learning initiatives, and standardization of practice. Evidence was identified to identify current practices and alternative approaches to enhance patient safety.

This report serves as an example of how efficiently reports can be refined and prepared when there is an immediate clinical need. Critical incidents can be daunting events that clinical departments encounter; prompt support by providing information on short notice has been demonstrated to be greatly useful to clinical stakeholder groups.

Presenting author: Dr. Laureen Rance, Senior Director, Centre of Excellence, TELUS Health Solutions

Co-author: Dr. Pieway Hwang, Consultant, TELUS Health Solutions

Background: Private payers are increasingly turning to approaches such as co-payment increases for plan members in an effort to control rising drug costs. However, evidence suggests an inverse relationship between co-payment amount and medication compliance, with resulting negative outcomes. Given this, plus the importance of compliance and existing poor compliance, more data to inform co-payment policies are warranted. The ACCESS Study is designed to evaluate whether eliminating co-payments for selected drugs is associated with better compliance. Secondary objectives are to measure the impact on persistence, sick days, and short-term disability claims. Study rationale, design, and implementation will be described.

Target audience: Health care decision- and policy-makers, and drug-plan managers.

Methods: From July 12, 2010 to July 11, 2011, enrolees (n = 33,435: 12,675 employees, 8,005 spouses, and 12,755 dependents) in the drug plan of TELUS Corporation will have the co-payment waived when filling prescriptions for selected drugs. Outcomes in the 12-month co-payment elimination period will be compared to the 12-month pre-implementation period. Outcomes include: compliance (measured by the Medication Possession Ratio), measures of persistence (i.e., days to discontinuation, six-month discontinuation rates, and persistence rates [no discontinuations or gaps > 30 days]), sick days, and short-term disability claims. Data analysis will be performed using data currently collected as part of prescription claims adjudication and casual absence/short-term disability data that are currently tracked by TELUS.

Discussion: To our knowledge, this is the first Canadian controlled trial of co-payment reductions. Results may provide evidence to support policy and innovative approaches with regard to drug benefit design and delivery.

Presenting author: Mr. Azim Kasmani, Canadian Agency for Drugs and Technologies in Health, and Master’s Student, University of Ottawa

Co-authors: Dr. Tammy Clifford, Chief Scientist, Canadian Agency for Drugs and Technologies in Health; Dr. Doug Coyle (Professor and Director of Graduate Studies) and Ms. Shannon Kelly (Master’s Student), University of Ottawa 

Background: The consistent availability of medical isotopes, including technetium-99m (Tc-99m), has become an issue with the closure of a Canadian nuclear reactor. Coronary artery disease (CAD) is the leading cause of death among patients with type 2 diabetes mellitus (T2DM) and is commonly tested for using Tc-99m myocardial perfusion imaging (MPI).

Objectives: To assess the prognostic value of Tc-99m MPI screening for CAD in asymptomatic patients with T2DM through a systematic review of the available literature and a health economic analysis.

Methods: Peer-reviewed literature searches were conducted in a broad range of bibliographic databases; grey literature was identified through the CADTH “Grey Matters” resource search tool. Inclusion criteria incorporated adult patients asymptomatic of CAD with T2DM; Tc-99m MPI screening for CAD; and cardiac-related death, myocardial infarction, or revascularization as outcomes. Randomized controlled trials (RCTs)and observational studies were assessed for inclusion by two independent reviewers. A relevant Markov transition model was developed and populated using data from the review; costs and utility values were determined from sources in the literature. Monte Carlo Simulations were conducted for analysis of uncertainty.

Results: Analysis is ongoing. Eight observational studies and two RCTs have been initially identified for inclusion. The observational studies show some benefit and the RCTs show no significant benefit of the intervention. The    cost-utility analysis of screening from a Canadian health care system perspective will be presented.

Conclusions: Conclusions on the clinical effectiveness and cost utility of Tc-99m MPI as a prognostic tool for detecting asymptomatic CAD in patients with T2DM will be presented.

Presenting author: Ms. Monika Mierzwinski-Urban, Information Specialist, Canadian Agency for Drugs and Technologies in Health

Co-authors: Ms. Amanda Hodgson (Manager, Information Services) and Ms. Melissa Severn (Information Specialist), Canadian Agency for Drugs and Technologies in Health

Purpose: Peer review of electronic search strategies has always been a standard practice and an integral part of information specialists’ (ISs’) search processes at CADTH. The purpose of this project was to evaluate and revise the PRESS quality assessment checklist tool (Sampson et al., 2008) according to CADTH IS needs and incorporate it into CADTH IS peer review processes.

Methods: The Sampson et al. PRESS report systematic review searches were updated to identify any additional evidence and any other assessment checklists that evaluate and validate the quality of electronic search strategies. A web-based survey was conducted among CADTH ISs to seek their feedback on the importance of the checklist elements indicated by the Sampson et al. report and to identify any other elements to the validity of electronic search strategies.

Results: Based on the systematic review search update, survey, and CADTH IS feedback, the CADTH PRESS checklist has been created and the final number of questions assessing possible errors in electronic search strategies has increased from seven to ten.

Conclusion: Implementing a validated checklist tool for peer reviewing electronic search strategies will improve the retrieval of relevant information. The aim of the CADTH PRESS checklist is to standardize peer review processes at CADTH and to improve the quality of electronic search strategies. A standardized and validated checklist tool will make the peer review processes more transparent and rigorous, increasing the quality and completeness of CADTH IS search strategies.

Presenting author: Dr. Jean-Eric Tarride, Associate Professor, PATH Research Institute, McMaster University

Co-authors: Ms. Natasha Burke (Research Associate), Ms. Camilla Von Keyserkingk (Research Associate), and Mr. Ron Goeree (Associate Professor), PATH Research Institute, McMaster University

Background: Although influenza affects all age groups, influenza is common in children. Between 15% and 42% of preschool and school-aged children experience influenza each season. Recently, LAIV has been approved in Canada for use in eligible persons aged two to 59 years.

Objectives: To determine the cost-effectiveness of LAIV compared to TIV in Canadian children and adolescents from a Ministry of Health (MoH) perspective and a societal perspective.

Methods: A previously published US cost-effectiveness model using patient-level data to compare LAIV and TIV was supplemented by secondary data (e.g., literature) and primary data (i.e., survey of 144 Canadian physicians). To compare the costs and benefits of LAIV and TIV, a cost-utility analysis was conducted. Parameter uncertainty was addressed through probability sensitivity analysis (PSA).

Results: Although LAIV increased vaccination costs compared to TIV, LAIV reduced the number of influenza illness cases and lowered the number of hospitalizations, ER visits, outpatient visits, and parents’ days lost from work. The estimated offsets in direct costs saved were $4.19 per vaccinated child aged two to 17 years. Societal savings were $35.33 per vaccinated child. When costs and outcomes were considered, LAIV was the dominant strategy when compared to TIV. At a willingness to pay of $50,000 per QALY gained, the results of the PSA indicated that the probability of LAIV being cost-effective was almost one.

Conclusions: LAIV reduces the burden of influenza in children and adolescents. Consistent with US results, vaccinating children with LAIV instead of TIV is the dominant strategy from a societal and MoH perspective.

Presenting authors: Dr. Ian Mitchell, Professor, Department Of Paediatrics, University Of Calgary; Ms. Abby Li, Research Assistant, Medical Outcomes and Research in Economics (MORE) Research Group

Co-authors: Dr. Krista Lanctot, Executive Director, Medical Outcomes and Research in Economics (MORE) Research Group; Dr. Bosco Paes, Professor, Department of Paediatrics, McMaster University

Objective: To evaluate the current management of children at high-risk of RSV infection who received palivizumab prophylaxis in tertiary care centers and community settings using a Canadian registry database.
Design/Methods: A prospective, observational registry of infants who received ≥ 1 dose of palivizumab during the 2005 to 2010 RSV seasons across 29 sites. Data on palivizumab utilization and compliance, and outcomes related to a respiratory infection were collected monthly until the full course of palivizumab was completed.
Results: 7,699 infants were enrolled, with an average age of 5.4 ± 6.0 months. Participants were typically male (56.4%), Caucasians (71.5%), with an average gestational age (GA) of 32.2 (SD 6.0) completed weeks. 5,237 (68.0%) infants received palivizumab for prematurity ( 35 completed weeks GA) only, 766 (9.9%) for congenital heart disease, 646 (8.4%) for chronic lung disease, and 1,050 (13.6%) for other risk factors (e.g., CNS disorders, airway anomalies, and cystic fibrosis). Patients received an average of 3.9 (SD 1.6) injections, with 30,040 doses given overall. 5.5% of patients withdrew from the study. No direct, drug-related serious adverse events were identified. 460 infants had a total of 541 hospitalizations for a spectrum of respiratory tract illnesses, resulting in a hospitalization rate of 6.0%.The overall RSV positive hospitalization rate was 1.47% with no mortality. Living with siblings was significantly correlated with a shorter time to first RSV-positive hospitalization (B = 0.615, df = 1, p = 0.046).

Conclusions: The RSV hospitalization rate observed in the 2005 to 2010 RSV seasons was similar to that found in several published reports of infants receiving prophylaxis (range 1.3% to 5.3%).

Presenting author: Mr. Khai Tran, Clinical Research Officer, Canadian Agency for Drugs and Technologies in Health

Co-authors: Ms. Karen Cimon (Clinical Research Assistant) and Mr. David Kaunelis (Information Specialist), Canadian Agency for Drugs and Technologies in Health; Dr. Andrew Pipe, The Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute; Dr. Peter Selby, Departments of Family and Community Medicine and Psychiatry, Faculty of Medicine and the Dalla Lana

Background: We conducted a systematic review and meta-analysis to compare the treatment effects of varenicline, bupropion, and six nicotine replacement therapies (patch, gum, lozenge, inhaler, sublingual tablet, and nasal spray) for smoking cessation in a general population of smokers with no apparent comorbidities (relatively “healthy”).

Methods: A literature search was conducted to identify randomized controlled trials that must have reported biochemically verified abstinence and follow-up at least six months post-initiation. Analyses were conducted using a Bayesian random effects model for mixed treatment comparisons meta-analysis. Odds ratio (OR) and credible interval (CrI) were calculated.

Results: Eighty one trials (from August 1982 to June 2009) were identified involving a total of 40,986 participants. Varenicline, bupropion, and all six nicotine replacement therapies were found to be more efficacious than placebo. Treatment with varenicline showed higher efficacy than with nicotine patch (OR 1.54, 95% CrI 1.15 to 2.06), nicotine gum (OR 1.63, 95% CrI 1.11 to 2.38), or bupropion (OR 1.41, 95% CrI 1.06 to 1.89) for one-year continuous abstinence. Similar results were obtained with six-month continuous abstinence and six-month point prevalence abstinence. Comparisons of the relative efficacy of bupropion and nicotine replacement therapy or between the various forms of nicotine replacement therapy were mostly inconclusive.

Conclusion: All eight pharmacotherapies under investigation could be used as aids in smoking cessation in relatively “healthy” adult smokers, with varenicline being better than the nicotine patch, nicotine gum, and bupropion.

Presenting author: Mr. Ba’ Pham, Research Associate, Toronto Health Economics and Technology Assessment Collaborative

Co-authors: Dr. Margaret Harrison (Professor) and Ms. Meg Carley (Data Manager, School of Nursing), Queen’s University; Ms. Maggie Chen, PhD Student, School of Public Health Sciences, University of Toronto

Background: Leg ulcers usually occur in older patients, a growing population with increasing demand for health care. Two compression-bandaging systems are frequent treatments. International studies demonstrate that one system leads to relatively faster healing and better quality-adjusted life-years for patients and cost-saving for providers. We evaluated whether this is relevant for community care of venous leg ulcers in Canada.

Methods: We conducted a cost-effectiveness analysis based upon clinical and economic data collected by the Community Randomized Control Trial of the Effectiveness of Two Compression Bandaging Technologies: four-layer (n = 215) or short-stretch (n = 209). We estimated costs according to the societal perspective and used a time horizon corresponding to the first year of the trial duration. We derived quality-adjusted life-years based upon successive responses by participants to the EQ-5D questionnaire.

Results: Median healing time was shorter with four-layer bandages although the 95% confidence interval crossed zero (15, -21 days to 32 days). Four-layer cost more than short-stretch bandages ($420, $235 to $739) and attained slightly higher mean QALYs (0.009, −0.019 to 0.037), resulting in an incremental cost per QALY gained of $46,667. If decision-makers are willing to pay $50,000 to $100,000 for an additional QALY, the probability that four-layer bandages were cost-effective was 51% to 63%, respectively. Results changed slightly with bandage prices and perspective.

Interpretation: Results from international studies are not extrapolated to community care of venous leg ulcers in Canada. There is no compelling clinical and economic evidence to support an unequivocal choice between four-layer and short-stretch bandages. Both yield high healing rates.

Presenting author: Ms. Nancy Risebrough, Senior Health Economist, Oxford Outcomes

Co-authors: Ms. Denise Zou, Health Economist, Oxford Outcomes; Dr. Rena Buckstein, Hematologist, Odette Cancer Center; Mr. Tony Kim, Manager, Celgene Canada; Dr. Adrian Levy, Professor, Dalhousie University

Objectives: To estimate the incremental cost-utility in Canada of azacitidine compared with conventional care regimens (CCR), including best supportive care (BSC) and low and standard dose chemotherapy (LDC/SDC) plus BSC in the treatment of higher-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) with 20% to 30% blasts.

Methods: The model is a lifetime, probabilistic Markov model with a 35-day cycle length consisting of three health states: MDS; transformation to AML with blasts > 30%; and death. A third-party, public-payer perspective was adopted. Overall survivals were extrapolated beyond the time horizon of the AZA-001 head-to-head trial. Resource use was determined through a questionnaire completed by Canadian clinical experts. The utility values were obtained from studies that mapped EQ-5D utility values from EORTC and SF-12 scores, respectively, elicited in 191 and 43 patients in two trials. Costs (2009 $C) and outcomes were discounted at 5% annually.

Results: In the base case, azacitidine had an incremental cost-effectiveness ratio (ICER) of C$78,963/quality-adjusted life-years (QALY) (95% CI; C$63,432, C$98,999) relative to CCR. The ICERs were C$84,395/QALY, C$88,786/QALY, and C$28,501/QALY, when comparing azacitidine to BSC, LDC plus BSC, and SDC plus BSC, respectively. Results were most sensitive to the estimates of utility for azacitidine after six-month treatment and overall survivals.

Conclusion: The nine-month survival benefit of azacitidine addresses unmet medical needs for patients with higher-risk MDS and AML with 20% to 30% blasts. The economic values of the benefits afforded by azacitidine

are within conventional thresholds of willingness-to-pay by third-party public payers for oncology treatments in Canada.

Presenting author: Dr. Paul Oh, Medical Director, Toronto Rehab, Cardiac Program

Co-authors: Dr. Peter Selby, Clinical Director, Addictions Program, Centre for Addiction and Mental Health; Dr. Gerald Brosky, Associate Professor, Department of Family Medicine, Dalhousie University; Ms. Carmen Arteaga, Chantix/Champix Project Statistical Lead, Pfizer Inc.; Dr. Suzanne Ranger (Medical Advisor, Medical Affairs) and Mr. Vincent Raymond (Manager, Health Economics & Outcomes Research), Pfizer Canada Inc.

Introduction: Facilitating access to effective pharmacological smoking cessation treatments (SCTs) by providing reimbursement could improve smoking cessation rates. SCTs are cost-effective compared with other reimbursed health care interventions, but they are currently not subsidized by most Canadian drug programs.

Objective: Evaluate the cost-effectiveness of adopting an SCT reimbursement drug policy in Canada.

Methods: A recently completed Canadian pragmatic randomized trial (ACCESSATION) showed that SCT coverage resulted in a higher quit rate at 26 weeks versus no coverage (20.8% versus 13.9% respectively (OR [95%CI): 1.64 [1.23, 2.18]). The lifetime health and economic benefits comparing the coverage policies was estimated using a published Markov model, Benefits of Smoking Cessation on Outcomes (BENESCO). Data on population demographics, abstinence rates, and SCT costs per eligible subject were directly obtained from the study. Relapse rates, mortality, and smoking-related comorbidity prevalence/incidence/utility data were obtained from the literature.

Results: The average cost per smoker randomized to SCT coverage was $338. The incremental cost per additional quitter between groups was $4,863 under a drug plan perspective. Using a Ministry of Health perspective, SCT coverage is a very cost-effective strategy, with discounted incremental cost utility ratios of $19,366/QALY and $5,448/QALY over 20-year and lifetime horizons, respectively. Sensitivity analysis indicated that both ratios are robust, but are relatively sensitive to abstinence rates and costs.

Conclusion: This economic evaluation demonstrates that adopting an SCT reimbursement drug policy is a cost-effective intervention over the long term. This information should be considered as government smoking cessation strategies and policies are reviewed.

Presenting author: Ms. Laurene Redding, Director, Government and Economic Affairs, Takeda Canada

Co-authors: Mr. John Hornberger (CEO and President), Mr. Wayne Cowens (Medical Advisor), and Ms. Rebecca Chien (Research Analyst), Cedar Associates LLC; Mr. Mike Wang, Director, Seminar Pro

Background: Febuxostat is a xanthine oxidase inhibitor indicated to lower serum uric acid (sUA) levels in patients with gout. Studies have indicated a positive correlation between elevated sUA and outcomes, such as flare and quality of life.

Methods: A Markov model was developed to compare the cost-effectiveness of febuxostat 80 mg versus allopurinol from the Canadian public payer perspective. Data on the efficacy of febuxostat and allopurinol in managing sUA levels were derived from febuxostat Phase III trials. Patient results were stratified by renal function. Risk of gout flare per sUA level was obtained from published literature. Drug cost and gout management costs were derived from Ontario Drug Benefit Formulary and a Canadian health records database. 5% discount rate and 30-year time horizon was applied in the base case analysis. The model predicts cost and quality-adjusted life-years (QALYs) gained for a representative patient with gout.

Results: Base case results show febuxostat to be cost-effective when compared to allopurinol with an incremental cost-effectiveness ratio (ICER) of $18,395 per QALY gained for patients with normal renal function. The model shows febuxostat to be moderately more cost-effective in the population with impaired renal function, (ICER of $15,468 per QALY gained). Probabilistic sensitivity analyses show febuxostat to be cost-effective in the population with normal renal function under various conditions with less than 5% probability of the ICER to exceed $33,000 per QALY gained.

Conclusions: Results suggest febuxostat is a cost-effective treatment in the Canadian health care setting for the management of hyperuricemia in patients with gout.

Presenting author: Dr. Huiying Sun, Statistician, CIHR Canadian HIV Trials Network

Co-authors: Dr. Bohdan Nosyk (Post-Doctoral Fellow) and Dr. Aslam Anis (National Co-Director), CIHR Canadian HIV Trials Network; Mr. Behnam Sharif (Research Assistant), Arthritis Research Centre of Canada; Dr. Curtis Cooper (Associate Professor of Medicine), University of Ottawa

Objective: Influenza vaccine immunogenicity is diminished in patients living with HIV/AIDS. We evaluated the cost-effectiveness of three alternative influenza vaccine dosing strategies intended to increase immunogenicity in those patients.

Design: Cost-effectiveness analysis conducted alongside a randomized controlled trial (RCT).

Methods: An RCT assessed the immunogenicity and efficacy of three influenza vaccine dosing strategies for HIV+ patients: Strategy A (single standard dose plus single standard dose booster), strategy B (Double dose plus double dose booster) and strategy C (single standard dose plus no booster). The comparator was practice in the previous year, in which 82.8% of HIV/AIDS received standard-dose vaccination (Strategy D). A Markov cohort model was developed to estimate the monthly probability of influenza-like illness (ILI) as a function of HIV virologic suppression (≤ 50 copies/mL), HI titre and influenza attack rates over one influenza season. The probability of ILI, ILI mortality, costs, and quality-adjusted life years (QALYs) were used in calculating incremental cost-effectiveness ratios (ICER).

Results: The 298 patients with median CD4 of 470 cells/μL and 76% with viral load suppression were randomized. Strategy B had the highest estimated cost and the lowest estimated probability of ILI. Strategy C dominated Strategy D in most model formulations, while strategies A (ICER: $5,261; 95% CI: Dominant – $238,680) and B (ICER:$13,675; 95% CI:$5,030 to $55,557) were cost-effective strategies for unsuppressed patients.

Conclusion: Ensuring influenza vaccination for all HIV/AIDS patients is a cost-effective strategy, while double-dose vaccination (Strategies A and B) was cost-effective for patients with unsuppressed HIV viremia at typically cited, willingness-to-pay thresholds.

Presenting author: Mr. Wesley Tong, Health Economics Research Analyst, Population Health Research Institute

Co-authors: Mr. Luc Sauriol, Sanofi-aventis; Dr. Andre Lamy, Population Health Research Institute

Objective: Atrial fibrillation and flutter (AFF) affects about a quarter of a million Canadians and causes 15% of all strokes. This study collected information from an academic teaching hospital in Ontario to determine the average cost per patient of those who presented in an emergency room setting and those who were hospitalized. 

Method: Data was extracted using ICD-10 codes pertaining to patients with either a most responsible diagnosis of AFF (primary criteria) or those with a most responsible diagnosis of congestive heart failure, acute coronary syndrome, syncope, transient ischemic attack or stroke, and a secondary diagnosis of AFF (secondary criteria) over a two-year period. A case-costing method was used to determine the average cost per patient for inpatient and emergency room cases. 

Results: The 1,186 patients who presented in the emergency room met our primary criteria, a further 251 patients met our secondary criteria, averaging $650 and $780 per visit respectively; 925 and 843 patients were hospitalized during this period and met our primary and secondary criteria respectively. Patients who met our primary criteria averaged $6,380 per visit versus $9,660 per visit for patients who met our secondary criteria. Patients who met our primary criteria had a shorter average length of stay than those who met our secondary criteria (5.4 versus 6.4 days).

Conclusion: Hospitalizations due to AFF are quite costly, but early treatment using appropriate options such as pharmacological agents would help reduce more costly complications such as stroke and lessen the burden to the health care system.

Presenting author: Ms. Alyson Mahar, Graduate Student, Queen’s University

Co-author: Dr. Ana Johnson, Assistant Professor, Queen’s University

Background: Gastric cancer is a highly fatal and rare disease in Canada. Although curative surgical therapy remains the standard, new techniques and adjuvant therapies are emerging and being integrated into the Canadian health care system. To gain an understanding of the costs of treating gastric cancer, a systematic qualitative literature review was performed.

Methods: A search of Embase (1947), MEDLINE (1950) and HealthSTAR (1966) databases was executed using search terms related to gastric cancer and health economics, supplemented by a manual search of review articles, current to June 1, 2010. The search was limited to primary data and English language. A standardized data abstraction form was used.

Results: 811 unique abstracts were identified. One article was found from manually searching references. Twenty-two articles were included: 20 cost identification, two economic evaluations. Ten were from Japan and one from Canada (published 1987). Only two studies reported a perspective, six a time horizon, and seven the year of cost valuation. Only 12 reported at least partial sources for cost information. The majority (17/22) reported costs related to surgery. Sensitivity analyses were performed in one study and a discount rate applied in two.

Conclusion: Contemporary Canadian data detailing the economic burden of gastric cancer on the health care system is non-existent. The available international literature is of poor methodological quality and difficult to translate to the Canadian health care system. Before decision-makers may be supported in creating evidence-based policy or health care planning related to gastric cancer, rigorous research into the costs of current practices is critical.

Presenting authors: Dr. Kukuh Noertjojo (Medical Analyst), Dr. Craig Martin (Senior Medical Advisor), and Dr. Celina Dunn (Manager, Medical Services) WorkSafeBC

Co-authors: Dr. Peter Rothfels (Chief Medical Officer and Director Clinical Services) and Ms. Gayle Pelman (Information Specialist), WorkSafeBC

Background: Policy Item # 15.50 and 15.51 on hernia in WorkSafeBC‘s Rehabilitation Services and Claim Manual was developed in the mid-1980s. This policy, which was developed by employing expert consensus, described various aspects of inguinal hernia including duration of return to work. This policy gives front line staff direction on how to deal with claims involving hernias.

Access to Cochrane Library in the early 2000s revealed a large discrepancy between the outcome of Cochrane review on hernia and Policy Item # 15.50, especially on duration of post-operative time off work.

Objectives: To describe the application of evidence-based medicine (EBM) at WorkSafeBC, through the work of Evidence-Based Practice Group, Clinical Services in policy development, and the dissemination of EBM by WorkSafeBC; to update WorkSafeBC 2003 systematic review on inguinal hernia focusing on duration of return to work; to investigate the impact of changes in Policy Item # 15.50 and 15.51 since 2004 in claim outcomes, costs, and duration of post-operative return to work for inguinal hernia related claims.

Methods: 2003 WorkSafeBC systematic review on inguinal hernia repair will be updated focusing on duration of post-operative return to activities; outcomes on hernia-related claims will be analyzed as a before (1999 to 2003) and after (2004 to 2008) analysis adjusted for various factors. 

Results: Systematic review update on inguinal hernia post-operative return to work and evaluation on hernia claim outcome will be presented.

Presenting author: Mr. Adam Raymakers, Health Economist, University of British Columbia/Collaboration for Outcomes Research and Evaluation (CORE)

Co-authors: Dr. Carlo Marra (Director, Associate Professor) and Mr. Mohsen Sadatsifavi (PhD Student), University of British Columbia/Collaboration for Outcomes Research and Evaluation (CORE); Dr. Fawziah Marra, Director, Associate Professor, British Columbia Center for Disease Control

Genital warts (GWs) are a sexually transmitted infection caused by various strains of the human papilloma virus (HPV). Several studies have described the direct and indirect costs of GWs while others have reported on the burden of GWs in terms of the impact on patients’ quality of life. The arrival of a quadrivalent HPV vaccine that protects against both cervical cancer and GWs stipulates a proper understanding of the impact of vaccines on costs and quality of life. Using predefined search terms and inclusion/exclusion criteria, we performed a systematic review of the economic and humanistic burden of GWs. The focus was on the direct and indirect costs of GWs per episode of care (EoC) or per year as well as the impact of GWs on disease specific, generic, or preference-based quality of life measures. We also reviewed the literature on the national burden of GWs from different countries’ perspectives. Other aspects of GW management that can inform economic modeling studies, such as length of EoC, number of physician visits, and indirect costs, were also explored. Our review sheds light on the high economic and humanistic burden of GWs, the important differences in the costs between men and women, as well as the difference in health resource utilization and costs across countries. Also, our study highlights the dearth of information on the impact of GWs on patients' quality of life.

Presenting author: Ms. Simone Sutherland, Research Associate, Programs for Assessment in Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton

Co-authors: Dr. Matthias Bischof (Post-Doctoral Fellow), Mr. Gord Blackhouse (Assistant Professor), Mr. Ron Goeree (Assistant Professor), Dr. Feng Xie (Assistant Professor), and Dr. Jean-Eric Tarride (Associate Professor), PATH Research Institute, McMaster University, St. Joseph's Healthcare Hamilton

Background: Interventions for coronary artery disease (CAD) may include coronary artery bypass graft surgery (CABG), medical therapy, or percutaneous coronary intervention (PCI). The Everolimus-Eluting Stent (EES) is a new drug-eluting stent (DES) that demonstrates superior clinical benefits to the Paclitaxel-Eluting Stent (PES); however, the cost-effectiveness of this DES has not been established.

Methods: A Markov model was developed to compare the cost-effectiveness of EES versus PES for patients undergoing a PCI from a Ministry of Health perspective. The model population had a mean age of 62 years. The time horizon was three years with a three-month cycle length. Outcomes were measured as costs and QALYs. Health states included were “well” (no event), “revascularization”, “myocardial infarction”, and “death”. Univariate and probabilistic sensitivity analyses (PSA) were conducted as well as a value of information (VOI) analysis.

Results: The incremental cost-effectiveness ratio (ICER) of EES compared to PES for the base case analysis was $72,770/QALY. At willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY, the probability of EES being cost-effective was 0.4 and 0.65, respectively. PSA results showed that the cost of the stent had the largest impact on the cost-effectiveness results. Expected Value of Perfect Information (EVPI) at WTP thresholds of $50,000/QALY and $100,000/QALY were $249.12 and $599.60 per patient, respectively.

Conclusion: EES would be considered cost-effective if society’s WTP is $72,770/QALY or higher. PSA and VOI analysis found a large amount of uncertainty at common WTP values and further research may be warranted.

Presenting author: Mr. Pierre Emmanuel Paradis, Senior Economist, Groupe D'analyse, Ltée

Co-authors: Ms. Valérie Carter (Economist) and Ms. Natalia Mishagina (Economist), Groupe d'analyse, Ltée; Mr. Vincent Raymond (Manager, Health Economics & Outcomes Research), Pfizer Canada Inc.

Rationale: Delayed access to effective medicines may lead to significant costs for society. Varenicline (Champix), a smoking cessation treatment (SCT), was recommended for listing by the Common Drug Review (CDR) in 2007. However, as of late 2010, no CDR-participating provincial drug plan had yet followed this recommendation.

Objective: To estimate the economic impact of delays in the public listing of varenicline in Canada.

Methods: Using data on smoking prevalence, SCT utilization, and peer-reviewed research, a cost-benefit model was developed to estimate the net economic impact of reimbursing varenicline from a society perspective. Flows of attempts, successful quits, and relapse rates were projected over a five-year period for the following scenarios: immediate listing of varenicline (2007, base case); one-year to five-year listing delays (2008 to 2012); and no reimbursement. Benefits and costs of delays were calculated from differential quitter flows among scenarios.

Results: Benefits of public reimbursement of varenicline in Canada would have been greater in the first year (C$299 million), then decrease due to the continuous erosion in smoking prevalence. The current three-year listing delay prevented a projected 17,811 current Canadian smokers from quitting, translating into a projected additional lifetime burden of C$700 million to society. Once reimbursement is enacted, a catch-up effect would occur, although initial delay costs would never be fully recovered.

Conclusions: Delaying reimbursement has an unrecoverable negative economic impact for Canada. While these results pertain specifically to varenicline, the reimbursement of other SCTs would further improve public health and economics.

Presenting author: Ms. Sherilyn Houle, Graduate Student, EPICORE Centre, University of Alberta

Co-authors: Dr. Anderson Chuck (Health Economist), Institute of Health Economics; Dr. Finlay McAlister (Associate Professor of Medicine) and Dr. Ross Tsuyuki (Professor of Medicine and Director of EPICORE Centre), University of Alberta

Background: Hypertension is a known risk factor for major cardiovascular (CV) events. Improving Blood Pressure Management in Patients with Diabetes (SCRIP-HTN) found that patients with diabetes and hypertension who received community pharmacy intervention had a mean systolic blood pressure reduction of 5.6 mm Hg more than patients receiving usual care. The aim of this study was to quantify potential health system savings as the result of such a program.

Methods: Two economic models were developed. Model 1 estimated cost savings from reduced CV events (myocardial infarction, stroke, heart failure hospitalization), and Model 2 integrated cost savings from reduced health resource utilization (nights in hospital, physician visits). CV event absolute risk reductions were calculated using published meta-analysis data, while resource utilization was determined from the Canadian Community Health Survey. Administrative data provided the cost per event, and thorough probabilistic sensitivity analyses were performed to assess the robustness of the results.

Results: Estimated cost-savings were calculated as $255 (95%CI: $230 to $279) and $4,002 (95%CI: $3,353 to $4,651) annually per patient in Models 1 and 2, respectively, in 2010 Canadian dollars. The variable most influential on mean savings in Model 1 was cost per inpatient care of stroke, while cost per night as an inpatient was the key contributor within Model 2.

Conclusions: Community pharmacy intervention for patients with hypertension and diabetes can result in cost savings of up to $4,002 annually per patient as a result of reduced CV events and health resource utilization. If similar programs could be developed and implemented for < $4,002 per patient per year, cost-savings would be achieved.

Presenting author: Dr. Nandini Dendukuri, Director, Technology Assessment Unit, McGill University Health Centre

Co-author: Ms. Irene Pan, Epidemiologist, Technology Assessment Unit, McGill University Health Centre Despite routine use of systemic antibiotics, high incidence of surgical site infections (SSIs) remains a concern in Canadian hospitals. These infections are associated with serious morbidity and increased health care costs. An adjuvant gentamicin-collagen sponge (GCS) treatment has been proposed as a novel solution to address the problem. In order to assist the McGill University Health Centre to develop a policy on the use of this technology, we carried out a health technology assessment of GCS for preventing SSI following cardiac and colorectal surgeries. A systematic review of the medical literature up to November 2010 identified three randomized controlled trials (RCTs) of GCS for sternal wound infection and 12 RCTs for SSI following colorectal surgery. Two large studies (3,452 patients provided starkly different results of the efficacy of GCS for sternal wound infection resulting in a wide overall confidence interval (risk ratio [RR] = 0.52; 95% CI: 0.15 to 1.79). For colorectal surgery as well, three moderate quality RCTs providing conflicting evidence of significant benefit or no benefit (overall RR = 0.85; 95% CI: 0.33 to 2.21). However, in two RCTs of open-wound colorectal surgeries, GCS did aid in wound healing (RR = 0.27; 95% CI: 0.10 to 0.69). We concluded that the development of a permanent ongoing policy for GCS usage is immature at present, given the uncertainty about its efficacy. It was recommended that the following steps be undertaken: assured strict adherence to the current oral and intravenous antibiotic protocol for colorectal surgery chart review to survey the infection risk factor profile at our institution for sternal wound infections.                                                                      

Presenting author: Ms. Rhonda Boudreau, Theme Lead, Canadian Agency for Drugs and Technologies in Health

Co-authors: Ms. Nancy Robertson (Knowledge Exchange Officer), Ms. Sandy Pagotto (Director, Program Development), and Mr. Michel Boucher (Theme Lead), Canadian Agency for Drugs and Technologies in Health

Purpose: To showcase the new CADTH theme-focused approach that will further meet Canadian health system customer needs. The presentation will highlight the roles of CADTH’s Theme Leads who are tasked with ensuring that the customer needs’ remain the focus throughout the project life cycle in order to deliver timely and relevant products and services with impact.

Audience: This presentation will benefit symposium attendees interested in learning about recent customer-focused improvements to the CADTH approach in the development and delivery of programs, products, and services.

Overview: Over the last year, CADTH has made strategic changes to the organization in a concerted effort to produce products and services that are more timely, more relevant, and have increased impact for CADTH customers. One significant change has been to devote four positions to championing the customer focus from topic development to knowledge exchange. These positions are Theme Leads.

Each Theme Lead has an assigned thematic area to ensure that the customer and health system needs are at the forefront throughout CADTH projects. Working with other pan-Canadian organizations to avoid duplication of effort and maximize impact, CADTH has identified six main thematic areas for 2010 to 2011: Cardiology, Diabetes, Emerging Issues, Infectious Disease, Mental Health, and Thoracic.

By maintaining current knowledge of changing system and customer environments within broad thematic areas, Theme Leads will help facilitate CADTH’s approach in ensuring that products address gaps between evidence and practice and that products are tailored to deliver the best support for informing health care decisions.

Presenting authors: Ms. Andra Morrison (Environmental Scanning Officer) and Ms. Lisa Farrell (Liaison Officer), Canadian Agency for Drugs and Technologies in Health

The Environmental Scanning Service at the Canadian Agency for Drugs and Technologies in Health (CADTH) keeps Canadian jurisdictions informed on the latest developments affecting health care. The service proactively alerts decision-makers to new and emerging health technologies, health care priorities, and health care system needs.

Methods: In an effort to be more responsive to our customers’ needs, CADTH provides tailored responses to specific information requests on issues of importance to decision-makers. Key issues are identified and the main trends and drivers of change affecting these issues are addressed.

Results: Environmental scans are recognized as a valuable tool by health care decision-makers. Environmental scans provide synthesized knowledge on pan-Canadian processes, structures, and practices at a local, regional, and jurisdictional level. This information enables policy-makers to make decisions regarding treatment options and choices to be adopted in the health care system that are informed by important contextual information.

The Environmental Scanning Service is supported by a pan-Canadian network of liaison officers who work in collaboration with individual ministries of health, regional health authorities, managers in hospitals, health professional associations, and researchers and specialists in medical, nursing, and pharmacy schools.

Next steps: Our environmental scanning briefs were developed in direct response to our customers’ needs. We will continue to engage our customers to ensure we are providing value-added information that can be used to make the best possible decisions regarding the delivery of health care.

Presenting author: Mr. Roderick Clark, Graduate Student, Dalhousie University

Co-authors: Dr. Judith Fisher (Post-Doctoral Fellow), Dr. Ingrid Sketris (Professor), and Dr. Grace Johnston (Professor), Dalhousie University

Introduction: Acetaminophen/opioid combination drugs are among the most commonly prescribed analgesics in Canada. These drugs are widely perceived as safe among prescribers and the public. However, acetaminophen use is associated with acute and chronic hepatotoxicity at doses above the recommended daily limit (4.0 g per day); and is associated with liver failure in certain populations at doses below the recommended daily limit.

Methods: Data was collected from the Nova Scotia Prescription Monitoring Program on all prescription opioid analgesics containing acetaminophen dispensed in Nova Scotia (NS) from 2005 to 2010. Daily doses and rates of prescriptions and of tablets dispensed were analyzed for trends over time and stratified by age, sex, and cancer diagnosis. The Cochran-Armitage Test was used to examine trends over time. Population standardized rates were computed for specific outcomes.

Results: During 2009-2010, 59,197 individuals (7.7% of the NS population) filled prescriptions for over 13 million acetaminophen/opioid combination tablets (average of 223 tablets per person filling a prescription). Roughly 6% of these individuals were dispensed prescriptions that exceeded the recommended daily limit (4.0 g/day) of acetaminophen and 18% exceeded 3.25 g/day. Stratified crude rates, population standardized rates, and results from the Cochran-Armitage test for trend will be presented.

Conclusions: Given the large number of individuals receiving over the recommended daily limit of acetaminophen, further research is warranted to explore patterns of use in populations at greatest risk, the reasons for use above the recommended dose, and the impact on patient outcomes.

Presenting author: Mr. Tarun Ahuja, Theme Lead, Canadian Agency for Drugs and Technologies in Health

Co-authors: Ms. Samantha Verbrugghe (Clinical Research Assistant), Mr. Changhua Yu (Clinical Research Officer), Mr. Sumeet Singh (Manager, Clinical Research), and Ms. Sandy Pagotto (Director, Program Development), Canadian Agency for Drugs and Technologies in Health

The mission at CADTH is to assist health care decision-makers, patients, and health care professionals in making well-informed decisions based on evidence. One way in which CADTH accomplishes this mandate is by conducting optimal use projects and HTAs. Traditionally, these projects moved forward with the arduous task of assimilating and assessing available evidence with little feedback. Some limitations of this approach include the considerable resources and time required in order to complete the project with the level of methodological rigour expected. The lengthy review process did not necessarily take the continuously changing landscape of evidence into account. Recently, CADTH has introduced priority themes within the agency with an associated Theme Lead (TL) who keeps apprised of emerging issues, monitors both internal and external initiatives, and keeps up-to-date on the ever-changing pool of evidence. Another addition to the process is the introduction of a Portfolio Committee (PC), which reviews deviations from the original research protocol. Establishment of both the TL and the PC has allowed the review process to become much more reactive and responsive to the feedback that they both provide. This ensures that the direction and the scope of projects can be adapted in reaction to changes in customers’ needs, initial review of the evidence, identified changes in the priority theme, and linkages to new internal and external projects within the theme.

This presentation will use a current CADTH Mental Health Optimal Use project onCombination and High Dose Use of Atypical Antipsychotics for Schizophrenia as a case study to highlight how feedback from TLs and the PC allow CADTH the opportunity to identify gaps in evidence and become more responsive to them.

Presenting author: Dr. Jennifer Davis, Postdoctoral Fellow, Centre for Clinical Epidemiology and Evaluation

Co-authors: Dr. Teresa Liu-Ambrose (Assistant Professor), Mr. Karim Khan (Professor), and Mr. Stirling Bryan (Professor), University of British Columbia

Rationale: The ICECAP-O is a new measure of capability for seniors that seeks to capture outcomes beyond health-related quality of life (HRQL). The EQ-5D is an established HRQL measure used extensively in senior populations. To judge whether the ICECAP-O measure can replace EQ-5D in economic evaluations, we sought to assess the level of association between the two instruments, and their respective construct validity in relation to known indicators of frailty.

Methods: For a cohort of consecutive patients attending the falls prevention service at Vancouver General Hospital, we collected data on EQ-5D and ICECAP-O at baseline, six months, and 12 months. At baseline, we collected a range of other variables, including the Physiological Profile Assessment (PPA), an accepted indicator of patient frailty. The association between ICECAP-O domains and EQ-5D value scores was assessed using one-way ANOVA. We compared the construct validity of the EQ-5D and ICECAP-O using several clinical measures, including the PPA.

Results: Between January 2009 and May 2010, 271 seniors were recruited whose mean age was 78.9 ± 6.6 years and mean PPA was 1.7 ± 1.2. Response rates for the EQ-5D and ICECAP-O were 90%, and item completion rates were almost 100%. Three domains of the ICECAP-O (”Thinking about the future”, ”Enjoyment”, and ”Independence”) were significantly associated with variation in the EQ-5D value score (p < 0.05). Variation in the PPA score was significantly reflected by three domains of the EQ-5D (”Mobility”, ”Self-care”, and ”Usual activities”). For ICECAP-O, only ”Independence” explained a statistically significant amount of variation in the PPA score.

Conclusions: Both EQ-5D and ICECAP-O can feasibly be administered in this patient group. However, our data suggest that some variability in EQ-5D is not captured by ICECAP-O, indicating they are complementary. The implications of our results for using both measures in the context of economic analyses require further consideration.

Presenting author: Dr. Gina Trubiani, Research Associate, Toronto Health Economics and Technology Assessment (THETA) Collaborative

Co-authors: Dr. Harindra Wijeysundera (Interventional Cardiologist), Mr. William Witteman (Information Systems Designer), Dr. Nicholas Mitsakakis (Biostatistician), Dr. Murray Krahn, (Director), THETA Collaborative

Background: Despite evidence from randomized controlled trials (RCTs) that specialized multidisciplinary heart failure (HF) clinics are cost-effective, such clinics do not receive provincial funding in Ontario. One concern is that current HF clinics may not reflect the model of care evaluated in RCTs. Our objectives were to identify all HF clinics in Ontario and describe their program components and intensity.

Methods: Clinics were identified using respondent-driven sampling from an initial seed of 15 clinics. Each clinic identified new clinics for the next generation of sampling. This “snowball” sampling technique continued until saturation. A structured interview was then conducted. We used a validated questionnaire to measure each clinic’s program intensity and complexity across 10 categories, including education and medication management. 

Results: Sampling reached saturation within three generations (34 HF clinics).There was substantial variation in treatment intensity across clinics, mostly with respect to education: some clinics only provided education on treatment adherence; other clinics emphasized the importance of surveillance, management, and treatment of symptoms. A number of clinics provided remote monitoring. Access to multidisciplinary teams that included pharmacists and dieticians was also variable. In contrast, there was little variation in type of clinic, intervention duration, and type of medical management.

Conclusion: We found that, despite the absence of funding, a large number of HF clinics are distributed across Ontario, each with widely varying services for patients. This is the initial phase of a comprehensive field evaluation which aims to identify HF program elements that are most effective and cost-effective. 

Presenting author: Dr. Nathalie Dourdin, Senior Research Application Associate, BioMedCom Consultants Inc.

Co-authors: Dr. Etienne Richer (Senior Research Application Associate) and Dr. Mireille Goetghebeur (Vice-President, Operations), BioMedCom Consultants Inc.

Background: Milk banks, which supply human milk prescribed by physicians, primarily to premature and ill infants, are well-established worldwide. In Canada, only one milk bank is currently operating in Vancouver and another one is in development in Toronto. Both banks are hospital-based.

Objective: To support evidence-based decision-making for implementing a milk bank administered by a blood bank in Quebec.

Methods: A systematic review of the literature was performed to identify available evidence (clinical, economic, epidemiological) on banked donor milk. This data was supplemented with contextual data collected during interviews with a wide range of stakeholders in Quebec.

Results: Banked donor milk reduces the rate of necrotizing enterocolitis (NEC), with a risk factor ranging from 0.21 to 0.4 compared to formulas. Given the burden associated with NEC and its costs (70 cases among very low birth weight infants in Quebec in 2008-2009, costing a total of C$5,426,128 [2010]) and the rising number of pre-term births in Quebec, the use of donor milk could have a positive clinical and economic impact. Preliminary data from a survey conducted with pediatricians, neonatologists, lactation consultants, midwives, public health representatives, and breastfeeding mothers in the province of Quebec suggests that a milk bank administered by a blood bank would receive support from many stakeholders.

Conclusion: Evidence suggests that the implementation of a milk bank in Quebec could be clinically and economically beneficial and would be supported by a wide range of stakeholders, although further validation is required before a final recommendation can be made.

Presenting author: Ms. Tennielle Loo, Student, University of British Columbia

Co-authors: Dr. Paul Grootendorst, Director of Division of Clinical, Social and Administrative Pharmacy, University of Toronto

Introduction: The exponential rise in pharmaceutical R&D expenditures strongly contrasts against the stagnant numbers of new chemical entities that are submitted to the FDA. This trend is alarming and poses the question: how can Canada support and encourage the innovation that is needed to continue the investment in Canada’s pharmaceutical industry and health care sector? In providing a pharmacoeconomic analysis of the state of Canada's pharmaceutical R&D sector, this work serves to address the challenges faced by Canadian policy-makers.

Objective: To develop a novel method of estimating the breakdown of funding sources (government and industry) and spending avenues (clinical and basic research) in pharmaceutical R&D, where key parameters affecting spending and funding patterns will be evaluated. Additional topics affecting Canada's investment in R&D and health care will also be investigated: the nature of public-private scientific partnerships, US legislation on intellectual property, and the concept of “innovation.”

Modeling methods: Sample frame data was obtained from the OECD database where the purchasing power of parity and uniform dollars were accounted between countries for 1991 to 1996 and 2001 to 2006. Canada will be compared against the three largest geographical areas of pharmaceutical goods: US, Europe, and Japan.

Results: Globally, the US overtakes Europe in overall spending; the US has more funding from the industry sector than the government (unlike Europe). Overall, more money is spent in clinical health research by all countries. Compared to the other countries, Canada lags significantly in all areas and has experienced a small growth. However, in recognition of this, Canada has placed unique policies that are encouraging investment in this field.

Conclusions: Canada's technology transfer initiatives, promotion of innovation, and private-public partnerships are creating a favourable environment for growth. However, Canada needs to develop clear policies on commercialization, ownership, and rights. Increases in government funding could supplement investments by the industry as seen by Europe to allow Canada to adopt strategies to be more efficient and competitive.

Presenting author: Mr. Mike Paulden, Research Associate, University of Toronto

The concept of a cost-effectiveness “threshold” has been adopted either explicitly or implicitly by health care decision-makers in numerous jurisdictions.

This paper demonstrates that, under very weak assumptions – applicable to all of Canada’s provincial health care systems – there are in fact “two” cost-effectiveness thresholds. The assumptions are that: (a) there is some fixity in the set of adopted technologies in the short term; and (b) technology, productivity, and/or input prices change over time, or the information available to decision-makers improves over time, or both.

Where these assumptions hold, one threshold ought to be adopted when appraising technologies with positive incremental costs (investment decisions) while another threshold should be adopted when appraising technologies with negative incremental costs (disinvestment decisions). This is true regardless of the marginality of the technologies under consideration.

This finding has profound implications for the practice of cost-effectiveness analysis, for ongoing and future empirical research into the nature of the threshold, and for health care policy-making. It has implications for the interpretation of ICERs, for the appropriate calculation of net (health) benefit, and for the estimation of the value of (perfect) information. It gives a theoretical underpinning to observations that the ICERs of technologies disinvested at the margin differ from those of technologies adopted at the margin. It also has significant implications for policy-making, in particular for decision-makers who currently adopt a single threshold and who wish to ensure that decisions are compatible with their stated values and objectives.

Presenting author: Ms. Tamryn Law, Medical Student, University of British Columbia

Co-authors: Mr. Ross Petersen (Research Coordinator) and Dr. Douglas Courtemanche (Principal Investigator), BCCH

Lipohamartomas are rare, benign nerve tumours that are usually associated with macrodactyly. Diagnosis and subsequent treatment occur as per impaired functionality, obvious disproportionate growth, or compressed nerve symptoms. Treatments include carpal tunnel release and, in severe cases, amputation. Currently, the rarity of this condition has led to sparse and controversial knowledge regarding timing and management options. Early diagnosis and intervention has the potential to significantly impact the management and the burden of disease for patients presenting with the same condition in addition to significantly reducing the costs associated with this disease. Furthermore, although the diagnosis can be made clinically, studies have proposed the use of MRI imaging evidence to identify pathognomonic features for diagnosis. Liphohamartomas are unique from other intraneural tumours, as demonstrated through differences in pathology, clinical presentation, and pathognomonic MRI imaging evidence. Therefore, determining the usefulness of clinical diagnosis versus the use of MRI resources is valuable from a resource allocation perspective in terms of allowing a better investment in health care expenditures.

We conducted a retrospective chart review of all pediatric plastic surgery patients with lipohamartoma diagnoses seen between 1993 and 2010. From these, we identified the 10 patients who were diagnosed with lipoharmatoma, and characterized their clinical features, treatment pathway, and clinical outcomes - including consideration of the necessity of MRI imaging for diagnosis, prognosis, and management. This is the largest pediatric case series reported in the literature.

The clinical classification of lipohamartomas as either progressive or non-progressive was possible without MRI imaging evidence. The classification is significant in terms of predicting disease progression, and is integral in the management of these patients. This provides support for significant savings in health care, which will allow the redirection of funds to other investments in health care. For each patient, surgical treatment was specific to each patient’s clinical and functional presentation. Further follow-up is necessary to assess long-term outcomes and to assess the resource economics.

Presenting authors: Ms. Eva Tsakonas, Consultant; Ms. Christine Perras, Clinical Research Officer, Canadian Agency for Drugs and Technologies in Health

Co-authors: Ms. Sarah Ndegwa, Consultant; Dr. John Conley, University of Calgary; Dr. Louis Valiquette, Université de Sherbrooke; Ms. Kelly Farrah, Information Specialist, Canadian Agency for Drugs and Technologies in Health

Clostridium difficile infection (CDI) is the most common cause of nosocomial infectious diarrhea in adults. Recently, the spread of a hypervirulent strain of C. difficile has caused an outbreak of infections. A primary economic evaluation comparing vancomycin and metronidazole in patients with an initial or recurrent episode of severe CDI was conducted to inform reimbursement policies in Canada.

A primary economic analysis based on the efficacy data from one randomized controlled trial compared the cost-effectiveness of first-line therapy with vancomycin versus metronidazole in patients with severe CDI. It was assumed that there was no difference between vancomycin and metronidazole in the incidence of serious complications. The economic evaluation estimated that each additional clinical cure attained through first-line vancomycin use would be at an additional cost of $1,161 to the health care system.

Deterministic sensitivity analyses showed that the incremental cost per clinical cure increased in an outbreak of a hypervirulent strain of C. difficile due to high doses of vancomycin being prescribed to an increasing proportion of patients. Another sensitivity analysis suggested that substituting oral vancomycin capsules with a lower-cost generic intravenous formulation administered orally could significantly decrease the incremental cost-effectiveness ratio. Also, small decreases in hospital stay among treatment successes could make vancomycin cost-saving. Finally, if serious complications occurred in equal rates among treatment failures, initial treatment with vancomycin would be cost-saving to the health care system due to savings in hospital costs.

The use of oral vancomycin in patients with severe CDI will incur an incremental cost of $1,161 per clinical cure, but vancomycin may be cost-saving if it impacts complication rates and reduces hospitalization costs.

Co-authors: Ms. Jessie Cunningham (Information Specialist) and Ms. Caitlyn Ford (Information Specialist), Canadian Agency for Drugs and Technologies in Health

Background: The Canadian Agency for Drugs and Technologies in Health (CADTH) has a Rapid Response service, which supplies available evidence for informed decision-making to Canadian health care providers. Increasingly, the Rapid Response service is receiving requests for information on topics related to health care human resources and health care provider occupational safety. In order to meet this need, CADTH information specialists sought to create an effective grey literature checklist that contained websites on human resource topics within the health care field.

Objective(s): To locate and identify websites (specifically nursing) that generate material on topics related to health care human resources and/or occupational safety. The goal is to create a grey literature resource base that has been evaluated for reliability, authoritativeness, and suitability for inclusion in Rapid Response reports.

Methods: Two information specialists conducted a focused Internet search for health care human resources using the CINAHL database as well as web-based resources. In addition, specific listservs were also used to solicit suggestions from other health information professionals across North America.

Results: The resulting resources were compiled and evaluated using predetermined criteria developed by CADTH information specialists. The preliminary results included sources from professional associations and academic health libraries, among other human resources sites. The content of each resource was evaluated, and then divided into appropriate topic areas.

Conclusions: CADTH’s Rapid Response service has expanded its grey literature searching practices to include sources or websites that specialize in providing relevant and authoritative information on topics in health care human resources and occupational health.

Presenting author: Mr. Kuhan Perampaladas, Graduate Student, PATH Research Institute, McMaster University

Co-authors: Dr. Xie Feng (Assistant Professor) and Mr. Brett Doble (Graduate Student), PATH Research Institute, McMaster University

Background: The EQ-5D is one of the most widely used instruments to estimate utility values. The scoring system of the EQ-5D were developed from valuation studies, which estimate a scoring function for all EQ-5D health states based on the general population’s preference for a subset of health states. Due to the widespread use of the EQ-5D, a number of country-specific scoring systems have been developed.

Objective: The objective of this study was to identify and compare all existing EQ-5D valuation studies and country-specific scoring systems.

Method: An electronic search of MEDLINE, Embase, NHS EED, HEED, and a search through the past proceedings of the Euroqol group up to September of 2010 was conducted to identify all EQ-5D preference elicitation studies. The review included a summary and comparison of study design, model estimation, study demographics, and scoring function.

Results: After screening 2,940 citations identified from the literature search, 31 elicitation studies that contained a unique scoring system were included for final review. The key areas of divergence between the studies include: differences in methodology used to directly value health (i.e., SG TTO, etc.), the number of health states that were directly valued, the transformation of the directly valued health states, the statistical methods used to derive the scoring system, and the model variables included in the scoring system.

Conclusion: Differences in methods do exist between population studies. Knowing the extent to which the identified methodological differences can explain the variation will help determine whether a global preference for health exists.

Presenting author: Dr. Mohsen Sadatsafavi, Student, University of British Columbia

Co-author: Dr. Faziah Marra, Professor, University of British Columbia

Background: The high efficacy of pneumococcal conjugate vaccines (PCVs) makes the universal childhood vaccination an attractive option. However, precise assessments of cost and effectiveness of competing vaccination programs is necessary to optimally use health care resources.

Methods: We created a dynamic model for the transmission of pneumococcal infection and the impact of vaccination with the seven-valent (PCV7, current standard), 10-valent (PCV10), or 13-valent (PCV13) vaccines in Canada. The model simulated dynamic population changes as well as incidence and consequences of pneumococcal disease, such as otitis media (OM), pneumonia (PN), meningitis (MN), and bacteremia (BM). The time horizon of the model was 20 years and was calibrated based on the pre- and post-vaccination status of pneumococcal diseases in the US.

Results: When comparing PCV10 to PCV7 vaccine, the model predicted that the annual incidence of pneumococcal diseases will decline by 11.5% for OM, 5.0% for PN, 7.7% for MN, and 5.8% for BM; the corresponding numbers for PCV13 to PCV7 vaccine are 46.2% (OM), 40.3% (PN), 46.2% (MN), and 42.3% (BM). PCV10 and PCV13 result in $17.6 and $32.3 reduction in the annual direct costs per person, respectively. They also result in a gain in the quality-adjusted life-years (QALY) of 0.001 and 0.006, respectively. As such, PCV10 and PCV13 are cost-saving compared to PCV7, and PCV13 is also cost-saving compared to PCV10.

Conclusion: This is the first cost-effectiveness analysis of PCVs based on a serotype-specific dynamic model of pneumococcal disease. With a broad set of assumptions, it appears PCV13 is the best vaccination strategy in Canada.

Presenting author:  Dr. Nandini Dendukuri, Director, Technology Assessment Unit, McGill University Health Centre

Co-authors: Professor Maurice McGregor (Chair) and Mr. Xuanqian Xie (Biostatician), Technology Assessment Unit , McGill University Health Centre

Background: Eight systematic reviews and eight health technology assessments (HTAs) have recently considered this issue. All failed to find sufficient evidence to support a conclusion that negative pressure wound therapy (NPWT) is more clinically effective than available alternatives. (Two reported positive evidence of “very poor” quality of effectiveness of NPWT for diabetic foot wounds.) In spite of this, the technology is increasingly used. We considered the possibility that the market, the users, might be right. We hypothesized that use of inappropriate quality criteria might be causing exclusion of valid positive evidence.

Methods: We made a systematic search for relevant randomized controlled trials (RCTs) and graded their credibility (A,B,C) using an instrument we considered more appropriate for evaluation of non-pharmacologic interventions than those commonly used. 

Results: We found 17 RCTs. Five had not been included in previous reviews or HTAs.  In seven RCTs of studies on diabetic foot ulcers (580 patients; 2A, 2B, 3C), there was consistent evidence of benefit of NPWT compared to control treatments. For pressure ulcers (three RCTs, 68 patients), one trial (B) found NPWT to be superior, while two (two C) did not. In five trials (267 patients) involving mixed wounds, one (B) provided statistically significant evidence of benefit, while four (one B and three C) did not. There was no evidence of any increase in complications.

Conclusions: There is now sufficient evidence to conclude that NPWT is safe and will accelerate healing of diabetes-associated chronic leg wounds. For other applications, additional evidence of efficacy is required.

Presenting author: Dr. Siavash Jafari, Community Medicine Student, University of British Columbia

Co-author: Dr. Baharlou Souzan, Research Assistant, University of British Columbia

Background: The main goal of any research project is to create knowledge that would contribute to improving the health and wellbeing of a population. Unfortunately, the process of knowledge production over the past three decades has been so rapid that the health care system has not been able to translate or transfer most of it to the population.

Objectives: The main objective of this project is to identify the public’s information needs and to collect, process, translate, and transfer credible knowledge to them.

Methods: As part of the needs assessment, we used online analytical softwares to identify the health issues that have been searched most frequently. Credible health information on relevant topics is being created and posted in an online knowledge translation repository.

Results: Twenty-three themes were merged from the searched databases. We identified the highly searched 50 health conditions on each of those 23 themes. “Pain”, “diet and nutrition”, “substances and drugs”, “skin care”, and “mental health” issues were among the most commonly searched topics in Canada and internationally. An online, free-to-access, knowledge-translation repository is created and is under continuous development to deliver the most requested information in audio-visual and text format to the public.

Discussion: Identification of health literacy needs of communities would assist our academics and health care system to allocate their resources in the most effective manner. Our preliminary results indicate that the availability of a free, user-friendly, reliable, and simple-to-understand health information system promotes the utilization of the information and contributes to health promotion in our society.

Presenting authors: Ms. Ann Vosilla, Liaison Officer, Canadian Agency for Drugs and Technologies in Health; Ms. Susan Chunick, Director, Department of Evaluation and Research Services, British Columbia Fraser Health Authority

Innovative solutions founded on building collaborations are critical in order to lead practice in today’s fiscally challenged health environments. Linking agencies that work together to provide health evidence to health care providers and decision-makers is a key step in creating sustainable patient-centered health services. Relationships that move away from competitive cultures and take full advantage of interorganizational collaborations need to be developed.

BC’s Fraser Health Authority and CADTH joined forces to develop a collaborative partnership that augments existing resources to enhance learning outcomes for health providers and decision-makers. This collaborative model has improved uptake of evidence by clarifying methodologies for selecting the highest quality and most relevant evidence and has increased knowledge exchange with other provincial agencies by identifying appropriate and reliable sources for retrieving evidence.

This collaboration between organizations with unique and different roles began by clarifying how each participates in health evidence delivery. Sharing and identifying differences and similarities augmented discovery of possibilities for interagency collaboration. Open dialogue and information sharing led to enhancement of existing resources as new pathways for delivering evidence, for example integrating library information scientists into knowledge brokering, were identified. One outcome of this collaboration is that other health delivery organizations have partnered with CADTH to adopt the same collaborative model within their own local environment in evidence delivery. Synergistic collaborative support is an effective means to transfer evidence knowledge within both the local and regional environments. Duplication of services is minimized and overall cost savings are realized as ultimate results.

Presenting author: Mr. Geoff Lewis, Clinical Editor, Canadian Pharmacists Association

Co-author: Dr. Brian Haynes (Chief) and Ms. Jennifer Lawson (Research Librarian), Health Information Research Unit, McMaster University; Ms. Carol Repchinsky, Editor in Chief, Canadian Pharmacists Association

e-Therapeutics is an online evidence-based therapeutic reference. Subscribers include pharmacists, physicians, and other health care practitioners. The Health Information Research Unit (HIRU) at McMaster University has developed a system (MacPLUS) to select high-quality articles in health research. These articles are appraised by research staff for scientific merit and rated by clinicians for clinical relevance and newsworthiness. Practitioners should be aware of highly rated articles when making decisions regarding patient care.

Objectives: Develop a link between e-Therapeutics and MacPLUS to provide new relevant articles within the content of e-Therapeutics and to the authors and editors to support and encourage content updates.

Methods: Each therapeutic topic has been mapped using SNOMED concepts. SNOMED coded articles are continuously added to the HIRU database and alerted to specific editors and authors via email as relevant to their topic. Web service transfer of selected articles from the HIRU database to CPhA database is followed by featuring articles at a link within relevant chapters to provide subscribers with access to new evidence.

Results: Authors and editors are receiving regular email updates to support them in ongoing revision of e-Therapeutics content. Subscribers are able to view article summaries from within the related chapter in e-Therapeutics. The SNOMED concept mapping is being refined to improve the relevance of articles matched to topics.

Conclusions: A continuously updated evidence infrastructure supports the mission of a therapeutics reference to provide health care practitioners with best evidence for patient care. Future development may refine how articles are presented to subscribers.

Presenting authors: Dr. Jean-Eric Tarride, Associate Professor, McMaster University; Mr. Kevin Harrington, Senior Manager Private Healthcare and Government Affairs, Abbott; Mrs. Ruth Balfour, Manager, External Implementation for the Group Client Development Department, Pacific Blue Cross

Co-authors: Mr. Peter Simpson, Senior Manager, Government Affairs, GlaxoSmithKline; Mrs. Leslie Foord, Senior Manager, External Relations, AstraZeneca; Dr. William Lakey (Medical Director of the Occupational Health Services) and Mrs. Lisa Anderson (Program Manager for Corporate Health and Benefits Programs), British Columbia Public Service Agency

Objective: To evaluate the My Health Matters! (MHM) program, a multifaceted workplace intervention relying on education and awareness, early detection, and disease management with a focus on risk factors for metabolic syndrome.

Participants: The MHM program was offered to 2,000 public servants working in more than 30 work sites in British Columbia, Canada.

Methods: The MHM program included a health risk assessment combined with an opportunity to attend an on-site screening and face-to-face call-back visits and related on-site educational programs. Clinical and economic outcomes were collected over time in this one-year prospective study coupled with administrative and survey data.

Results: Forty-three per cent of employees (n = 857) completed the online HRA and 23% (n = 447) attended the initial clinical visit with the nurse. Risk factors for metabolic syndrome were identified in more than half of those attending the clinical visit. The number of risk factors significantly decreased by 15% over six months (n = 141). The cost per employee completing the HRA was $205 while the cost per employee attending the initial clinical visit was $394. Eighty-two per cent of employees would recommend the program to other employers.

Conclusions: This study supports that workplace interventions are feasible, sustainable, and valued by employees. As such, this study provides a new framework for implementing and evaluating workplace interventions focusing on metabolic disorders.

Presenting author: Ms. Anna Liovas, Senior Manager, Reimbursement, AstraZeneca Canada Inc.

Co-authors: Ms. Christine Folia (Vice President) and Dr. Kristin Beard (Consultant), Agro Health Associates Inc.

Objective: Clopidogrel with aspirin is used to prevent thrombosis. However, up to 33% of patients are clopidogrel non-responders (CNRs). A meta-analysis has shown that clopidogrel resistance is associated with a 3.5-fold increased risk of ischemic events. There are several platelet function assays (PFAs) available to assess clopidogrel resistance, the gold standard being light transmission aggregometry (LTA). Other PFAs include vasodilator-stimulated phosphoprotein phosphorylation (VASP) and VerifyNow^® (VN). PFAs are not frequently used clinically because they are expensive, and time- and labour-intensive. It is of interest to compare the reliability of various PFAs in the identification of CNRs.

Methods: A MEDLINE search was conducted (1966 to 2010) using the following MeSH terms: “clopidogrel”, “resistance”, and “platelet function assay”. Patient-based studies that compared the proportion of CNRs using different PFAs were retrieved.

Results: Four studies were retrieved. Of these studies, three demonstrated significant heterogeneity among PFAs in their identification of CNRs. The proportion of CNRs identified with the various PFAs ranged from 13% to 39%, 44% to 69%, 35% to 90%, and 69% to 70% in the four studies, respectively.

Conclusion: The ability to identify CNRs by different PFAs varies greatly according to the assay used. In addition, LTA and VASP are associated with poor quality control, expense, and long turnaround times, and they are typically restricted to specialized laboratories in research hospitals. The inability of PFAs to accurately assess clopidogrel resistance may place unidentified CNRs at increased risk of ischemic events. The challenges and costs associated with PFAs may be eliminated by newer therapies that have less response variability than clopidogrel.

Presenting authors: Dr. Line Guénette (Post-Doctoral Fellow) and Dr. Barbara Mintzes (Assistant Professor), University of British Columbia

Introduction: Contact with pharmaceutical sales representatives (PSR) affects prescribing quality and cost, but little is known about the effectiveness of differing approaches to regulation.

Objectives: To compare the regulation of PSR activities in Canada, France, and the United States, and the opinions of key stakeholders on the effectiveness of current regulatory practices.

Methods: A literature review and document synthesis were performed to identify key stakeholders from government and affected sectors, and to describe national regulations. Semi-structured, open-ended interviews were carried out, and a qualitative analysis used to compare regulatory approaches between countries, and barriers and enablers contributing to perceived effectiveness.

Results: In Canada, regulation of PSRs is largely delegated to the industry via a Code of Conduct and voluntary pre-approval of promotional materials. Pre-approval is seen as an enabler to effectiveness; identified barriers are lack of formal monitoring, voluntary compliance, weak enforcement, and lack of transparency. In France, regulation is partly delegated to the industry via certification of companies that conform to the Sales Visit Charter. The French regulatory agency also approves promotional material a posteriori. Enablers include publication of violations and financial penalties; barriers include omission of information quality from certification criteria. The United States Food and Drug Administration also requires a posteriori approval of materials and encourages voluntary industry compliance. Enablers include proactive monitoring and enforcement; barriers are monitoring difficulties and pressures on staff time from direct to consumer advertising.

Conclusion: Voluntary compliance by industry is encouraged in these three countries. However, proactive monitoring and strong enforcement procedures are seen as essential to effective health protection.

Presenting authors: Ms. Abby Li, Research Assistant, Medical Outcomes And Research In Economics (MORE) Research Group; Dr. Ian Mitchell, Professor, Department of Paediatrics, University of Calgary

Co-authors: Dr. Bosco Paes, Professor, Department of Paediatrics, McMaster University;

Dr. Krista Lanctot, Executive Director, Medical Outcomes and Research in Economics (MORE) Research Group

Objective: To compare palivizumab utilization and compliance, and respiratory infection (RI) outcomes in sub-groups of infants at high risk for RSV within the Canadian Registry Database (CARESS).

Design/Methods: A prospective, observational registry of infants across 29 sites who received ≥ 1 dose of palivizumab during the 2006 to 2010 RSV seasons. Utilization and RI outcomes were collected monthly over the full course of palivizumab. Infants ≤ 35 completed weeks gestational age without medical conditions who met standard approval criteria (Group 1) were compared to those at high risk of RI due to underlying medical illnesses (Group 2).

Results: There were more infants in Group 1 (n = 4,880, 84%) than Group 2 (n = 952, 16%). Group 2 included Down syndrome (20.2%), upper airway anomalies (18.5%), pulmonary disorders (13.3%), cystic fibrosis (12.3%), neuromuscular impairment (8.2%), multiple system disorders (6.1%), cardiac disorders (2.7%), immunocompromise (1.8%), and miscellaneous disorders (16.9%). From 2006 to 2010, the proportion of Group 2 infants increased four-fold, from 5.6% (69/1224) to 19.1% (462/2413). Group 2 was older at enrollment (10.2 ± 9.2 versus 3.5 ± 3.1 months, p < 0.005), had more advanced gestational age (35.9 ± 6.0 versus 30.9 ± 5.4 weeks, p < 0.005), and had higher RI (9.0% versus 4.2%, p < 0.0005) and RSV hospitalization (2.35% versus 1.32%, p = 0.003) rates. Group 2 infants tended to be less compliant with treatment (69.4% versus 72.8%, p = 0.048). Group (p = 0.015) was an independent predictor of RSV hospitalization over compliance (p = 0.951; model: χ² = 5.273, df = 1, p = 0.022).

Conclusion: Results imply that infants with underlying medical disorders, though not currently approved for prophylaxis, are at an elevated risk for both RI and RSV hospitalization.

Presenting authors: Dr. Sandjar Djalalov (Post-Doctorate) and Dr. Jeffrey Hoch (Scientist), Li Ka Shing Knowledge Institute, St. Michael's Hospital

Co-authors: Dr. George Tomlinson (Affiliate Scientist), Toronto General Hospital

Objectives: To perform a systematic review of the literature on utility weights for colorectal cancer (CRC) health states; to determine the effects of study characteristics and “time to/from initial care” on utility values.

Methods: In a systematic review, we identified 22 articles in English, providing 171 utilities for CRC health states elicited from 3,574 respondents. Data were analyzed using linear mixed effects with CRC cancer type, condition, stage, time to/from initial care, instrument, administration, and study design as independent variables.  

Results: In the base model, the estimated utility of the reference case for a stage I-II CRC patient on continuous care and more than one year post-operation, rated by using EQ-5D or HUI3, was 0.75. Cancer type, condition, stage, time to/from initial care, utility instrument, and study design were associated with utility differences of 0.06 to 0.13             (p < 0.05). Utilities derived from EQ-5D or HUI3 instruments were 0.07 lower than EQ5Dvas and 0.12 lower than   SF-36 (p < 0.05) derived utilities in the base model. Utilities for I-II stage were 0.13 (p < 0.05) higher than VI stage and 0.13 (p = 0.05) lower than Dukes stages. Utilities elicited at “post-operation more than one year” were 0.08         (p < 0.05) less than “pre-operative” and 0.06 (p < 0.05) lower than “post-operation three months” in the base model.

Conclusions: Utilities are associated with factors such as cancer type, time to/from initial care, and utility derivation instruments. More research is needed to study why apparently “similar” patients report different quality of life.

Presenting authors: Ms. Christine Perras, Clinical Research Officer, Canadian Agency for Drugs and Technologies in Health; Ms. Eva Tsakonas, Consultant

Co-authors: Dr. John Conley, University of Calgary; Dr. Louis Valiquette, Université de Sherbrooke; Ms. Kelly Farrah, Information Specialist, Canadian Agency for Drugs and Technologies in Health

Introduction: Clostridium difficile infection (CDI) is the most common cause of nosocomial infectious diarrhea in adults. Recently, the spread of a hypervirulent strain of C. difficile has caused outbreaks of CDI. A systematic review of studies that compared metronidazole and vancomycin in patients with an initial or recurrent episode of moderate or severe CDI was completed.

Methods: A search for systematic reviews, health technology assessments, randomized controlled trials (RCTs), and observational studies was conducted. Databases (e.g., MEDLINE and Embase) were searched through the Ovid interface. The main search concepts were vancomycin, metronidazole, and C. difficile. The search was not restricted by publication date, but was restricted to English and French language publications. Two reviewers independently selected studies and extracted data. Relative risks (RR) with corresponding 95% confidence interval (CI) were calculated. The findings were summarized narratively and interpreted in light of the heterogeneity of the studies and their quality.

Results: Five RCTs and 13 observational studies were found. All but one of the observational studies were conducted in populations that included both initial and recurrent CDI. Few studies classified patients by disease severity. One RCT and one observational study included a sub-group analysis of patients with moderate CDI; two RCTs had a sub-group analysis of patients with pseudomembraneous colitis (a marker for severe disease); and two RCTs and one observational study included sub-groups of patients with severe CDI.

One RCT of adult patients with moderate CDI showed no difference in cure rate. Two RCTs of adult patients with severe CDI showed higher cure rates with vancomycin than metronidazole (RR 1.27 [95% CI; 1.05, 1.53] and RR 1.31 [95% CI; 1.03, 1.66]). Other study results yielded inconclusive findings or effect measures were not calculated because the number of events was too small for adequate comparisons.

Conclusion: Compared to metronidazole, vancomycin has a higher cure rate in patients with severe CDI, and a similar cure rate in patients with moderate CDI.

Presenting author: Dr. Thanh Nguyen, Health Economist, Institute of Health Economics

Co-authors: Dr. Anderson Chuck (Health Economist & Manager, Decision Analytic Modeling Unit) and Dr. Arto Ohinmaa Senior Health Economist), Institute of Health Economics

Objective: To estimate the societal monetary benefit of Ramipril to three separate groups: 1) developing manufacturer (DM), 2) generic manufacturer (GM), and 3) society.

Methods: The monetary benefits for DM and GM were estimated by calculating annual revenues based on IMS sales data between 2000 and 2009. We used a dynamic Markov model to estimate the monetary benefits for society over the same time period in terms of cost avoidance associated with prevented adverse events, including stroke, heart failure, myocardial infarction, and lost productivity due to disability and premature death in the working population. Input estimates for prevented adverse events and costs were derived from systematic review and meta-analysis when possible. Input estimates for reduction in health care utilization and disability days were estimated from multivariate regressions using data in the 2003 Canadian Community Health Survey. All costs and benefits were expressed in 2010 Canadian dollars.

Results: Preliminary results indicate that there is significant benefit to both society and industry. More detailed results will be presented at the symposium, including results broken down by year, cost component, and analysis group.

Conclusion: Policy implications for health care system and industry will be discussed.

Presenting authors: Ms. Jocelyn Chisamore, Program Officer, Canadian Agency for Drugs and Technologies in Health; Ms. Kelly Wilson, Patient Safety Coordinator, Interior Health Authority

Co-authors: Mr. Allan Brown (Health Economist), Ms. Kirsten Gartenburg (Knowledge Exchange Officer), and Ms. Ann Vosilla (Liaison Officer), Canadian Agency for Drugs and Technologies in Health

Hip fractures are a significant health risk for seniors. In long-term care facilities, about half of residents will fall at least once. If a senior fractures a hip, 20% will die within one year and 7% will die within 30 days. Hip protectors are garments or undergarments that can protect hips in case of a fall. 

Initiative: With the negative impact of hip fractures on patient health, CADTH selected hip protectors for a pilot project in 2010 that would assist end users in interpreting and applying analyses from CADTH’s reviews of non-drug health technologies. 

CADTH convened a panel of experts with researchers, practitioners, and decision-makers to review the evidence and produce implementation guidance on hip protectors. The output included a set of guidance statements as well as a practical guidance card for care providers containing key information and considerations.

Results: The project stimulated uptake and application of this evidence at both the local health region level and the national level. Lessons regarding mobilization of evidence were realized with shared collaboration strategies that included the joining of jurisdictional expertise, knowledge exchange via liaison officers, and clarity of practical key messages.

Presenting author: Ms. S. Carolyn Wayne, Project Assistant, Cochrane Effective Practice and Organisation of Care (EPOC) Review Group

Co-authors: Ms. Rachel Bennett, Prevention and Research Analyst, Public Health Agency of Canada; Dr. Jeremy Grimshaw,Senior Scientist, Ottawa Hospital Research Institute; Ms. Julia Worswick (Project Lead), Mr. Alain Mayhew (Managing Editor), Ms. Michelle Fiander (Information Specialist) and Ms. Michelle Weir (Project Assistant), Cochrane Effective Practice and Organisation of Care (EPOC) Review Group

Objectives: To provide a comprehensive overview of systematic reviews assessing the effects of quality of care improvement initiatives in diabetes management.

Methods: An extensive literature search was conducted in multiple databases: MEDLINE, Embase, HealthSTAR (OVID), AgeLine (Ebsco), Health Systems Evidence and Rx for Change from January 1976 to October 2009. Screening was conducted following standard systematic review methodology, employing a priori inclusion criteria. Data was extracted in a structured format to allow for consistent presentation of results.

Results: Thirty-six reviews were selected for analysis. The most commonly reported interventions involved patient education, followed by skill mix changes for health care professionals, telemedicine, organizational or structural changes to the health care system, and multifaceted interventions. Glycemic control and vascular risk factor control outcomes were predominant across reviews, with relatively few reporting on other important processes of care measures. Patient education and skill mix changes (the use of multidisciplinary teams) were associated with improved glycemic control. Some interventions showed promise for improving other outcomes of interest, but more evidence is needed.

Conclusions: Current initiatives should be informed by this evidence and preferably involve patient education and the use of multidisciplinary health care teams. Future review authors should concentrate their efforts on investigating the effectiveness of other interventions or attempting to disentangle the effects of specific intervention components.

Presenting author:  Ms. Deirdre DeJean, PhD Candidate, McMaster University

Co-authors: Professor Mita Giacomini (Professor) and Ms. Dorina Simeonov (MSc Student), McMaster University

Objective: Qualitative research can provide valuable information about social contexts relevant to specific technologies and conditions, and can inform health technology assessment. However, methods for systematically retrieving qualitative research are underdeveloped. We present an evaluation of the effectiveness of published search strategies to identify qualitative research in three bibliographic databases in the areas of pharmacogenomic testing and early stage breast cancer.

Methods: Three databases (MEDLINE, CINAHL, and Social Sciences Citation Index [SSCI]) were searched systematically using published search filters to identify relevant qualitative research studies. The searches were compared for sensitivity (potentially relevant studies found) and precision (actually relevant studies found).

Results: Qualitative research on both pharmacogenomic testing and early stage breast cancer was most prevalent in SSCI. For pharmacogenomic testing, the CINAHL search strategies demonstrated the highest sensitivity (100%) but extremely poor precision (0.5%), while the MEDLINE strategies established the highest precision (17%) but sacrificed sensitivity (5%). For early stage breast cancer, CINAHL again had the highest sensitivity (88%) with a precision level of 15%, while SSCI had only 59% sensitivity but a higher precision (23%).

Conclusion: Trade-offs between precision and sensitivity are unavoidable. They vary depending on the search strategy used, the database searched, and the topic area. Because qualitative research includes a variety of terms in different disciplines, search strategies that attempt to maximize the sensitivity may yield an overwhelming number of irrelevant papers. Although qualitative research is most prevalent in SSCI, the thesaurus indexes in MEDLINE and CINAHL are better suited to systematic retrieval.

Presenting authors: Mr. Alain Mayhew (Managing Editor), Ms. Julia Worswick (Project Lead), and Ms. Carolyn Wayne (Project Assistant), Cochrane Effective Practice and Organisation of Care (EPOC) Review Group

Co-authors: Ms. Michelle Fiander, Information Specialist, Cochrane Effective Practice and Organisation of Care (EPOC) Review Group; Ms. Rachel Bennett, Prevention and Research Analyst, Public Health Agency of Canada; Dr. Jeremy Grimshaw, Ottawa Hospital Research Institute

Background: There is abundant evidence available on the effects of strategies targeting professionals, health care systems, and consumers to improve practice behaviour. Since 2007, the Cochrane Effective Practice and Organisation of Care Research Group has collaborated with the Canadian Agency for Drugs and Technologies in Health and the Cochrane Consumers and Communication Review Group to summarize this evidence for use by decision-makers. Since its inception, the Rx for Change database has been updated five times, most recently in November 2010.

Objectives: To provide updated evidence from the Rx for Change database on the effectiveness of interventions to change professional practice behaviour.

Methods: Systematic reviews published between 1966 and May 2010 were identified by searching MEDLINE, the Cochrane Library, Embase, and DARE. Screening was conducted following standard systematic review methodology, employing a priori inclusion criteria. Vote counting was used for data synthesis; interventions were classified as being effective if more than two-thirds of the included studies in a review demonstrated benefit.

Results: Over 35,000 systematic reviews have been identified; approximately 180 have been included for analysis. Examples of professional interventions found to be generally effective for improving process of care and prescribing include: the distribution of printed educational materials, educational outreach visits, local opinion leaders, and audit and feedback.

Presenting author: Dr. Alison Sinclair, Research Scientist, Technology Assessment Unit, McGill University Health Centre

Co-authors: Xuanqian Xie (Biostatistician) and Nandini Dendukuri (Director), Technology Assessment Unit, McGill University Health Centre

Background: In 2005 and 2009 we reviewed the use of probiotics for prevention of antibiotic-induced CDAD, concluding that the evidence did not support their routine use. Subsequent publications prompted a re-evaluation.

Methods: We carried out a systematic literature review and meta-analysis to estimate the relative risk of CDAD by preventative treatment with probioticscontaining Lactobacillus species. We performed sub-group analyses to probe the impact of biases within individual studies. We also conducted a Bayesian credibility analysis to assess the strength of the evidence.

Results: We identified eight double-blinded RCTs meeting our inclusion criteria. Studies were heterogenous in dosing and design. Using a Bayesian hierarchical model for meta-analysis (with low information prior distributions), the median pooled RR of CDAD (95% confidence interval) associated with Lactobacillus was 0.22 (95% credible interval 0.08, 0.44) versus placebo. Sensitivity analyses showed similar results. However, a Bayesian credibility analysis suggested that a null trial with as few as 60 cases would be sufficient to produce a meta-analytic credible interval encompassing one. None of the studies suggested an excess of adverse events associated with Lactobacillus.

Conclusion: Standard meta-analysis suggests that Lactobacillus is associated with a lower risk of CDAD in inpatients receiving antibiotics. However, we do not consider the evidence robust enough to direct a change in preventative practice at this time. There remains a need for well-designed randomized controlled trials to validate these results, particularly in populations with good infection control practices and a low incidence of CDAD.

Presenting authors: Mr. Glenn McAuley, Senior Pharmacist, Ontario Public Drug Programs; Dr. Mona Sabharwal, Executive Director, Pan-Canadian Oncology Drug Review

Ontario’s Exceptional Access Program (EAP) facilitates case-by-case patient access to drugs not funded on the Ontario Drug Benefit Formulary. EAP requests are evaluated against specific clinical criteria, as recommended by the Committee to Evaluate Drugs and approved for funding by the Executive Officer for Ontario Public Drug Programs. For Health Canada approved indications, the onus is on the manufacturer to provide a formal submission to support a product review. The CED may also perform a review and provide a funding recommendation in the absence of a manufacturer submission solely for the purposes of consideration under EAP (e.g., for off-label indications). In general, a drug or indication that has not been reviewed is not considered for funding.

Under the new EAP Compassionate Review Policy, requests are also considered in the absence of a manufacturer submission or CED review, for rare clinical circumstances in immediately life-, limb-, or organ-threatening conditions. Criteria have been developed for clarity and to ensure consistent application of the policy. Requests must be supported by published evidence meeting a minimum threshold; case-series reports are accepted.

We present information from the first year of experience with the Compassionate Review Policy. Of the 250 requests assessed under the policy, 142 (57%) were approved. Overall drug expenditures were approximately $1.3 million. Multiple requests for similar drugs and indications have resulted in several formal evidence-based reviews by the CED.

The Compassionate Review Policy provides access to drugs in truly exceptional circumstances while also generating information to support evidence-based reviews for several off-label indications.

Presenting author: Mr. David Kaunelis, Information Specialist, Canadian Agency for Drugs and Technologies in Health

Introduction: Search filters are pretested strategies used by information specialists to focus the results of a database query. A recent CADTH report evaluated existing economic search filters and determined that while these filters retrieved nearly 100% of relevant economics-related article citations, they also retrieved an inordinate number of irrelevant citations.

Methods: As part of the CADTH report, additional filters were developed to allow for searches that could be much more focused while still retrieving most relevant citations. These filters were tested using a validated gold standard citation set of economic evaluations. CADTH information specialists subsequently identified one high-performing filter from this project and added selected additional search terms, based on input from CADTH health economists. This revised filter was tested against the gold standard citation set.

Results: This new filter, the CADTH narrow economic filter, performed well against the gold standard, retrieving approximately 76% of gold standard articles. Initial results show that the filter significantly cuts down on search sizes compared to current comprehensive economic filters. Versions for both PubMed and Ovid MEDLINE/Embase were created.

Conclusion: The CADTH narrow economic filter works well where a comprehensive economic search is not required, such as for rapid reviews or for formulary recommendations where an existing model is critiqued. Use of this filter will allow for dramatic time savings for both HTA researchers and information specialists.