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The Evidence Speaks

The Evidence Speaks (August 2019)

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The Evidence Speaks Series is a recurring feature highlighting the latest in CHÉOS research. This series features summaries of select publications as well as in-depth features on the latest work from our investigators. The Series is designed to keep media and the research community up-to-date with CHÉOS’ current research results in the health outcomes field.

Mrkobrada M, Chan MTV, Cowan D, Campbell D, Wang CY,…Brown C, Raval M, Phang PT, et al; The NeuroVISION Investigators. Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): A prospective cohort study. Lancet. 2019 Aug 15 epub ahead of print.

CHÉOS colorectal surgery researchers Drs. Carl Brown, Manoj Raval, and Terry Phang are co-authors on a recently published large, international, clinical study to describe the relationship between minor stroke during non-cardiac surgery and cognitive decline after the surgery. Undergoing surgery of any kind can lead to complications. One possible complication is a type of minor stroke that is not easily identified and can usually only be detected with brain imaging, called a covert stroke. Outside of surgery, covert strokes are associated with cognitive decline and increased risk of more serious stroke (overt stroke). To identify the relationship between covert stroke related to surgery and cognitive decline, researchers enrolled patients over 65 years of age undergoing non-cardiac surgery in 12 centres in 9 countries, including St. Paul’s Hospital. Participants underwent baseline assessments, MRI within 10 days after surgery, and follow-up 30 days and 1 year after surgery. MRI results revealed that 7 per cent of patients had one or more covert strokes, occurring across all types of surgery. Cognitive decline after 1 year was more common in people who had a covert stroke compared to those who did not (42 vs. 29 per cent). Overall, people who had a covert stroke had a 13 per cent increased risk of cognitive decline. Covert stroke was also associated with delirium and more serious stroke. Cognitive decline is one of the most worrying surgical complications for patients and this research demonstrates a clear relationship with covert stroke. There is a need for research to identify the cause of covert stroke and the development of related treatment and management strategies.

Wang Y, Ding Y, Park E, Hunte G. Do financial incentives change length-of-stay performance in emergency departments? A retrospective study of the pay-for-performance program in Metro Vancouver. Acad Emerg Med. 2019 Aug;26(8):856-66.

Dr. Garth Hunte, an emergency medicine researcher at CHÉOS, is part of a small group of researchers who analyzed the impact of financial incentives on length of stay (LOS) in the emergency department (ED). Longer LOS in the ED is associated with worse health outcomes and higher mortality. The researchers were interested in whether pay-for-performance schemes, where hospitals or clinicians receive money for meeting admission and discharge targets improve LOS. These schemes are already in place in some places but their impact has not been demonstrated in detail. Between 2007 and 2014, the provincial government provided financial incentives to four EDs in Metro Vancouver for discharging patients in less than 4 hours or admitting patients to the hospital in less than 10 hours; following this pilot period, Vancouver Coastal Health continued to provide financial incentives for the 10-hour admission target while the 4-hour discharge incentive was discontinued. Dr. Hunte and his colleagues described the impact of these incentive schemes by analyzing the change in ED behaviour during and after the pilot period. During the incentive period, they found that in the two low-volume EDs, there was a sharp drop in patient discharges after the 4-hour target, which was not seen after the incentive period or in the high-volume EDs. This signifies that the incentives effectively reduced LOS for discharged patients in low-volume EDs. However, the behaviour of the two smaller EDs was different; one had a large spike in discharges right before the 4-hour mark and the patients that were discharged right before the cut-off had a higher rate of return to the ED within 7 days, suggesting that patients were being rushed through the system and, in some cases, receiving incomplete care. The other small-volume ED had a more consistent rate of discharge during the 4-hour window and no difference in ED return rate. For the 10-hour admission LOS target, there was a noticeable difference in admission rates up to the 10-hour mark in all of the 4 EDs. This research demonstrates that financial incentives can be effective in reducing LOS, however, not all hospitals will respond to them in the same way and there is potential for negative effects on overall quality of care.

Bansback N, Chiu JA, Carruthers R, Metcalfe R, Lapointe E, Schabas A, Lenzen M, Lynd LD, Traboulsee A. Development and usability testing of a patient decision aid for newly diagnosed relapsing multiple sclerosis patients. BMC Neurol. 2019 Jul;19(1):173.

Dr. Nick Bansback, CHÉOS Program Head for Decision Sciences, and CHÉOS Scientist Dr. Larry Lynd recently developed a treatment decision aid for new multiple sclerosis (MS) patients in collaboration with a group of researchers from UBC. Treatment decisions for MS patients can be complex and overwhelming, leading to late treatment initiation and poor adherence, ultimately decreasing treatment effectiveness. For many treatment decisions, patient decision aids can be used to promote shared-decision making between patients and caregivers, helping patients to feel more informed, understand their own preferences, and make decisions that better match their values. However, existing decision aids for MS do not capture the full process of decision making and do not clearly match patients with available treatment options. To fill this gap, the researchers developed a new treatment decision aid aimed at newly diagnosed MS patients and then tested the usability and acceptability of the tool. The initial prototype of the tool was developed through a scoping review, using both previous research on patient perspectives, and focus groups, semi-structured interviews, and feedback from physicians.The decision tool consists of 5 sections: (1) medical history, (2) treatment effectiveness and side effects, (3) values and treatment attribute ranking, (4) decision module to compare treatment options and identify best fit, and (5) a summary that describes choices and preferences that can be emailed directly to care providers and included in patient electronic medical records. Twenty-five MS patients tested the tool and found it to be highly useable, consistent, and acceptable. Patients were split on the degree to which the information provided in the decision aid aligned with what they received from their care providers. Feedback on the usefulness of the decision aid was overwhelmingly positive. This new decision aid will help promote shared decision-making in MS patients by providing comprehensive, credible information on treatments and side effects. The tool is available at