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C Bombardier

Publications and source records attributed to C Bombardier.

At least 73 records · Page 4Linked to original sources
PubMed1998

Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State.

OBJECTIVE: To examine back and neck hospitalizations in the Province of Ontario and Washington State. Because of their different organization and financing, there has been considerable interest in comparing healthcare systems in Canada and the United States. Features of healthcare systems might be expected to result in greater variations in care for elective than urgent conditions. DATA SOURCE: Automated hospital discharge databases. STUDY DESIGN: Previously developed algorithms were used to identify surgical and nonsurgical hospitalizations for back and neck problems in the administrative databases. We compared overall rates of hospitalization and lengths of hospital stay in Ontario and Washington as well as small area variations within the province and state. PRINCIPAL FINDINGS: Surgical back and neck hospitalizations were three times as common in Washington, but medical hospitalizations were twice as common in Ontario. Provincial lengths of stay were longer for both surgical and nonsurgical hospitalizations. Admission rates varied substantially and significantly among small areas in both Washington and Ontario. Variations in hospital length of stay were greater in Ontario, particularly for nonsurgical back and neck hospitalizations. CONCLUSION: The two jurisdictions had very different patterns of hospital utilization for one of the most common health problems seen by physicians. Our results suggest that the global controls on hospital budgets and access to technology in Ontario were associated with lower rates of surgery, higher rates of hospital-based medical care, and longer lengths of stay. They also indicate that the utilization review process in Washington was associated with lower small area variation rates for medical back care.

Adult↗
PubMed1998

How Canadian and US rheumatologists treat moderate or aggressive rheumatoid arthritis: a survey.

OBJECTIVE: To determine which second line agents Canadian and US rheumatologists use to treat patients with active rheumatoid arthritis (RA). METHODS: A one page survey was sent by fax or mail to all 263 members of the Canadian Rheumatology Association and 320 members of the American College of Rheumatology (10% random sample weighted by region) known to practice adult rheumatology. The survey asked for first and second treatment preferences in patients with (1) aggressive RA; (2) moderate RA; and (3) aggressive RA failing a trial of methotrexate (MTX) 25 mg. RESULTS: Altogether 231 (87.8%) Canadian and 230 (71.7%) US rheumatologists responded, and 214 responses in each survey were analyzable. In aggressive RA. MTX was the drug of first choice of most Canadian (68.7%) and US (78.5%) rheumatologists. Intramuscular gold was a drug of first choice for 14.5 and 1.9% of Canadians and Americans, respectively. 93.9% of Canadian and 90.2% of US respondents preferred single agents for the treatment of moderate RA. Among US rheumatologists. no clear leader emerged as a single agent alternative for the management of aggressive RA unresponsive to MTX. Most said they would use combination (38.3%) or triple (23.8%) therapy involving MTX plus sulfasalazine and/or hydroxychloroquine. 52.3% of Canadians preferred single agent therapy, with 34.6% choosing gold as an alternative to MTX. CONCLUSION: Canadian and US rheumatologists preferred MTX for the treatment of aggressive RA. Canadian rheumatologists saw a small but significant role for intramuscular gold. No single agent emerged as a clear alternative to MTX among US rheumatologists.

Antirheumatic Agents↗
PubMed1997

Prednisone and aspirin in women with autoantibodies and unexplained recurrent fetal loss.

BACKGROUND: Recurrent fetal loss has been well described in women with antiphospholipid antibodies. Such women also often have other autoantibodies commonly found in patients with systemic lupus erythematosus. Treating them with prednisone and aspirin may reduce the risk of fetal loss. METHODS: We screened 773 nonpregnant women who had the unexplained loss of at least two fetuses for antinuclear, anti-DNA, antilymphocyte, and anticardiolipin antibodies and for the lupus anticoagulant. Of 385 women with at least one autoantibody, 202 who later became pregnant were randomly assigned in equal numbers to receive either prednisone (0.5 to 0.8 mg per kilogram of body weight per day) and aspirin (100 mg per day) or placebo for the duration of the pregnancy. The women were stratified according to age (18 to 34 years or 35 to 39 years) and the week of gestation at which the previous fetal losses had occurred (< or = 12 or > 12 weeks). The primary outcome measure was a successful pregnancy. RESULTS: Live infants were born to 66 women in the treatment group (65 percent) and 57 women in the placebo group (56 percent, P=0.19). More infants were born prematurely in the treatment group than in the placebo group (62 percent vs. 12 percent, P<0.001). The major side effects of therapy in the mothers were hypertension (treatment group, 13 percent; placebo group, 5 percent; P=0.05) and diabetes mellitus (15 percent and 5 percent, P=0.02). CONCLUSIONS: Treating women who have autoantibodies and recurrent fetal loss with prednisone and aspirin is not effective in promoting live birth, and it increases the risk of prematurity.

Abortion, Habitual↗
PubMed1997

A summary of economic evaluations published in the field of rheumatology and related disciplines.

INTRODUCTION: The relationship between the effectiveness of health care interventions and their costs is of increasing interest. The goal of the present study was to summarize the economic evaluations (EEs) published in the field of rheumatology and related disciplines, and to focus in particular on methodologic issues. METHODS: MEDLINE was searched in order to identify all relevant EEs published between 1966 and February 1995. Titles and abstracts of 1,435 articles were retrieved and independently reviewed by 2 assessors. Overall, 63 articles were identified by either assessor as being definite or possible full EEs (defined as an analysis comparing 2 or more strategies involving the assessment of both costs and consequences), and were assessed independently. RESULTS: Thirty-six articles were determined to be full EEs (33 cost-effectiveness and 3 cost-utility analyses). Most were published in the periods 1984-1990 (31%) and 1991-1995 (61%). Main areas covered were methods of prevention (44%), treatment (31%), and treatment-prevention (22%). Disorders most frequently studied were osteoarthritis (36%), osteoporosis (22%), and rheumatoid arthritis (14%). Direct and indirect costs were measured or estimated in 100% and 28% of the EEs, respectively. The viewpoint of the analysis was stated explicitly in 12 studies (33%). Incremental and sensitivity analyses were presented in 17 (47%) and 23 (64%), respectively. Inadequate use of economic terms was also documented. CONCLUSION: The EE articles reviewed adhered partially to basic analytic methods. Economic evaluations in the field of rheumatology need to be improved to comply with current standards for the evaluation of health care interventions.

Cost-Benefit Analysis↗
PubMed1997

Evaluating changes in health status: reliability and responsiveness of five generic health status measures in workers with musculoskeletal disorders.

OBJECTIVES: To compare the measurement properties over time of five generic health status assessment techniques. METHODS: Five health status measures were completed on two occasions by a sample of workers with musculoskeletal disorders. They included the SF-36, Nottingham Health Profile, Health Status Section of the Ontario Health Survey (OHS), Duke Health Profile, the Sickness Impact Profile and a self-report of change in health between tests. SETTING: Subjects were accrued from a work site (within one week of injury) (n = 53), physiotherapy clinics (four weeks after injury), (n = 34), and a tertiary level rehabilitation center (more than four weeks after injury) (n = 40). ANALYSIS: Intraclass correlation coefficients (ICC) derived from nonparametric one-way analysis of variance were used for test-retest reliability in those who had not changed (n = 49). Various responsiveness statistics were used to evaluate responsiveness in those who claimed they had a positive change in health (n = 45) and in those who would have been expected to have a positive change (n = 79). RESULTS: Of the 127 subjects recruited, 114 completed both questionnaires (89.8%). In the subjects who reported no change in health, analysis of targeted dimensions (overall scores, physical function, and pain) demonstrated acceptable to excellent test-retest reliability in all but the Duke Health Profile. In subjects with change in health, the SF-36 was the most responsive measure (moderate to large effect sizes [0.55-0.97] and standardized response means ranging between 0.81 and 1.13). CONCLUSIONS: The results suggest that the SF-36 was the most appropriate questionnaire to measure health changes in the population studied. The selection of a health status measure must be context-specific, taking into account the purpose and population of the planned research.

Confidence Intervals↗
PubMed1997

Accuracy of administrative data for assessing outcomes after knee replacement surgery.

OBJECTIVE: To assess the accuracy of information in an administrative database (Canadian Institute for Health Information; CIHI) compared with the hospital record for patients undergoing knee replacement (KR). METHODS: A stratified random sample of 185 KR recipients from 5 Ontario hospitals were chosen. Their hospital records and corresponding CIHI files were compared to assess percent complete agreement, false negative (FN) and false positive (FP) rates for demographic data, procedures, and diagnoses. RESULTS: Of 185 records, 175 (95%) were reviewed. Percent complete agreement was greater than 94% for each of patient demographics and procedures (mean FN rates: 0%; mean FP rates: 0-5%). For comorbidities and complications, although mean percent complete agreement was high, and FP rates were low, mean FN rates were 63% for specific comorbid conditions and 70% for organ systems. CONCLUSIONS: High FN rates have been found in documentation of comorbidities and in-hospital complications for CIHI data compared with the hospital record. Under-coding of comorbidities and in-hospital complications has potential implications for researchers using administrative databases.

Comorbidity↗
PubMed1997

Osteoarthritis of the hip and knee and mechanical occupational exposure--a systematic overview of the evidence.

OBJECTIVE: To clarify examine the epidemiologic evidence linking work related exposure to osteoarthritis (OA) of the hip and knee. METHODS: We investigated MEDLINE and EMBASE 1966-1994 with search terms of osteoarthritis, osteoarthrosis, arthrosis; risk factors, exposure; occupational diseases, agricultural workers' diseases, work. From 123 original studies on risk factors for OA, 17 studies were identified as providing a comparison group and relating the presence or absence of radiologically diagnosed OA to occupational factors. The quality of the methodology of each study was evaluated independently by 4 reviewers using a standardized protocol. RESULTS: Common methodological problems were encountered in areas such as representatives, recall of exposure, and evaluation of exposure and outcome. These problems often made a cause-effect relationship difficult to interpret. However, 7 of the 17 studies met our criteria for good methodological quality. A critical analysis of their results led to the following conclusions: (1) A consistently positive relationship exists between work involving knee bending and knee OA in men (range of odds ratio: 1.4-6). (2) The evidence suggesting a relationship between knee OA and occupational exposure in women is inconclusive. (3) A consistently positive but weak relationship exists between work related exposure (i.e., farming in particular) and hip OA in men. We felt we could not conclude with confidence that this relationship is strong due to the potential biases that exist in each of these studies. (4) No study attempted to investigate occupational exposure and hip OA in women. CONCLUSION: Studies suggest a strong positive relationship between work related knee bending exposure and knee OA. The evidence between work related exposure, farming in particular, and hip OA is consistently positive but weak.

Female↗
PubMed1996

Lack of concordance between the ICD-9 classification of soft tissue disorders of the neck and upper limb and chart review diagnosis: one steel mill's experience.

The aim of this study is to determine the validity of the ICD-9 for diagnostic classification of soft tissue disorders of the neck and upper limb, using routinely collected data at a large steel company. The documentation in the clinical chart served as the gold standard. First, the overall accuracy of identifying these disorders from the ICD-9 was examined. Second, we examined whether the codes themselves, on an individual basis, accurately reflected the underlying problems as documented in the medical records. There were 1,267 new cases identified in 1991 by inclusion of all potentially applicable ICD-9 codes. Only 805 (63.5%) fulfilled the definition of a soft tissue disorder of the neck or upper limb as determined by chart review. A more restrictive strategy that only included cases coded by those ICD-9 codes that specifically pertain to these disorders yielded a higher proportion of true cases 458/480 cases (95.4%), but failed to identify the other 347 cases. The anatomical site of the problem could not be identified from the codes describing 651/1,267 cases (51.4%). There was poor agreement between the diagnostic labels recorded in the medical records and the ICD-9 codes, suggesting that many of the terms are being used interchangeably. Our results suggest that conclusions about these disorders drawn from analysis of administrative data which rely upon the ICD-9 for diagnostic classification must be interpreted cautiously. For these soft tissue disorders, researchers will need to develop strategies which would improve upon and supplement the ICD-9.

Adult↗
PubMed1996

Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG)

This paper describes the development of an evaluative outcome measure for patients with upper extremity musculoskeletal conditions. The goal is to produce a brief, self-administered measure of symptoms and functional status, with a focus on physical function, to be used by clinicians in daily practice and as a research tool. This is a joint initiative of the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS), and the Institute for Work and Health (Toronto, Ontario). Our approach is consistent with previously described strategies for scale development. In Stage 1, Item Generation, a group of methodologists and clinical experts reviewed 13 outcome measurement scales currently in use and generated a list of 821 items. In Stage 2a, Initial Item Reduction, these 821 items were reduced to 78 items using various strategies including removal of items which were generic, repetitive, not reflective of disability, or not relevant to the upper extremity or to one of the targeted concepts of symptoms and functional status. Items not highly endorsed in a survey of content experts were also eliminated. Stage 2b, Further Item Reduction, will be based on results of field testing in which patients complete the 78-item questionnaire. This field testing, which is currently underway in 20 centers in the United States, Canada, and Australia, will generate the final format and content of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Future work includes plans for validity and reliability testing.

Activities of Daily Living↗
PubMed1996

Measuring health in injured workers: a cross-sectional comparison of five generic health status instruments in workers with musculoskeletal injuries.

The purpose of this study was to compare the measurement properties of five generic health status measures in a cross-sectional study of injured workers. One hundred twenty-seven injured workers participated in the study. Forty-seven percent had disorders of the upper limb, 12% neck and upper back, and 27% lower back (14% unspecified). All participants completed a package containing: SF-36 (Acute), Nottingham Health Profile (NHP). Duke Health Profile (Duke). Health status section of the Ontario Health Survey (OHS), and the Sickness Impact Profile (SIP). Frequency distributions were examined, correlations carried out, and the ability to discriminate between part of body and overall health state evaluated using analysis of variance. The results showed a ceiling (healthy) effect in the OHS, NHP, and SIP. Correlations were moderate to good. Upper limb subjects appeared "healthier" than low back pain subjects. The instruments were able to discriminate between health states (p < 0.05) except the OHS-Physical function (p = 0.51). Different questionnaires give a different impression of health. Clinicians and researchers should be thoughtful in their selection of outcome measures as different instruments may alter the description, intervention, and priorization of a particular disorder.

Analysis of Variance↗
PubMed1996

Development of a measure of physical function for patients with bone and soft tissue sarcoma.

Patients undergoing limb salvage surgery for bone and soft tissue sarcoma of the extremities experience significant physical disability as a result of life-preserving treatment. The existing health status measures do not adequately evaluate physical function from the patient's perspective. This paper presents the developmental studies (item selection, reduction, reliability, validity and responsiveness) of a new measure, The Toronto Extremity Salvage Score (TESS). Patients with bone and soft tissue sarcoma (76 upper and 83 lower extremity) were randomly selected and mailed the TESS. Patients rated the severity and importance of physical disabilities; the response options included a 'not applicable' category and open-ended questions that allowed patients to suggest additional items for inclusion in the questionnaire. Therefore, patient perceptions were used to determine item content. Difficulty and importance frequencies were calculated and items rated 'totally unimportant' or 'not applicable' by 30% of the sample were eliminated. Extra items identified 30% of the time were added to the questionnaire. Internal consistency was evaluated by Cronbach's alpha. Test-retest reliability and validity were evaluated on subsequent patient samples. The intraclass correlation coefficient (ICC) was calculated for test-retest reliability and correlations with The Musculoskeletal Tumour Society Rating Scale (MSTS) were calculated for construct validity. Standardized effect sizes were calculated as a measure of responsiveness. Fifty upper extremity and sixty-six lower extremity patients responded to the mailed questionnaire. No items were eliminated based on importance or not applicable ratings. Sporting activities were identified as additional items in both the upper and lower extremity questionnaire. High internal consistency was demonstrated: 0.94 for the lower and 0.92 for the upper extremity questionnaires respectively. Test-retest reliability was evaluated at multiple time-points and the intraclass correlation coefficient was greater than 0.87 in all instances. Construct validity was shown by a moderate correlation with the MSTS. The effect sizes were large demonstrating responsiveness. The use of patients' perceptions in determining the content of the TESS has resulted in a reliable and valid measure that is able to detect change over time.

Activities of Daily Living↗
PubMed1996

Classification systems of soft tissue disorders of the neck and upper limb: do they satisfy methodological guidelines?

A critical appraisal of existing classifications of soft tissue disorders of the neck and upper limb was performed utilizing methodological criteria including appropriateness for purpose, validity, reliability, feasibility, and generalizability. Five classifications were assessed independently by three raters using standardized forms. For those criteria that can be assessed by inspection of the classification itself, none of the classification systems appeared acceptable for reasons such as failure to be comprehensive, overlap of categories, and lack of demonstration that the criteria for inclusion into the categories are valid and reliable. No judgement could be passed about those criteria that require formal testing, such as reliability and construct validity, because of the absence of data. The overall interrater reliability of the critical appraisal was high, with an intraclass correlation coefficient of 0.82. The validity of studies that have relied upon existing classifications of soft tissue disorders of the neck and upper limb to group the entities under study is questioned in light of the findings of this study. Future work should be directed toward improving existing classification systems and/or developing new ones that fulfil basic measurement criteria.

Arm↗
PubMed1996

The context of measuring disability: does it matter whether capability or performance is measured?

This study assesses the differences between two methods of conceptually framing physical disability questions, using two scenarios (capability and performance). The relationship between capability and performance was explored on the basis of the literature and empirically tested by administering two versions of the Activities Scale for Kids (ASK) to 28 physically disabled children. The capability version asked children what they "could do," whereas the performance version asked what they "did do." Capability was found to exceed performance (p < 0.001) by approximately 18%. The difference may relate to a difference in environmental contexts between the two versions, with performance reflecting abilities in usual (or real life) circumstances and capability reflecting abilities in a defined situation apart from real life. Researchers must, therefore, consider carefully the environmental circumstances in which they wish to evaluate outcomes, and use this information to decide whether to measure capability, performance, or both.

Activities of Daily Living↗
PubMed1996

New stone formation: a comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy.

PURPOSE: There is theoretical concern that stone recurrence rates may be higher following extracorporeal shock wave lithotripsy (ESWL) compared to other techniques because of residual stone debris. MATERIALS AND METHODS: We documented all new stone formations in 298 consecutive patients who initially achieved a stone-free status following ESWL for renal calculi less that 2 cm in largest dimension, and compared the findings to those of 62 patients treated with percutaneous nephrolithotomy without ultrasonic fragmentation. Stone-free status was assessed by a centrally reviewed plain abdominal film and renal tomograms at 3 months. A plain abdominal film was repeated at 12 and 24 months to detect recurrence. RESULTS: New stones formed in 22.2% of patients after ESWL and 4.2% after percutaneous nephrolithotomy at 1 year (p = 0.004), and in 34.8% versus 22.6%, respectively, at 2 years (p =0.190). Furthermore, more new stones recurred in the lower and mid calices compared to baseline location in the ESWL group (chi-square <0.0001), which was not observed in the percutaneous nephrolithotomy group. CONCLUSIONS: Our data support a trend toward higher stone recurrence rates in ESWL treated patients, which may be due to microscopic sand particles migrating to dependent calices and acting as a nidus for new stone formation.

Female↗
PubMed1995

Variation in orthopedic surgeons' perceptions of the indications for and outcomes of knee replacement.

OBJECTIVE: To determine the agreement among orthopedic surgeons' indications for knee replacement, their perceptions of the usefulness of various treatments for osteoarthritis of the knee and their expected outcomes of knee replacement, and to determine the relation between these opinions and the number of knee replacement procedures performed by individual surgeons. DESIGN: Survey. SETTING: Ontario. PARTICIPANTS: All 392 orthopedic surgeons in the province. Of the 325 practising traceable surgeons 234 (72.0%) responded. OUTCOME MEASURES: Indications for knee replacement, perceived usefulness of treatments for osteoarthritis, perceived outcomes of knee replacement and number of knee replacement procedures performed by individual surgeons. RESULTS: The respondents disagreed on how 20 of 34 patient characteristics affected their decision to perform knee replacement surgery. They also disagreed on the usefulness of seven of eight treatments for arthritis of the knee. The respondents demonstrated variation in their expected outcomes of knee replacement. The surgeons who performed more procedures judged, on average, the outcomes to be better and to have fewer complications than the surgeons who performed fewer procedures. CONCLUSIONS: Orthopedic surgeons demonstrated disagreement about some of the indications for knee replacement, the usefulness of treatments for arthritis of the knee and the perceived outcomes of knee replacement. The areas of greatest disagreement should be the focus of future research and the development of practice guidelines.

Adult↗
PubMed1995

American College of Rheumatology. Preliminary definition of improvement in rheumatoid arthritis.

OBJECTIVE: Trials of rheumatoid arthritis (RA) treatments report the average response in multiple outcome measures for treated patients. It is more clinically relevant to test whether individual patients improve with treatment, and this identifies a single primary efficacy measure. Multiple definitions of improvement are currently in use in different trials. The goal of this study was to promulgate a single definition for use in RA trials. METHODS: Using the American College of Rheumatology (ACR) core set of outcome measures for RA trials, we tested 40 different definitions of improvement, using a 3-step process. First, we performed a survey of rheumatologists, using actual patient cases from trials, to evaluate which definitions corresponded best to rheumatologists' impressions of improvement, eliminating most candidate definitions of improvement. Second, we tested 20 remaining definitions to determine which maximally discriminated effective treatment from placebo treatment and also minimized placebo response rates. With 8 candidate definitions of improvement remaining, we tested to see which were easiest to use and were best in accord with rheumatologists' impressions of improvement. RESULTS: The following definition of improvement was selected: 20% improvement in tender and swollen joint counts and 20% improvement in 3 of the 5 remaining ACR core set measures: patient and physician global assessments, pain, disability, and an acute-phase reactant. Additional validation of this definition was carried out in a comparative trial, and the results suggest that the definition is statistically powerful and does not identify a large percentage of placebo-treated patients as being improved. CONCLUSION: We present a definition of improvement which we hope will be used widely in RA trials.

Adult↗
PubMed1995

Which outcome measures should be used in rheumatoid arthritis clinical trials? Clinical and quality-of-life measures' responsiveness to treatment in a randomized controlled trial.

OBJECTIVE: To determine the discriminant validity of the core set of outcome measures proposed by the American College of Rheumatology (ACR) and the Outcome Measures in Clinical Trials (OMERACT) conference committee to be used in clinical trials of rheumatoid arthritis (RA). METHODS: Utilizing data from a multicenter randomized double-blind clinical trial of low-dose cyclosporine and placebo in RA, we estimated the relative efficiency (RE) of measures to detect a treatment effect (relative to tender joint count, which was assigned a value of 1). Four pain measures (10-cm visual analog scale [VAS], 5-point categorical scale, Health Assessment Questionnaire [HAQ] pain index, Arthritis Impact Measurement Scales [AIMS] pain score) and 3 quality-of-life measures (Problem Elicitation Technique [PET], HAQ, AIMS) were compared. RESULTS: Physician and patient global measures were the most responsive instruments, although neither was statistically superior to tender joint count. Swollen joint count, grip strength, pain measured on a 10-cm VAS, and functional status as measured by the PET and HAQ were all of intermediate responsiveness. Morning stiffness, 5-point pain scale, and erythrocyte sedimentation rate were the least responsive instruments. CONCLUSION: This study provides further evidence to support the core set of outcome measures proposed by the ACR and OMERACT:

Adolescent↗