Browsing by Author "Jetté, Nathalie"

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    A systematic approach to using regression modelling and ‘big data’ to derive a meaningful clinical decision rule for epilepsy
    (2018-08-22) Josephson, Colin Bruce; Wiebe, Samuel; Jetté, Nathalie; Sajobi, Tolulope T.; Marshall, Deborah A.
    Introduction: clinical decision rules (CDRs) have been developed in a number of medical fields resulting in improved patient outcomes, quality of care, and health economics. Aims: to identify all CDRs developed for epilepsy and to derive one that guides the prescription of the antiepileptic drug (AED), levetiracetam, according to its risk of a psychiatric adverse effect. Methods: a systematic review and meta-analysis was first performed to determine the state of the literature with respect to CDRs in epilepsy. The Health Improvement Network (THIN) electronic medical records register was used to identify patients with epilepsy by employing a modified validated case definition with a 5-year washout. Analyses were restricted to patients receiving AED monotherapy and the association between levetiracetam use and psychiatric adverse effects was explored Cox proportional hazards regression with timevarying covariates. Finally, logistic regression with parameter regularisation and k=5 fold cross validation was used to derive the CDR that predicts the development of psychiatric adverse effects following levetiracetam prescription. Results: the systematic review identified four epilepsy-specific CDRs, none of which guided AED prescription. A total of 9595 presumed incident cases of epilepsy (85.7 cases per 100,000 persons) were identified in THIN. Both carbamazepine (hazard ratio [HR]: 0.84, 95% confidence interval [95% CI]: 0.73– 0.97; p = 0.02) and lamotrigine (HR: 0.83, 95% CI: 0.70–0.99; p = 0.03) were associated with reduced hazards of a psychiatric sign, symptom, or disorder iii compared to no AED treatment. Levetiracetam was not associated with psychiatric adverse effects but the analyses were underpowered (n=202; 3%). All patients receiving levetiracetam (1173/7400; 16%) were included for CDR derivation. Prediction variables were incorporated into multiple logistic regression models with parameter regularisation. Odds of reporting a psychiatric complaint were elevated for females and those with a pre-exposure history of depression, anxiety, recreational drug use, or higher social deprivation. The prediction model performed well (area under the curve [AUC] 0.68; 95% confidence interval 0.58- 0.79 after stratified k=5 fold cross-validation). Using a cut-off threshold 0.1, the CDR had a specificity of 83%. Conclusion: If externally validated and properly implemented, this CDR could be used to guide prescription in clinical practice.
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    Depression in Epilepsy
    (2014-05-02) Fiest, Kirsten; Patten, Scott; Jetté, Nathalie
    A relationship between depression and epilepsy has been consistently reported in the literature. Most of this research has estimated the proportion of people with depression in epilepsy. More recently, research has focused on determining fast and accurate methods of diagnosing depression in clinical samples. In contrast, there is a relative dearth of research into the treatment of depression in epilepsy using both pharmacological and non-pharmacological methods. Despite this research, there are still gaps in the knowledge base of this association. The literature on depression in epilepsy has not been reviewed and summarized. Screening tools for identifying depression in epilepsy have either not been validated, or have not been validated with a gold standard tool. Finally, patterns of pharmacological and non-pharmacological treatment of depression in epilepsy have not been well characterized. The work reported in this dissertation addresses each of these three knowledge gaps. Based on a systematic review, the overall pooled prevalence of active depression in persons with epilepsy was found to be 23.1% (95% Confidence Interval (CI): 20.6%-28.3%), and the overall odds ratio of active depression in those with epilepsy, relative to those without, was 2.77 (95% CI: 2.09-3.67). Three depression screening tools, one of which was previously not validated, and new cut-points for scoring were explored in a group of 185 persons with epilepsy. Compared to a gold-standard diagnostic interview, the tools with the best overall balance of sensitivity and specificity were the Hospital Anxiety and Depression Scale at a cut-point of seven and the Patient Health Questionnaire with a cut-point of nine. Newly suggested cut-points for scoring performed better than those cut-points recommended for use in the general population. Considering both pharmacological and non- pharmacological treatments for depression in persons with epilepsy, the majority of persons (70.3%) with current depression were not receiving depression-related therapy. Of those treated, ii most were receiving non-pharmacological treatments for depression. More persons with a past history of depression (37.2%) were receiving treatment, of which the majority was by pharmacological management. The results of these studies characterize the identification and management of depression, addressing knowledge gaps and providing direction for future research.
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    Development and Validation of an ICD-10 Case Definition for Pediatric Traumatic Brain Injury using Canadian Administrative Data
    (2012-12-12) McChesney, Jane; Jetté, Nathalie
    Background: Administrative data are used for disease surveillance and research. A validated case definition to study pediatric traumatic brain injury(TBI)using administrative data is not available. Methods: Using systematic review methodology, we identified studies validating TBI ICD coding. Second, a cohort of children with and without TBI from a pediatric emergency department (ER) was linked to administrative hospital and emergency databases. Nine ICD-10 based algorithms were tested. Sensitivity, specificity, and positive/negative predictive value (PPV, NPV) were calculated. Results: We identified three studies from the systematic review with varying diagnostic accuracy, and none were pediatric specific. The best algorithm to identify TBI cases was, “1 Hospital or 1 ER visit in 1 year”: sensitivity 69.8%, (67.3-72.2), specificity 96.7% (96.2-97.2), PPV 84.2% (82.0-86.3), NPV 92.7% (92.0-93.3). Conclusion: This study algorithm is best to capture ER or hospitalized TBI cases. Future research should develop algorithms which include children seen in the community.
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    Guidelines for Epilepsy Care – Gaps, Knowledge and Implementation
    (2016) Sauro, Khara; Wiebe, Samuel; Jetté, Nathalie; Quan, Hude; Holroyd-Leduc, Jayna; DeCoster, Carolyn
    Epilepsy is the second most common neurological condition and can be associated with significant morbidity, premature mortality, and high resource use. Epilepsy is a spectrum disorder due its diverse presentation, making it challenging to manage. As a result, treatment gaps exist. Clinical practice guidelines should facilitate the care of people with epilepsy. While evidence exists that guidelines are effective in improving the quality of care in some clinical settings, this has not been demonstrated for epilepsy. The objectives of this thesis are to: 1) Identify gaps in epilepsy guidelines, 2) Determine barriers and facilitators to implementation of epilepsy guidelines, and 3) Develop a knowledge translation (KT) strategy to optimize dissemination and implementation of epilepsy guidelines. Several methods were used to achieve the study objectives. A systematic review of epilepsy guidelines was conducted to identify gaps. A mixed-methods approach (quantitative survey and focus groups) was used to identify the determinants of guideline use among neurologists. Based on the results of the study examining determinants of guideline use, a theory-based KT strategy was proposed to facilitate future implementation of epilepsy guidelines in clinical practice. The systematic review identified 63 guidelines for the care of epilepsy covering 19 populations/conditions. Gaps in the availability of guidelines for high priority areas (i.e. elderly) and significant heterogeneity in quality were identified. Despite the number of guidelines available for the care of people with epilepsy, use of these guidelines clinically is poor. Reasons for the poor implementation of these guidelines among neurologists (end-users of epilepsy guidelines) were identified here, and include: lack of knowledge, poor credibility, applicability and motivation, insufficient resources, and lack of clarity regarding the target users. A three-pillared KT strategy to overcome the barriers of guideline use, and leverage facilitators is proposed to improve implementation in clinical practice. This body of work provides novel evidence into the current state of epilepsy guidelines, and the factors that determine their use clinically. This novel insight helps bridge a knowledge gap while the KT strategy outlined here provides the tools required to move towards improving implementation of guidelines for the care of people with epilepsy internationally.
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    Intranasal Insulin for Treatment of Diabetic Polyneuropathy
    (2013-11-19) Korngut, Lawrence; Wiebe, Samuel; Jetté, Nathalie
    Intranasal insulin administration is a novel approach to slow the progression of diabetic polyneuropathy (DPN). We performed a pilot randomized controlled trial of intranasal insulin in 12 type 1 diabetes mellitus patients with DPN to assess safety. We administered intranasal insulin for 6 weeks using biweekly dose-escalation up to 160 IU/d or intranasal saline. The primary outcome measure was frequency of hypoglycaemia. Frequency of mild (mHG) and serious hypoglycaemic (sHG) events was recorded. Secondary outcomes included clinical (Utah Early Neuropathy Score (UENS)) and laboratory (corneal confocal microscopy and electrophysiology) measures. There were no differences in glycemia between groups after supervised initial administration. The 40 IU/d and 80 IU/d doses were safe and well tolerated with comparable mHG events between groups. One intranasal insulin subject suffered a sHG at home while receiving 160 IU/d. Intranasal insulin was safe and well tolerated at 40 and 80 IU/d.
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    Investigating the Association between Migraine and Major Depression A Retrospective Cohort Study
    (2010) Modgill, Geeta; Patten, Scott B.; Jetté, Nathalie
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    Physical Activity, Smoking, and Other Health-Related Behaviours in Canadians with Epilepsy: Are Behaviours Changing Over Time?
    (2014-07-21) Roberts, Jodie; Jetté, Nathalie; Patten, Scott
    Previous studies have indicated that people with epilepsy (PWE) are more likely to smoke cigarettes and less likely to engage in physical activity or consume fruits and vegetables. It is unknown whether improvements have occurred following updated guidelines and public health interventions. This project aimed to explore patterns of health related behaviors (HRBs) such as smoking and physical activity in Canadians with epilepsy and examine whether behaviors have changed over time using data from a series of five national population-based surveys spanning from 2001 to 2011. In total, 522,722 Canadians were included in the dataset, including 3,220 PWE. The proportion of PWE who did not participate in any physical activity decreased over time (2001=17.2%, 2010/2011=8.5%), as did the proportion of PWE who currently smoked (2001=32.3%, 2010/2011=18.0%). However, fruit and vegetable consumption was consistently inadequate among PWE. Physicians should continue to counsel epilepsy patients on the importance of healthy lifestyle choices.
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    Physician Payment: Data Integrity and Policies for Improvement
    (2016) Cunningham, Ceara Tess; Quan, Hude; Jetté, Nathalie; Noseworthy, Tom; DeCoster, Carolyn
    Physician compensation is a key component of any health system. In Canada, various reimbursement models which exist for physicians include fee-for-service (FFS), capitation and salaries [1, 2]. There are concerns nationally that the implementation of alternative payment plans (APP) may be affecting certain processes, such as changes in billing claims submissions (i.e. decreases), potentially leading to incomplete billing data and underestimates of disease burdens and outcomes [3, 4]. Thus, four studies were conducted to examine billing patterns between traditional FFS and APP specialists and to assess existing APP policies aimed at governing issues related to physician billing. In the first study, a survey was conducted to gain consent to access medical and surgical specialist claims data in Calgary, Alberta. With a 35.0% (317/904) response rate, 317 physicians consented to data access (47.7% (71/149) of physicians on APP plans versus 38.9% (46/119) on FFS plans). The second study validated billing claims submitted by surveyed APP and FFS physicians. The proportion of submitted claims for APP and FFS physicians was over 90%. The third study looked at physician claims data to examine the impact of physician reimbursement programs on estimates of hypertension prevalence, cardiovascular disease hospitalization rate and mortality. These estimates (APP claims; 0.6%, n=3677, FFS claims; 99.4%, n=610,167) were minimally impacted if APP physicians did not submit claims. The final study surveyed and interviewed faculty of medicine department heads nationally about APP programs and government stakeholders to determine current policies regarding specialist shadow billing. Disincentive programs appear to be an efficient tool to promote APP physician billing submission. Similar studies should now be conducted in other Canadian regions to confirm the findings, to objectively explore the extent of the variability between billing submission processes nationally and to determine the impact of APP programs on disease estimates.
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    The Prevalence of Depression and the Accuracy of Depression Screening Tools in Migraine Patients
    (2014-04-23) Amoozegar, Farnaz; Jetté, Nathalie; Patten, Scott
    Migraine and major depressive disorders are common comorbid conditions. The purpose of this cross-sectional study was to assess how well the Patient Health Questionnaire (9 items) and the Hospital Anxiety and Depression Scale perform as depression screening tools in migraine patients attending a headache clinic, determine the prevalence of depression in this patient population using a gold standard semi-structured psychiatric interview, and examine disability and quality of life for these patients. The Patient Health Questionnaire (cut-point 14) and the Hospital Anxiety and Depression Scale (cut-point 11) produced an optimal balance of psychometric properties for the studied migraine population. The point prevalence of depression was 25.0% (95% CI 19.0-31.0), and the prevalence of untreated depression was 17.0% (95% CI 10.8 – 23.2). Patients with both migraine and depression had significantly higher degrees of disability and a poorer quality of life as compared to patients without depression.