There was evidence indicating that in the treatment of opioid use disorder, injectable hydromorphone, or injectable methadone provided more benefit at less cost compared with injectable diacetylmorphine over a 6-month time horizon. Evidence suggests that in the treatment of opioid use disorder, both injectable hydromorphone and injectable diacetylmorphine are likely to provide more benefit at less cost than methadone maintenance treatment. Treatment with injectable hydromorphone was more cost-effective than injectable diacetylmorphine in opioid use disorder patients who do not respond to or relapse from drug treatments. The evidence is limited because observed data were collected during a short-term follow-up, and long-term cost-effectiveness outcomes were based on extrapolations beyond data from the actual studies. One guideline provided a weak recommendation, supported by low-quality evidence, for using slow-release oral morphine in older adults with adequate renal function in whom buprenorphine and methadone maintenance have been ineffective to treat opioid use disorder or could not be tolerated. Another guideline recommends using injectable hydromorphone or injectable diacetylmorphine for individuals with severe opioid use disorders who relapsed previous treatments failed. No relevant cost-effectiveness evidence or guidelines with recommendations regarding the use of oral hydromorphone, fentanyl patches, or fentanyl buccal tablets for opioid use disorder treatment were identified; therefore, no summary can be provided.

visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study-and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (<25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level >20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate >110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up. Keywords: hyperglycemia, emergency department, risk factors P141 Predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool

Introduction: Utilization of CT pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) has risen dramatically but diagnostic yield has fallen over the past several decades, suggesting that lower risk patients are being tested. Given little evidence to suggest improved patient outcomes with higher CTPA utilization, and increasing evidence of harm, evidence-based guidelines have been developed to reduce unnecessary CTPA use. The objective of this study was to assess the impact of an electronic clinical decision support (CDS) intervention to reduce unnecessary CTPA utilization for emergency department (ED) patients with suspected PE. Methods: This was a cluster-randomized, controlled trial with physicians as the unit of randomization. All emergency physicians (EPs) at 4 urban adult EDs and 1 urgent care center were randomly assigned to receive either evidence-based imaging CDS for patients with suspected PE (intervention) or no CDS (control) over a 1-year study period. CDS was launched in an external web browser whenever an intervention EP ordered a CTPA from the computerized physician order entry software for ED patients CTAS 2-5; however, physician interaction with CDS was voluntary. The CDS tool enabled calculation of patient-specific information, including the patients Wells score, PERC score, and age-adjusted D-dimer, as well as prediction of each patients pre-test risk of PE along with an imaging/no imaging recommendation. CDS recommendations could be printed for the medical record as could educational patient handouts to support physician decision-making. The primary outcome was CTPA utilization for patients with CEDIS chief complaints of shortness of breath or chest pain on the index visit. Secondary outcomes included index visit length of stay (LOS), and CTPA use or VTE diagnosis within 90-days. This study was REB approved. Results: Demographics were similar among intervention and control EPs; however, during a 2-year pre-intervention period control EPs had a higher baseline CTPA rate (8.5% vs. 7.7%, p < 0.001). In the first 8-months following CDS implementation, 94 intervention EPs saw 9,609 patients and voluntarily interacted with the CDS tool on 43.2% of eligible encounters while 91 control EPs saw 9,498 patients. CTPA utilization was higher among intervention EPs than control (9.6% vs. 8.3%, p < 0.001) as was ED LOS (302 vs. 287 minutes, p < 0.001). There was no difference in 90-day CTPA use or VTE diagnoses. Conclusion: In one of the largest RCTs of CDS to date, exposure to CDS was associated with higher rates of CTPA utilization and longer ED LOS on the index visit, and no difference in 90-day CT use or VTE diagnoses. These results differ from a concurrent study of CDS for patients with mild traumatic brain injury in the same physician population and may relate to the implementation of the CDS intervention and/or complexity of the underlying evidence-based algorithms.Introduction: Pulmonary embolism (PE) is a common cardiovascular condition with high mortality rates if left untreated. Given ...

Four systematic reviews (SRs) and 6 retrospective cohort studies provided evidence for the clinical effectiveness of transcatheter mitral valve repair (TMVR) versus open heart conventional surgical mitral valve repair or replacement (SMVR) in patients with primary or secondary mitral regurgitation (MR). No relevant evidence regarding the cost-effectiveness of TMVR versus SMVR in patients with primary or secondary MR was identified; therefore, no summary can be provided. There was evidence indicating a statistically significant difference in favour of TMVR over SMVR regarding the odds of post-procedure bleeding, need for permanent pacemaker implantation, 30-day readmission, and a shorter duration of hospitalization. There was evidence suggesting a statistically significant difference in favour of SMVR over TMVR regarding the odds of recurrent MR, the need for reoperation, and mortality rate (i.e., during hospitalization, at 1 year, and > 3 years). Also, compared with TMVR, the likelihood of residual MR grade > 2 or freedom from MR grade ≥ 2 or ≥ 3 at 4 years was statistically significantly lower or higher, respectively, with SMVR. Evidence regarding the comparative clinical effectiveness of TMVR versus SMVR concerning stroke, acute kidney injury (AKI), cardiogenic shock, and death during hospitalization was conflicting and inconclusive. There was no evidence of a significant difference between the 2 interventions regarding overall mortality or mortality at 5 years, overall survival, freedom from cardiac death at 4 years, cardiac arrest, acute myocardial infarction (MI), and respiratory or vascular complications. A major limitation of the evidence was that it derives from studies of low or unknown quality and risk of bias, Furthermore, all the findings are confounded by differences in patient selection, which reflect the approved indications for the interventions but prevent a direct comparison between the TMVR and SMVR groups.

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Horizon Scan reports provide brief summaries of information regarding new and emerging health technologies; Heath Technology Update articles typically focus on a single device or intervention. These technologies are identified through the CADTH Horizon Scanning Service as topics of potential interest to health care decision-makers in Canada. This Horizon Scan summarizes the available information regarding an emerging technology, Percept PC Deep Brain Stimulation (DBS) system with BrainSense technology, for the treatment of Parkinson disease and essential tremors.

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The main cost considerations related to electric consultation (eConsult) can be grouped as start-up or infrastructure costs (e.g., equipment, developing electronic forms, creating workflows, and web page design), remunerations, (e.g., for primary care providers, specialist, and auxiliary staff), and societal cost (e.g., productivity loss, time spent travelling, cost of fuel to travel). Considerations for a successful integration of eConsult models into clinical workflows may be broadly categorized into pre-implementation factors (e.g., appropriate training for staff, anticipating and addressing potential barriers or concerns, and having contingency plans for technological failures), implementation factors (e.g., ensuring availability of appropriate data collection and processing devices and software, defining appropriateness of eConsult, building efficiency into the design by using standardized data capture forms, maximizing auto-populating data fields to reduce documentation time, ensuring appropriate confidential documentation, and emphasizing critical information). There were limitations in that no papers were identified to address the questions regarding ethical and professional considerations for the collection, use, and disclosure of protected health information, or the strengths and limitations of a standalone eConsult versus an eConsult platform integrated within an electronic medical records system. Furthermore, although the included studies contained some useful answers, they were not designed to address any of the research questions. Thus, well-designed studies focusing on the individual questions may be necessary for more comprehensive answers.