Congratulations to our 2017 award winners!
We receive many nominations from our participating Governance Organizations, and our reviewers were most impressed with the quality of work being undertaken by our AHSC AFP physicians and their project teams. This year, the nominations were grouped into 5 categories, and the winners chosen from among the excellent nominations in each group.
Dr. Paul J. Karanicolas
From Sunnybrook Health Sciences Centre for “Multicentre Evaluation of a Novel Technique of Analgesia Following Open Liver Resection: Medial Open Transversus Abdominis Plane (MOTAP) Catheters”
Quality and Safety, Improving Outcomes, Enhanced Effectiveness, and Collaborative Care
Dr. Richard Kim
From Academic Medical Organization of Southwestern Ontario for “Implementation of Pharmacogenomics Guided Warfarin Dosing and INR monitoring for Hospitalized Patients: Focus on Health Economics and Adverse Event Rates”
Cancer, Cardiovascular, Neurological, and Diabetes Management
Dr. Lillian Lai
From the Children’s Hospital Academic Medical Organization for “What is the impact of eConsultation in a Pediatric Specialty Referral Process?”
Award Category: Technology and Education
Dr. Nikhil Pai
From Hamilton Academic Health Sciences Organization for “Pediatric Fecal Microbial Transplant for the Treatment of Ulcerative Colitis (PediFETCh): A Multicenter Pilot Study”
Mental, Women’s, Children’s, Geriatric, and Indigenous Health
Dr. Venkatesh Thiruganasambandamoorthy
From The Ottawa Hospital Academic Medical Organization for “Early Discharge of Chest Pain Patients using the new Troponin Assay to Improve Emergency Overcrowding”
Emergency Care and Critical Care
Multicentre Evaluation of a Novel Technique of Analgesia Following Open Liver Resection: Medial Open Transversus Abdominis Plane (MOTAP) Catheters
Dr. Paul J Karanicolas
Objectives: Conventional management of pain following open liver surgery involves intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia, both of which have major limitations. The objective of this trial was to assess the efficacy of a novel regional technique that we developed called Medial Open Transversus Abdominis Plane (MOTAP) catheter analgesia for reducing postoperative opioid requirements.
Innovation: We conducted a double blind, randomized controlled trial at two high volume centers. Patients undergoing liver resection through a subcostal incision were enrolled. Using a standardized technique, two catheters were placed into the muscular layers of the abdominal wall in each patient after resection. Patients received either ropivacaine 0.2% (ROP) or saline (NS) through both catheters for 72 hours following surgery. All patients received IV PCA with hydromorphone. Primary outcome was hydromorphone use over the first 48 hours. 153 patients were included in the trial (71 ROP, 82 NS). Patients receiving ROP used significantly less opioid than patients with NS at 48 hours (median 39.6 mg morphine equivalent vs 49.2 mg, p=0.033) and at 72 hours (median 50.0 mg vs 66.4 mg, p=0.046). Patients receiving ROP had significantly less pain at rest and with coughing compared to patients with NS through the post-operative period (p=0.002). Median length of hospital stay was 5 days in patients receiving ROP and 6 days in patients who received NS (p=0.035). Two patients experienced catheter-related complications, both of which resolved prior to discharge.
Potential for Spread: This trial demonstrates that MOTAP catheter analgesia reduces opioid requirements, pain, and length of hospital stay compared with IV PCA following open liver resection. The MOTAP technique is simple to learn; we have developed an instructional video and published a step-by-step guide to the process. We have presented this work at national and international meetings, garnering interest from surgeons at other institutions across the province and beyond.
Beyond the IF: Based on the findings of this trial, MOTAP analgesia has been adopted by our institution as the standard technique of analgesia for patients undergoing open liver resection.
Implementation of Pharmacogenomics Guided Warfarin Dosing and INR monitoring for Hospitalized Patients: Focus on Health Economics and Adverse Event Rates
Dr. R. Kim
Transformation: Currently, drug therapy is a “shotgun” or iterative approach. Implementation of Personalized Medicine (PM)-based patient care can enhance drug safety and effectiveness, while lowering overall health care costs through reduced hospitalizations and clinic visits.
Adoptability: Our PM approach that leverage expert physicians, pharmacists, and nurses as well as genomics technologies is scalable and adoptable to other hospitals across Ontario.
Outcomes: Decrease the average length of stay (ALOS) in patients prescribed oral anticoagulants. Improvement in metrics adverse events, such as bleeding events, emergency room visits, and hospitalizations. Increase the standardization and individuation drug dosing and selection.
Background: In acute can hospital settings across North America, serious adverse drug reactions (ADRs) are observed in 6.7% of patients, and considered to be the 4th leading cause of death (Lazarou J, Pomeranz B, Corey PN. Incidence of adverse drug reactions in hospitalized patients: A meta-analysis of prospective studies. JAMA 1998;279:1200–1205).
Oral anticoagulants, used in the prevention and treatment of blood clotting in patients and results in the largest number of drug related admissions in tertiary hospitals. In addition to warfarin, a new class of oral anticoagulants known as Direct Oral Anticoagulant (DOAC) is increasingly prescribed as an alternative to warfarin, but currently, there is no standardized assessment of DOAC efficacy or bleeding risk in a routine clinical setting.
Methods: Our personalized medicine (PM) care team supported by the current AMOSO Innovation Fund, provided genomic-guided warfarin dosing and recommendation for 152 patients, and on target for 200 patients over a 2 year funding period. In addition, for those who are started on a DOAC, we have utilized a state-of-the-art liquid chromatography- tandem mass spectrometry (LC-MS/MS) system to measure the plasma DOAC concentration in our patients as a way to assess compliance and to ensure optimal dosing (n= ~ 100 rivaroxaban and >250 for apixaban).
Results: Analysis of inpatient data suggest that when our PM inpatient consult service is involved for the initiation of warfarin dosing, we are able to enhance discharge planning and thereby reduce average length of hospital stay. We have carried out detailed case costing and determined that even if we reduce the length of stay (LOS) by one day (last day of the stay), this will result in an average direct cost savings of $776/patient for those who are admitted under cardiology and $616/patient for clinical teaching unit (CTU-Medicine). With regards to DOACs, we note a marked interpatient variation (nearly 50-fold) in observed DOAC plasma concentrations, and a much higher proportion of our patients appear to exhibit high DOAC concentrations compared to the clinical trials that led to the approval of these agents.
Conclusions: We are now able to demonstrate that implementation of personalized medicine-based approach is a viable and cost effective solution for tertiary care hospitals for high risk drugs such as warfarin and DOACs.
Current and Future Direction: Our PM program has created a multidisciplinary team, focused on EMR integration, scaling of the approach for adoption by other hospital, as well as cost effectiveness assessment through in-depth linkage with Institute for Clinical and Evaluative Sciences (ICES), by leveraging large scale funding to proceed with hospital-wide PM approach for not only oral anticoagulants, but for other drugs associated with high toxicity risk, such as cancer chemotherapeutics.
What is the impact of eConsultation in a Pediatric Specialty Referral Process?
Dr. Lillian Lai
Objectives: The Champlain BASE™ (Building Access to Specialists through eConsultation) service, herein referred to as This project implemented eConsult into a tertiary care pediatric referral service and evaluated its impact on the delivery of pediatric specialty consultation by our institution. Success was measured on survey data from PCPs using the service and specialists providing the service, and analysis of utilization and wait times. “eConsult”, is a web-based asynchronous electronic communication service that allows primary care practitioners (PCP) to submit “elective” clinical questions to a specialist.
Innovation: At the time of study, no other Canadian institution had implemented eConsult or similar service in a pediatric tertiary care facility. We demonstrated that access to specialist advice was decreased to 1 day and in 36.7% of referrals PCPs reported that they would have sent the patient in for a FTF referral were it not for eConsult. There was high user and provider satisfaction. This type of service is transferable to other regions in the province of Ontario.
Potential for Spread: The ability to increase access and timeliness to specialist advice, makes eConsult applicable to any system. Several other provinces in Canada (Manitoba, British Columbia and Newfoundland) have shown interest in implementing eConsult into their healthcare institutions. The study demonstrated significant potential for improving efficiency in the provision of care, most notably for remote underserviced areas, where access to specialists require the time and financial burden of flying patients to a specialty center.
Beyond the IF: The project has secured funding for another study (Innovation grant 2016-2018) focusing on tracking the health care activity of patients who have had an eConsult performed during the pilot study period of 2014-2016. This would provide hard data confirming that ~40% of eConsults would have been deferred from a FTF referral as reported by PCPs. As of September 2016, the Children’s Hospital of Eastern Ontario endorsed eConsult as a consistent service it provides to its community. The Ministry of Health and Long Term Care (MOHLTC) has been funding eConsult as a demonstration project since January 2015. As of spring 2017, the MOHLTC has endorsed eConsult as a service that should be provided to the province and has committed budget to this endeavor.
Pediatric Fecal Microbial Transplant for the Treatment of Ulcerative Colitis (PediFETCh): A Multicenter Pilot Study
Dr. Nikhil Pai
Objectives: Ulcerative colitis (UC) is a lifelong disease that affects a person’s ability to digest food, absorb nutrients, and eliminate waste . Ontario has one of the highest rates of childhood-onset UC in the entire world. Current treatment of UC involves lifelong medication therapy. These medications are known to impair a child’s immune system and increase future cancer risk. Recent studies have shown that children with UC have a unique intestinal bacterial composition (microbiome) that differs from healthy children.
Reversing this abnormal microbiome back to its healthy state through bacterial therapy, or fecal microbial transplant (FMT), may offer an innovative treatment option. Studies of FMT in adults suggest this may be as effective and safer than lifelong medications. This project will try to determine whether healthy human stool can be used as treatment for children with UC. This will be the highest quality, placebo-controlled trial of FMT for children, with any condition, in the world. The impacts of this study on health care delivery are two-fold: 1) developing the very first, scientifically-tested treatment approach for microbial therapy in children, and 2) describing an effective, affordable treatment option for UC that may carry fewer long-term side effects. We will measure our project’s
success in two phases: 1) whether patients respond to the treatment in the current study, and 2) the uptake of our FMT protocol in research trials for children across other pediatric centers.
Innovation: This project is innovative for McMaster because it represents one of the first McMaster-conducted adult Department of Medicine studies to be reproduced locally by McMaster’s Department of Pediatrics. Our project built off existing research done on FMT by McMaster’s Department of Gastroenterology (Moayyedi et al. Investigators from the adult FMT study are collaborators on our pediatric trial, and have offered support and guidance. This project has already been transferred to other institutions across the province. We have invited London Health Sciences Center (Western University), and St. Justine’s Hospital (University of Montreal) to become collaborators. London is already recruiting patients, and Montreal is awaiting ethics board approval. Both sites will be using our study protocol for their own patients at their institutions.
Potential for Spread: We have already demonstrated how our protocol can be applied beyond McMaster. Nationally, and internationally, bacterial therapy for UC and other autoimmune conditions has become fs- extremely popular. We have received many calls from patients and physicians across the United States (California, Indiana, Florida, Massachusetts, etc.) and Canada (Vancouver, Ottawa, Halifax) to enter our trial. The FMT product that we are studying is prepared centrally. Thus, our project is directly transferable to other regions of the province or elsewhere. particularly using the validated protocol we have developed.
Beyond the IF: This project received Hamilton Health Sciences New Investigator Grant funding prior to HAHSO funding. We have not secured next phase funding until results of this phase of our project are reviewed. If our project shows benefit, we will apply for a CIHR Team Grant to launch a broader, national trial.
Early Discharge of Chest Pain Patients using the new Troponin Assay to Improve Emergency Overcrowding
Dr. Venkatesh Thiruganasambandamoorthy
Objectives: Chest pain is a common Emergency Department (ED) presentation. Most patients are placed on a cardiac monitor for fear of a potentially life-threatening arrhythmia which is rare (<2%). ED cardiac monitors are a scarce resource. We have previously derived a The Ottawa Chest Pain Cardiac Monitoring (OCPCM) Rule for identification of low-risk patients for arrhythmias. Chest pain can be associated with myocardial infarction (MI), diagnosed either by ECG (ST elevation MI – STEMI) or by biomarker Troponin (TnI). The goal of this study is to: 1) validate the OCPCM Rule; 2) assess the role of a single TNI assay in the diagnosis of NSTEMI (without the need for repeat test) among patients with prolonged duration of symptoms; and the assess the role of a repeat troponin at 3-hours for safe and efficient rule out of NSTEMI.
Innovation: Our previous study found that 60% of chest pain patients receive cardiac monitoring and at least one-third can be removed off monitoring making this resource available for other sicker patients. All published guidelines recommend two sets of blood test be performed 6 to 8 hours apart on all patients for diagnosis of MI. Currently at our hospital patients stay up to 8 hours in the ED with repeat blood test done at 6 hours. We conducted a prospective cohort study at the EDs in our institution (N=1,742) and using data from 796 patients we found that the OCPCM rule was 100% sensitive in identification of low-risk patients for arrhythmias; arrhythmias are rare (1.9%) and 35.7% of all chest pain patients can be removed off cardiac monitoring. We also found that among patients with prolonged symptoms (N=235), one TNI measurement will identify NSTEMI with high sensitivity (100%) and that 13.5% of patients can be discharged after one TNI. We are currently in the process of ascertaining that a 3-hour repeat testing will result in safe and efficient way of diagnosing NSTEMI in the majority of the remaining patients.
Potential for Spread: Approximately 1 million Canadian visit the ED for chest pain (second most common reason for ED visit). Application of our study results will lead to efficient use of health care resources to reduce ED overcrowding: 1) Optimal use of ED cardiac monitoring; and 2) Quicker and safe disposition of patients with prolonged symptoms. Once we ascertain that a 3-hour repeat TNI testing is sufficient for robust diagnosis of NSTEMI, the ED length of stay among chest pain patients can be reduced by 50%. These results are transferable to all Canadian EDs and to all EDs in the world.
Beyond the IF: We have established a Canadian Chest Pain Consortium and plan to submit a multicenter CIHR grant for implementation of our study results and for improving chest pain care in the ED and post-ED. Our future study will lead to safe and efficient use of health care resources and reduce ED overcrowding.