Category: PSI Spotlights

A potentially practice-changing study led by a PSI Foundation-funded surgical resident has challenged long-held beliefs about care for small bowel obstructions (SBOs).

SBO, a blockage in the intestine often cause by scar tissue (or “adhesions”) from previous surgery, is a common condition, representing about 20% of all hospital admissions for abdominal pain. A small number of patients whose conditions don’t resolve with usual treatment receive surgery, but most patients, about 80%, recover from SBO through treatment with bowel rest, IV fluids and gastric decompression. These patients are considered to be successfully treated and released from hospital, yet many of them will return – sometimes as often as every few months – with a recurrence.

Dr. Ramy Behman, a surgical resident with the University of Toronto, wanted to study the long-term natural history of SBO and potentially improve treatment. “We’ve been treating SBO the same way for a long time. Some people bounce back from an SBO, but then they’re dealing with it every few months,” says Dr. Behman. “SBOs aren’t very well studied, so a better understanding of the natural history could be helpful to improve treatment.”

Dr. Behman applied for and received PSI Foundation funding, which he says was crucial to the research, especially so early in his career. “I don’t know how we would have done the study without the funding,” he says. “And having people outside of your research committee think that the research is worthwhile is very encouraging when you’re just starting off.”

With a Resident Research Grant, Dr. Behman looked at 10 years of health administrative data, identifying nearly 40,000 patients in Ontario admitted to hospital for their first SBO during that time period. They then followed how the patients were treated on that occasion and any following recurrences and tracked the outcomes. The large dataset allowed them to examine the different ways that SBOs are managed and how outcomes are affected.

“We were one of the first groups to really step back and look at the long-term disease course,” he says. “And what we found was challenging to the dogma.”

Physicians have long believed that surgery for SBO would increase the risk of recurrence by creating new adhesions and usually don’t recommended surgery for SBO unless other treatments are unsuccessful. But Dr. Behman’s research suggested that this actually isn’t the case – in fact, surgery could reduce the risk of recurrence. According to their results, patients with SBO treated with surgery – whether on the first or subsequent occurrences – cut the risk of recurrence by about half.

“Operating can take patients off the recurrence cycle. It can really change the trajectory of disease for patients,” says Dr. Behman.

Surgery does have its own risks, namely the risk of complications that could potentially have been avoided, as well as a greater upfront cost than standard treatment. Dr. Behman and his team are analyzing the cost-utility to examine whether the greater upfront costs are offset by fewer hospital readmissions due to recurrences, and he is hoping to publish the results soon.

He notes that the study may influence guidelines for SBO management and help physicians make informed decisions about how the condition can be managed.

“This isn’t a uniform prescription for every patient with SBO, but it adds to our understanding of the disease and facilitates informed decision making,” he says. “The optimal practice will be the right intervention for the right patient.”

As the child of immigrants, Dr. Shixin (Cindy) Shen has had a long-standing interest in immigrant health issues, including cancer screening. While pursuing the Public Health and Preventive Medicine Residency at the University of Toronto, she found that there was little information about the barriers to colorectal cancer screening that immigrants in Ontario may face. “Colorectal cancer is the second most common cause of cancer, and 40% of all immigrants in Canada live in Ontario,” she says. “Yet, there wasn’t much information about colorectal cancer screening in immigrants in Ontario, despite the fact that they tend to have lower screening rates.”

To address this knowledge gap, Dr. Shen and her supervisors, Dr. Aisha Lofters and Dr. Richard Glazier, looked at the immigration and non-immigration factors that influence screening rates in immigrants, in order to get a better understanding of which are the most important.

They looked at data from a number of health care administrative databases, as well as the Immigration, Refugee and Citizenship Canada’s Permanent Resident Database, which contains records of individuals who obtained immigrant status since 1985.

Dr. Shen found that within the immigrant population there were significant differences in rates of screening non-adherence, related to different factors. Among the factors related to immigration, an individual’s region of birth and the income level of that region, as well as their immigration class (economic, family or refugee) were the most important factors that predicted screening non-adherence. Among the factors not related to immigration, individuals with no or moderate use of the health care system and those not rostered to a care team were less likely to be screened.

The results emphasize the health inequalities that immigrants may face in Ontario. “Some of these factors, especially when combined, contributed to significant disparities in screening uptake,” says Dr. Shen. “For example, among refugees from low-income countries who were not rostered and who lived in low-income areas, the rate of non-adherence to screening was 71%, compared to 25% for economic immigrants from high-income countries who were rostered and lived in high-income areas.”

The study was supported by a Resident Research Grant from PSI Foundation, which was critical for allowing the team to access the multiple databases and to support Dr. Shen’s work on the study. “The funding from PSI Foundation allowed me to lead the study from beginning to end, which was a very helpful learning experience,” she says. “I was able to further develop my skills in critical thinking, problem solving, and evidence generation, which will be helpful in my career as a public health physician.”

Dr. Shen notes that the study is just the starting point in understanding the screening barriers in this population, and that further research is needed to explore these factors in more depth. Ultimately, she hopes that the research can be used to help policymakers find ways to increase screening rates in this priority population.

“We know that screening is important for reducing cancer incidence and death rates, and we know that there are social factors that lead to poorer access to services and poorer health status,” she says. “With this research, we hope to have a better understanding of the potential causes of differential access to preventive care, so that we can address them properly and bridge the gap in health outcomes. The goal is to level the playing field so that everyone can lead healthy lives.”

Health professionals agree that breastfeeding is important for long-term child health, and it has also been suggested by policymakers as a way to reduce the risk of poverty and household food insecurity (HFI). But a recent PSI Foundation–funded study has challenged the conventional wisdom regarding breastfeeding duration and HFI, suggesting that it may be more important to focus on other strategies to reduce poverty.

“The benefits of breastfeeding are well recognized, but will it protect families from household food insecurity? Maybe not,” says Dr. Peter Wong, a pediatrician in Toronto.

Because breastmilk substitutes are expensive and could take money away from a household’s food budget, policymakers have suggested that encouraging longer duration of breastfeeding can be one way to decrease the risk of HFI. No research demonstrating the effectiveness of this strategy had previously been done, although studies have shown that the presence of HFI may adversely affect the duration of breastfeeding.

With a PSI Foundation Healthcare Research by Community Physicians grant, Dr. Wong and a team of researchers led by Drs. Patricia Parkin, Jonathon Maguire, Cory Borkhoff and Catherine Birken at TARGetKids!, a research group that focuses on early childhood health, explored this question. A unique research group in Canada, TARGetKids! includes a study population of 10,000 healthy children recruited at community-based practices to provide information about their growth, development and lifestyle to help researchers answer questions about this understudied group.

Dr. Wong and his colleagues surveyed 3,000 families from TARGetKids!, asking questions about breastfeeding duration, household food insecurity and family income. Surprisingly, they did not find an association between breastfeeding duration and HFI, suggesting that shorter duration does not increase the risk of HFI in their study population.

While Dr. Wong notes that the TARGetKids! study group provided access to a large study sample, he also says that the participants were not necessarily reflective of the population where HFI is a pressing concern, which may have influenced the results. Still, the study suggests that breastfeeding on its own may not be enough to help families struggling with poverty and HFI.

“To address household food insecurity, we need a higher level, upstream strategy that addresses more societal problems,” says Dr. Wong. “We need policies that will reduce insufficient income and poor employment. That’s where we’ll make a greater difference.”

Dr. Wong and the team are now planning to examine how breastfeeding and other health-related factors might influence measures of early childhood health, such as nutrition, development and cardiometabolic health. His primary role as a practising pediatrician, as well as his interest in community engagement, public health and epidemiology, gives him unique insight into these types of research questions. “As community physicians, we interact with families and kids on a daily basis, and we have a good appreciation for their health and social challenges,” he says. “We are able to formulate research questions that really have an impact on the health of families and communities.”

And he appreciates that PSI Foundation is supportive of physicians like him who do not have access to the same resources as academic researchers. “Full-time community clinicians have a challenging time competing in the same funding pool as academic researchers,” he says. “PSI Foundation demonstrates that physicians really do care about medical research and about asking questions that address the health of Ontarians.”

Degenerative Cervical Myelopathy (DCM)

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord impairments in adults worldwide. Recent evidence indicates that surgical intervention for DCM is associated with improved function and quality of life, regardless of disease severity. Albeit effective, surgery for DCM remains costly. Moreover, wait times for spine surgery in Ontario remain lengthy and this is likely to continue as the population ages. Health policymakers require an assessment of quality and value of surgery to develop an informed decision and optimize health resource allocation.

Cost-Effectiveness of Surgery for DCM – Dr. Christopher Witiw and Dr. Michael Fehlings

Through PSI’s Resident Research funding stream, Dr. Christopher Witiw, along with his supervisor Dr. Michael G. Fehlings of Toronto Western Hospital, conducted a study to determine the cost effectiveness of surgical intervention for DCM. The investigators found that surgery provided a significant improvement in quality of life and by using health economic calculations; they determined that 97.9% of interventions are very cost-effective relative to non-operative management. This finding suggests that resource allocation toward improving access to spinal surgery for those with debilitating condition is an effective allocation of resources. These findings will serve to provide surgeons and policymakers with the evidence needed to guide decision-making and optimize healthcare expenditures.

“This resident research grant, which I received from the PSI Foundation was a tremendous resource. The funding was instrumental in providing the means to combine my research training in health economics with my clinical focus on spine surgery to complete this important evaluation of the value of surgery for Degenerative Cervical Myelopathy.”

Impact of the Findings

Dr. Witiw was awarded the highly prestigious North American Spine Society Outstanding Paper Award for the manuscript based upon the findings of the study, which was published in The Spine Journal. Moreover, the data has been presented at numerous international spine surgical conferences and have been honoured with prestigious awards from a number of spinal surgical societies. Furthermore, the findings have been recently incorporated into international surgical guidelines regarding the management of Degenerative Cervical Myelopathy. Despite the success in knowledge translation to the academic spine surgery community thus far, Dr. Witiw believes more is needed to disseminate these findings to those responsible for healthcare resource allocation.

“Much of the care provided by spine surgeons is costly, but at the same time makes a tremendously positive impact on a patient’s quality of life. As healthcare resources become increasingly strained, more research pertaining to cost-effectiveness is needed to empower physicians to work with health policy makers to provide optimal care.”

Future Directions

Dr. Witiw has recently completed his neurosurgical residency training at the University of Toronto and is currently spending 1 year enrolled in a Spinal Neurosurgery Fellowship at Rush University Medical Center in Chicago. Here he is focusing on learning minimally invasive techniques for spine surgery, with the goals of lessening post-operative pain, reducing length of hospital stay and complications and optimizing outcomes. Following this, he plans to return to Toronto to a position as a spine surgeon at the University of Toronto and St. Michael’s Hospital where he hopes to continue his work on studying and improving the value of spine surgery for patients in Ontario.

Drs. Yaron Finkelstein and Suzanne Schuh’s PSI grant, BRonchiolitis Epidemiology: Air pollution and Trends of Hospitalization (The BREATH Study) was awarded in December 2014. Since then, their first manuscript, Predictors of Critical Care and Mortality in Bronchiolitis after Emergency Department Discharge, has been accepted for publication in the Journal of Pediatrics. Moreover, its critical findings led to its selection as one of the top four out of more than 3,000 abstract submissions to the annual conference of the Pediatric Academic Societies. This was presented as a platform at the American Pediatric Associations Presidential Plenary on May 7^th, 2018, at the Toronto Metro Convention Centre.

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