No description available.

No description available.

Note: Manuscript very warped.

Note: Title page omits author and title in manuscript. Taken from McGill University Thesis Directory.

No description available.

BACKGROUND: The Canadian healthcare system is subject to national standards that may be challenging to meet, given the evolution and integration of technology in healthcare in disciplines like functional neurosurgery, utilizing therapies such as deep brain stimulation (DBS), whereby implanted devices have provided benefit for patients with movement disorders. A comprehensive assessment of the need for this service to match with the delivery of DBS has not been performed. This thesis comprises a series of studies that aim to address this knowledge gap through the quadruple aim of health service research. METHODS: The first study is a systematic review and meta-analysis including economic evaluations comparing DBS for movement disorders with medical management only. The second is a mixed methods survey of Canadian stakeholders for DBS. The final study is a nationwide retrospective cohort study of DBS patients from 2019-2022 to determine factors that may influence access. RESULTS: Through analysis of 14 economic evaluations, DBS appears to be a cost-effective treatment when considered across the remaining lifespan of the patient with positive incremental net benefit for DBS with a mean difference of 40,504.81USD (95% CI 2,422.42; 78,587.19). Additionally, 220 responses from all DBS stakeholder groups revealed that costs associated with travel, waitlists, lack of specific resources, poor understanding of movement disorders and DBS indications, and referral pathways were barriers to accessing DBS. Finally, preliminary results identified 162 DBS patients. Potential factors that may increase access to DBS were indication (Parkinson’s disease), higher socioeconomic status, and race. CONCLUSIONS: While DBS is a cost-effective therapy for patients with movement disorders, the current delivery of this service needs significant improvement. This includes improved education, streamlined referral pathways, and policy change at a governmental level, with further investigation to determine regions of the country where need for DBS far exceeds current access. / Dissertation / Candidate in Philosophy / Movement disorders are progressive, debilitating neurologic conditions that severely impact the quality, speed and fluency of movement as a result of basal ganglia dysfunction. Medical therapies remain the mainstay of treatment, however high quality evidence supports the use of deep brain stimulation (DBS) to relieve these symptoms in well-selected patients. Given the upfront cost of surgery associated with DBS, and the comprehensive evaluations at tertiary care centres (including a multidisciplinary team with neurologists, neurosurgeons, neuropsychologists, psychiatrists, and electrophysiologists), this is a limited resource, particularly in overburdened publicly funded healthcare systems. There have been no previous attempts to comprehensively analyze access to DBS in Canada’s public healthcare system through investigation of need for these services, matched access, and investigation of barriers to access. This thesis comprises 5 chapters that inform this knowledge gap through the quadruple aim of health service research (patient perspective, health care provider perspective, cost, and population level data), aiming for equitable access to care in Canada. Chapter 1 is an introduction providing the rationale for conducting each of the included studies. Chapter 2 reports on an evaluation of cost, titled Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis. Chapter 3 presents an evaluation of healthcare provider and patient perspective, titled Mixed Methods Survey of Stakeholders to Identify Barriers to Accessing Deep Brain Stimulation for Movement Disorders in Canada. Chapter 4 is a retrospective cohort study providing population level data assessing patients who have received DBS in Canada, titled Canadian Access to Deep Brain Stimulation for Movement Disorders: A Nationwide Retrospective Study. Finally, Chapter 5 discusses the conclusion, limitations, and implications of the research presented in this PhD thesis.

Background Clinical Care Pathways (CCPs) are a form of organized care processes and mutual decision making regarding select patient groups in a specific context. Their aim is to enhance care quality, patient satisfaction, and outcomes while optimizing safety and resource utilization. CCPs are poorly characterized in the Canadian context, with a few examples of successful programs but no organizational framework. Aims & Methods Through an interview series and qualitative descriptive content analysis, this thesis attempts to discern neurosurgeon perspectives on CCPs, important content and processes, and barriers to CCP development. Through a retrospective case control study, for operative patients at one Canadian center, a second project describes characteristics of entry to neurosurgical care for the purpose of understanding system inputs and subsequent CCP development. Results Interviewed neurosurgeons describe a positive sentiment toward CCPs overall, with nuanced understanding coalescing between numerous perspectives. Respondents described CCPs heterogeneously, but overall recognized their structure. Current care barriers were identified. Numerous existing informal or partial CCPs were discussed. CCPs are noted to have specific essential elements in their design. Retrospective review of care entry from July through December 2022 analyzed 654 operative cases and 2135 regional urgent consult requests. This analysis revealed differences in care entry dependent on disease entity, referral characteristics, patient characteristics, and patient acuity. Conclusions Design and development of CCPs is an emerging practice in the Canadian neurosurgical context. Numerous institutions and groups are presently developing their local CCPs. This analysis serves as a preliminary structure of CCP design, with an example retrospective analysis of the care entry component at a local institution. / Thesis / Master of Science (MSc) / Clinical Care Pathways (CCPs) are processes describing how to care for a group of patients, from diagnosis through treatment and follow-up. Interviewed surgeons suggested that while significant barriers exist, such as resource limitations and prolonged wait times, CCP implementation would improve care. These pathways need to be evidence based, expert led, collect data, and contain a team from multiple specialties. CCPs should be uniquely built for certain disease groups such as spine, trauma, or oncology. Review of care entry at a specialized neurosurgical center suggested that care capacity is currently very strained. Wait times from assessment to surgery are lengthy. Many surgeries are happening as emergency cases, and some emergency cases would likely be done in a scheduled fashion, if resources were available for this. Similar reviews of referral sources can assist an institution to plan, in an informed way, for current and future needs for neurosurgery patients. This type of study serves as an example, when constructing a CCP, of how one can analyze system inputs.

No description available.

No description available.

Neurosurgery is an effective method for prolonging life and improving outcomes for patients with brain tumors. However, this option bears the risk of damaging areas of eloquent cortex, areas associated with motor and language tasks that, when lesioned, will result in a functional deficit for the patient. Functional magnetic resonance imaging (fMRI) is a valuable tool in the localization of eloquent cortex for preoperative neurosurgical planning. Through use of this modality of functional neuroimaging, the neurosurgeon can adjust the surgical trajectory to incur the least amount of damage to sites of functional activity. The supplementary motor area (SMA) is one such site of eloquent cortex that must be visualized preoperatively due to the risk of postoperative deficit with lesions in this area. However, due to both the effects of tumor pathology and naturally occurring interindividual variability, the SMA’s location and functional fingerprint can be highly variable. We present a study in which patients with frontal tumor (n=46) underwent task-based fMRI for motor and language network mapping. The patient-specific functional data were normalized and evaluated using ROI analysis to illustrate group-level activation patterns within the SMA during the language and motor tasks. The results illustrate a distinct pattern of activation including a rostro-caudal organization of language and motor activation, overlapping extent cluster volumes throughout the two functional subdivisions of the SMA, the pre-SMA and SMA proper, and discrete activation foci.