Background and Purpose— The Ottawa subarachnoid hemorrhage (SAH) rule identifies patients with headache requiring no testing for SAH, while the 6-hour computed tomography (CT) rule guides when to forgo a lumbar puncture. Our objectives were to: (1) estimate the clinical impact of the Ottawa SAH rule and the 6-hour-CT rule on testing rates (ie, CT, lumbar puncture, CT angiography); (2) validate the 6-hour-CT rule for SAH when applied prospectively in a new cohort of patients. Methods— We conducted a multicenter prospective before/after implementation study from 2011 to 2016 with 6 months follow-up at 6 tertiary-care Canadian Academic Emergency Departments. Consecutive alert, neurologically intact adults with headache were included. For intervention period, physicians were given a 1-hour lecture, pocket cards, posters were installed, and physicians indicated Ottawa SAH rule criteria when ordering CTs. SAH was defined by blood on CT, xanthochromia in cerebrospinal fluid, or >1×10 6 /L red blood cells in cerebrospinal fluid with aneurysm. Results— We enrolled 3672 patients, 1743 before and 1929 after implementation, including 188 with SAH. Proportions undergoing CT was unchanged (88.0% versus 87.5%; P =0.643). Lumbar puncture use decreased (38.9% versus 25.9%; P <0.0001). Additional testing following CT (ie, lumbar puncture or CT angiography) decreased (51.3% versus 42.2%; P <0.0001). Admissions declined (9.8% versus 7.4%; P =0.011). Mean emergency department stay was unchanged (6.3±4.0 versus 6.4±4.2 hours; P =0.685). The Ottawa SAH rule was 100% (95% CI, 98.1%–100%) sensitive, and the 6-hour-CT rule was 95.5% (95% CI, 89.8–98.5) sensitive for SAH. The 6-hour-CT rule missed 5 SAHs: 1 radiology misread, 2 incidental aneurysms, 1 nonaneurysmal cause, and 1 profoundly anemic patient. Conclusions— The Ottawa SAH rule and the 6-hour-CT rule are highly sensitive and can be used routinely when SAH is considered in patients with headache. Implementing both rules was associated with a meaningful decrease in testing and admissions to hospital.

ObjectivesPhysicians are a commonly targeted group in health research surveys, but their response rates are often relatively low. The goal of this paper was to evaluate the effect of unconditional incentives in the form of a coffee card on physician postal survey response rates.DesignFollowing 13 key informant interviews and eight cognitive interviews a survey questionnaire was developed.ParticipantsA random sample of 534 physicians, stratified by physician group (geriatricians, family physicians, emergency physicians) was selected from a national medical directory.SettingUsing computer generated random numbers; half of the physicians in each stratum were allocated to receive a coffee card to a popular national coffee chain together with the first survey mailout.InterventionsThe intervention was a $10 Tim Hortons gift card given to half of the physicians who were randomly allocated to receive the incentive.Results265 (57.0%) physicians completed the survey. The response rate was significantly higher in the group allocated to receive the incentive (62.7% vs 51.3% in the control group; p=0.01).ConclusionsOur results indicate that an unconditional incentive in the form of a coffee gift card can substantially improve physician response rates. Future research can look at the effect of varying amounts of cash on the gift cards on response rates.

Objective To validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack. Design Prospective cohort study. Setting 13 Canadian emergency departments over five years. Participants 7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke. Main outcome measures The primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit. Results Of the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days. Conclusion The Canadian TIA Score stratifies patients’ seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.

In the clinical setting, previous studies have shown personalized risk assessment and communication improves risk perception and motivation. We evaluated an online health calculator that estimated and presented six different measures of life expectancy/mortality based on a person's sociodemographic and health behavior profile. Immediately after receiving calculator results, participants were invited to complete an online survey that asked how informative and motivating they found each risk measure, whether they would share their results and whether the calculator provided information they need to make lifestyle changes. Over 80% of the 317 survey respondents found at least one of six healthy living measures highly informative and motivating, but there was moderate heterogeneity regarding which measures respondents found most informative and motivating. Overall, health age was most informative and life expectancy most motivating. Approximately 40% of respondents would share the results with their clinician (44%) or social networks (38%), although the information they would share was often different from what they found informative or motivational. Online personalized risk assessment allows for a more personalized communication compared to historic paper-based risk assessment to maximize knowledge and motivation, and people should be provided a range of risk communication measures that reflect different risk perspectives.