Journal of Gastrointestinal Surgery

https://doi.org/10.1007/s11605-018-3881-z

ORIGINAL ARTICLE

Evolving Management Strategies in Patients with Adhesive Small Bowel

Obstruction: a Population-Based Analysis
Ramy Behman 1 & Avery B. Nathens 1,2,3 & Nicole Look Hong 1,2,3 & Petros Pechlivanoglou 3,4 & Paul J Karanicolas 1,2,3

Received: 15 May 2018 / Accepted: 10 July 2018

# 2018 The Society for Surgery of the Alimentary Tract

Abstract
Background In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and
technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described
at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO
in a large North American population.
Methods We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005–2014.
We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable
logistic regressions were used to assess trends when controlling for potential confounders.
Results Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were
female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons
per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p < 0.0001).
Among those who underwent surgery, there were significant increases in the proportions of patients who underwent laparoscopic
procedures (4 to 14%, p < 0.0001) and who underwent surgery within 1 day of admission (51 to 60%, p < 0.0001).
Conclusion Between 2005 and 2014, there was a decrease in the population-based rate of aSBO, which may reflect increased
utilization of minimally invasive techniques. There were significant trends towards increased operative intervention, with surgery
occurring earlier and increasingly using laparoscopic approach.

Keywords Small bowel obstruction . Adhesions . Trends

Introduction common cause of small bowel obstruction (SBO), accounting

Intra-abdominal adhesions are a consequence of almost all
surgical procedures that involve entry into the peritoneal cav-
ity. In developed countries, where surgical procedures are
more common, intra-abdominal adhesions are the most
* Paul J Karanicolas
paul.karanicolas@sunnybrook.ca
1
Division of General Surgery, Department of Surgery, University of
Toronto, Toronto, Canada
2
Division of General Surgery, Sunnybrook Health Sciences Centre,
2075 Bayview Ave, T2-016, Toronto, ON M4N 3M5, Canada
3
Institute of Health Policy Management and Evaluation, University of
Toronto, Toronto, Canada
4
Child Health Evaluative Sciences, The Hospital for Sick Children,
Toronto, Canada
for approximately 65–75% of admissions for SBO. 1,2
Adhesive small bowel obstruction (aSBO) is one of the most
common reasons for emergency admission to a surgical ser-
vice in developed countries, accounting for up to 20% of all
admissions for acute abdomen.3–5
Management guidelines for aSBO have long advocated for
a trial of non-operative management in patients without signs
of bowel ischemia or sepsis.6,7 In most published guidelines,
surgical intervention is reserved for patients with signs of
bowel compromise and those without clinical signs of resolu-
tion after several days.
Management of aSBO is a complex, multi-disciplinary pro-
cess that has the potential for considerable institutional and
provider variability. The decision for admission to a medical
or a surgical service, the decision to operate, the duration of a
trial of non-operative management, and the surgical approach
(laparoscopic vs. open) are all management decisions that
have been shown to have a significant impact on patient

outcomes.8–15 The adherence of practitioners to current guide-
lines is not unknown, nor have trends in the management since
the proliferation of laparoscopic techniques for aSBO been
well described at the population level.
We suspect that there have been significant changes in the
strategies employed in the management of aSBO over time.
The expansion of acute care surgery services has likely shaped
the way that aSBO is managed today. The purpose of this
study is to evaluate the secular trends in the management of
aSBO over a large region using a population-based approach.
Methods
Study Design and Setting
This is a population-based retrospective cohort study of pa-
tients admitted with their first episode of adhesive small bowel
obstruction between April 1, 2005 and March 31, 2014. We
evaluated management strategies including primary care ser-
vice, operative management, timing of operative intervention,
and utilization of laparoscopic approaches over the 10-year
interval.
We used linked administrative databases for the province of
Ontario, Canada. The universally accessible, single-payer
healthcare system in Ontario allows for the capture of all
healthcare encounters for all of Ontario’s 13.6 million resi-
dents. Data collected by the Ministry of Health and Long-
term Care was made available for this study through the
Institute for Clinical Evaluative Sciences (ICES). The
Research Ethics Board of Sunnybrook Health Sciences
Centre approved this study.
Data Sources
We obtained data from the following sources: (1) Canadian
Institute for Health Information-Discharge Abstract
Database (CIHI-DAD)—an administrative database for de-
mographic, diagnostic, and discharge data, including the
reasons for admission; (2) Registered Persons Database
(RPDB)—an administrative database of demographic data
for all Ontario residents who are eligible for care under the
Ontario Health Insurance Plan (OHIP); (3) OHIP Claims
Database—an administrative database of all physician
claims data; and (4) the National Ambulatory Care
Reporting System (NACRS)—an administrative database
that captures all emergency department visits in Ontario.
These datasets were linked using unique encoded identi-
fiers and analyzed at the ICES. These data sources have
been previously validated for a number of surgical and
non-surgical diseases.16–20
J Gastrointest Surg
Cohort
We set out to create a cohort consisting of all adult patients
admitted to hospital with their first episode of aSBO between
2005 and 2014 (all years fiscal). We opted to restrict the cohort
to patients admitted for their first episode of aSBO. This ap-
proach creates a more uniform cohort than would be otherwise
if patients with multiple previous admissions and/or previous
operations for aSBO were included.
To create this cohort, we identified all patients admitted
with a principle diagnosis of either adhesive intestinal
obstruction [International Classification of Disease (ICD)
10 code K56.5] or unspecified intestinal obstruction
(ICD10 code K56.6). Using a 5-year look-back window
for each patient, we excluded any prior admissions for
bowel obstruction to limit to those patients with a first
episode to the extent possible. We then excluded patients
with any diagnoses codes consistent with potentially non-
adhesive etiologies for bowel obstruction, including her-
nias, volvulus, ileus, gallstone ileus, intussusception, and
abdominal malignancy at the time of admission for bowel
obstruction. Additionally, prior to each patient’s entry into
the cohort, a 5-year look-back window was used to iden-
tify patients with a history of abdominal radiation therapy
or a previous diagnosis of inflammatory bowel disease,
who were also excluded.
Exposure
We evaluated the strategies in the management of aSBO as a
function of calendar year and then again by stratifying the
cohort into three periods by their date of inception: (Bfirst^:
2005–2007, Bsecond^: 2008–2011, and Bthird^: 2012–2014)
and comparing practices between periods.
Outcomes
The primary outcome was the rate of operative manage-
ment. Secondary outcomes included the proportion of op-
erations initiated laparoscopically, the proportion of oper-
ations that were performed early in the admission, the
proportion of procedures performed Bafter-hours,^ and
the proportion of patients managed primarily by a general
surgery services. After-hours procedures included those
performed between 5 p.m. and 7 a.m. and weekdays or
on weekends. Management by a general surgery service
was defined by the specialty of the most responsible phy-
sician for an admission. For the purposes of this study, we
defined any procedures that were done on the calendar
day of admission or the calendar day after admission as
Bearly.^
J Gastrointest Surg
Covariates
Patient- and hospital-level factors that might influence the
management strategy were included in our analyses. Patient
factors included age, sex, income quintile, comorbidity bur-
den, and rurality of their home residence. In multivariable
analyses, patient age was categorized into four age groups:
< 40 years, 40–59 years, 60–74 years, and 75 years and older.
Income quintiles were obtained from census data and are
based on the median income of a patient’s six-digit postal
code. To measure a patient’s comorbidity burden, we used
the adjusted clinical groups (ACG) developed by Johns
Hopkins with a 2-year look-back period.21 This look-back
window included all inpatient and outpatient records. We then
collapsed the ACG groups into resource utilization bands
(RUBs). RUBs allowed us to categorize patients based on
their healthcare resource utilization. The use of RUBs has
been validated in both Canadian and American datasets as
an effective measure of comorbidity burden.21–23 We mea-
sured rurality using Rurality Index of Ontario (RIO), which
is calculated using population density as well as the distance to
the nearest basic and advanced referral centers. We dichoto-
mized RIO into Brural^ or Burban^ as has been validated
previously.24 Finally, we included hospital-level covariates
including hospital size (number of beds) and teaching status.
Hospital size was dichotomized into two categories: those that
had 250 or more beds and those that had fewer than 250 beds.
Analytic Approach
We performed descriptive statistics to evaluate the demo-
graphic characteristics of the cohort. We then calculated the
proportion of patients admitted with aSBO each year who
were managed operatively. The baseline characteristics of pa-
tients who underwent operation for aSBO were compared to
those of patients managed non-operatively using t tests and
chi-square tests as appropriate. Due to the large sample size,
Fig. 1 Patient eligibility
flowchart
we reported standardized differences, which are not sensitive
to sample size.25 A standardized difference of 10% or greater
was determined a priori to represent a significant difference.26
Among patients who were managed operatively, we also
estimated the proportion of patients managed with early oper-
ations and the proportion of patients managed with laparo-
scopic procedures for each year.
We used Cochran-Armitage tests to evaluate secular trends
over the study period.27,28 Results of Cochran-Armitage tests
were reported as p values, with p < 0.05 being statistically
significant. We then performed multivariable analyses using
hierarchical mixed-effects binomial logistic regressions to
evaluate the association of time interval on the operative man-
agement strategy including surgery vs non-surgical, and
among patients undergoing surgery, a laparoscopic vs open
approach and the timing of intervention. These models
allowed us to estimate the odds of each outcome while
adjusting for covariates while also accounting for the random
effects associated with clustering at the hospital level.
Results
We identified 40,800 patients meeting our inclusion criteria
with a first episode of aSBO over 2005–2014 (Fig. 1). Over
the study period, the mean rate of admission for a first episode
of aSBO was 38.8 per 100,000 persons per year. The mean
age of this cohort was 68.5 ± 16.2 years and just over half
were female (54.3%). The cohort had a high comorbidity bur-
den at the time of their index admission, as measured by health
resource utilization: 64% patients had high or very high utili-
zation in the 2 years prior to admission, with 31% being mod-
erate users and only 5% of patients being healthy or low users
(Table 1).
In this study population, 8584 patients (21.1%) underwent
operative management during their index admission for
aSBO. Compared to patients who were managed non-
 J Gastrointest Surg

Table 1 Baseline characteristics of patients managed operatively at the index admission

All patients Patients managed Patients managed Standardized

(n = 40,800) non-operatively operatively difference
(n = 32,216) (n = 8584)

Age (year)—mean (std dev) 68.5 (16.2) 68.9 (16.0) 66.9 (16.6) 0.12
Sex (F)—n(%) 22,104 (54.3) 16,882 (52.5) 5222 (60.8) 0.12
Comorbidity (RUB)—n(%) 0.25
• Healthy users 550 (1.4) 392 (1.2) 158 (1.8)
• Low users 1483 (3.6) 1062 (3.3) 421 (4.9)
• Moderate users 12,579 (30.9) 9415 (29.3) 3164 (36.9)
• High users 10,284 (25.2) 8019 (24.9) 2265 (26.4)
• Very high users 15,844 (38.9) 13,269 (41.3) 2575 (30.0)
Income Quintile—n(%) 0.04
• 1st (lowest) 8865 (21.3) 6870 (21.4) 1795 (20.9)
• 2nd 8489 (20.8) 6755 (21.0) 1734 (20.2)
• 3rd 8024 (19.7) 6358 (19.8) 1666 (19.4)
• 4th 7851 (19.3) 6135 (19.1) 1716 (20.0)
• 5th (highest) 7523 (18.5) 5881 (18.3) 1642 (19.1)
Residence (rural)—n(%) 3214 (7.9) 2740 (8.5) 474 (5.5) 0.12
Hospital beds ≥ 250—n(%) 17,025 (41.8) 12,953 (40.3) 4072 (47.5) 0.07
Teaching hospital—n(%) 9719 (23.9) 7453 (23.2) 2266 (26.4) 0.15

operatively, patients who underwent surgery were younger
(66.9 vs 68.9 years), were more likely to be women (60.8 vs
52.5%, SD 0.12), and had a lower pre-admission comorbidity
burden (Table 1). Overall, 80% of procedures for aSBO were
performed after-hours, 55% were performed on the day of
admission or the day after, and 7.8% were performed
laparoscopically.
Incidence and Demographic Characteristics
The population-based rate of a first episode of aSBO was
stable over the study period, with a mean of 39.1 per
100,000 persons per year in the early period and a mean of
38.1 in the late period (p = 0.049). There was no significant
change in the age distribution over time, with patients aged
65–84 representing slightly less than half of the cohort and
patients aged 45–64 consistently representing approximately
25% of the cohort. In each year of the study period, the pro-
portion of patients who were female was around 55%.
Surgical Management
The proportion of patients who underwent surgical manage-
ment increased over the study period from 19.3% in 2005 to
22.8% in 2014 (p < 0.0001), representing a 3.5% absolute and
18% relative increase. Among patients who underwent sur-
gery, there was also a significant increase in the proportion
of patients who underwent laparoscopic procedures (4 to 14%,
p < 0.0001) (Fig. 2). There was no significant change in the
proportion of patients who underwent after-hours procedures,
which was consistently around 80% of those who underwent
surgery (p = 0.17).
After adjusting for patient and hospital factors, the period
in which patients were treated was significantly associated
with the odds of operative management. The latter two of
the three periods were associated with odds ratios of 1.11
(95%CI 1.05–1.18) and 1.09 (95%CI 1.02–1.16), respective-
ly, for operative management compared to the early period
(Table 2). Additional factors that were significantly associated
with greater odds of operative management for aSBO includ-
ed younger patient age, female sex, lower comorbidity burden,
non-rural residence, and being treated at a hospital with a
greater number of beds.
Surgery in the latter periods was also associated with great-
er odds of a laparoscopic procedure [OR 1.45 (95%CI 1.15–
1.84) in the second period (2008–2011) and OR 2.52 (95%CI:
2.0–3.19) in the third period (2012–2014), compared to the
first period (2005–2007). Patient and institutional factors as-
sociated with a higher rate of laparoscopic procedures were
younger patient age, greater hospital bed-size, and non-
teaching status (Table 3).
Time to Surgery
Among patients who underwent surgery, there was a signifi-
cant increase over the study period in the proportion of pa-
tients who underwent early intervention on the day or day
following admission (49.7 to 60.5%, p < 0.0001) (Fig. 3).
J Gastrointest Surg

Fig. 2 The proportion of patients

undergoing laparoscopic
procedures among patients treated
surgically as a function of year

After adjusting for patient and hospital factors, surgery in a 1.53 (1.36–1.72) in the third period]. Additional factors that
later period was significantly associated with early operation were associated with an early operation included younger pa-
[OR 1.37 (95%CI 1.23–1.53) in the second period and OR tient age, male sex, higher income quintile, non-rural resi-
dence, and being treated at a larger hospital (Table 3).

Table 2 Multivariable regression for operative management Admitting Service

Odds ratio (95% CI)
Overall, 62% of the cohort was admitted to a general surgical
Age service. There was a small but statistically significant increase
< 40 1 in the proportion of patients admitted to a general surgical
40–59 0.86 (0.77–0.96) service over the study period, from 60.1% in 2005 to 64.6%
60–74 0.81 (0.72–0.90) in 2014 (p < 0.0001). Overall, patients admitted to a general
75+ 0.81 (0.73–0.91) surgery service were significantly younger (65.3 vs
Female sex 1.43 (1.36–1.50) 69.7 years), less comorbid (33.9% very high users RUB vs
Comorbidity burden (RUB) 45.9%), and more likely to have non-rural residence (96.5 vs
Healthy users 1 84.5%) (p < 0.001 for all). Patients admitted to a general sur-
Low users 0.91 (0.73–1.14) gery service were also more likely to be treated at larger hos-
Moderate users 0.77 (0.63–0.94) pitals (51.4 vs. 25.8%) and teaching hospitals (29.4%v s
High users 0.64 (0.52–0.78) 14.7%) (p < 0.0001 for both).
Very high users 0.45 (0.37–0.54)
Income quintile
1st (lowest) 1 Discussion
2nd 0.98 (0.90–1.06)
3rd 1.02 (0.94–1.10) In this population-based retrospective cohort study of patients
4th 1.07 (0.99–1.16) admitted for their first episode of aSBO, we found significant
5th 1.06 (0.98–1.15) changes in management strategies over a 10-year time
Rural residence 0.81 (0.71–0.92) interval.
Study period We identified a higher rate of operative management and
Early (2005–2007) 1 among these patients a shorter interval between admission and
Middle (2008–2011) 1.11 (1.05–1.18) operation. These changes might in part be explained by strong
Late (2012–2014) 1.09 (1.02–1.16) evidence from several recent studies suggesting that delayed
Teaching hospital 1.15 (0.91–1.45) operation in this patient population is associated with an in-
Large hospital (beds ≥ 250) 1.29 (1.13–1.48) crease in morbidity and mortality.8,10,11,13,29,30 These studies
may have resulted in greater importance being placed on
 J Gastrointest Surg

Table 3 Multivariable regression for early and laparoscopic procedures superior image quality may better identify high-grade obstruc-
among patients treated operatively
tions and those that are unlikely to resolve non-operatively.4
Early procedure Laparoscopic The use of water-soluble contrast studies to identify patients
procedure who will likely require operative intervention also likely con-
Odds ratio (95% CI) Odds ratio (95% CI) tributed to this trend.7,31–33 Finally, the increased utilization of
Age
laparoscopy may lower the threshold to attempt a lysis of
< 40 1 1
adhesions in patients for whom laparotomy may have been
considered too morbid.
40–59 0.87 (0.71–1.05) 0.81 (0.60–1.09)
The increased use of laparoscopic techniques in patients
60–74 0.68 (0.56–0.82) 0.65 (0.48–0.88)
with aSBO is consistent with the general trend towards mini-
75+ 0.60 (0.49–0.72) 0.55 (0.40–0.74)
mally invasive approaches in acute surgical illnesses.34,35
Female sex 0.76 (0.69–0.83) 0.89 (0.76–1.05)
Laparoscopic procedures in patients with aSBO are associated
Comorbidity burden (RUB)
with shorter length of stay and fewer complications compared
Healthy users 1 1
to open procedures.9,12,36,37 Greater experience with laparos-
Low users 1.29 (0.88–1.90) 1.24 (0.64–2.41)
copy among practicing surgeons as well as more formal lapa-
Moderate users 0.89 (0.64–1.25) 1.19 (0.66–2.15)
roscopic training among graduating surgical trainees likely
High users 0.85 (0.61–1.20) 1.05 (0.58–1.93)
contributed to the increased rates of laparoscopy.37
Very high users 0.72 (0.51–1.01) 1.06 (0.58–1.94)
We also identified a slight decrease in the population-based
Income quintile
incidence of admission for a first episode of aSBO. This de-
1st (lowest) 1 1
crease may reflect an increase in the use of minimally invasive
2nd 1.11 (0.98–1.28) 0.99 (0.77–1.27)
techniques such as laparoscopy. Alternatively, increased use
3rd 1.05 (0.92–1.21) 0.93 (0.72–1.21) of adhesion barriers may also have contributed to the decrease
4th 1.01 (0.88–1.16) 0.97 (0.75–1.25) in the incidence of aSBO.38,39
5th 1.21 (1.05–1.39) 0.95 (0.73–1.24) The increase in management by a surgical service over time
Rural residence 0.78 (0.62–0.98) 0.83 (0.53–1.31) that we observed over the study period was small but statisti-
Study period cally significant. There is evidence to suggest that admission
Early (2005–2007) 1 1 to a general surgical service is associated with improved clin-
Middle (2008–2011) 1.37 (1.23–1.53) 1.45 (1.15–1.84) ical outcomes.15,40–42 In a population-based study, patients
Late (2012–2014) 1.53 (1.36–1.72) 2.52 (2.0–3.19) admitted to a surgical service had a shorter time to surgery,
Teaching hospital 1.31 (0.96–1.80) 0.53 (0.30–0.96) shorter length of stay, lower mortality, lower rate of readmis-
Large hospital (beds ≥ 250) 1.14 (0.93–1.39 1.57 (1.08–2.28) sion, and lower costs compared to those admitted to medical
services.15 Additionally, the decision regarding admission ser-
vice may be an important early management decision that
avoiding delayed operations, encouraging surgeons to manage underpins other trends noted in this study.
patients operatively earlier in the admission. Additionally, in- We found significant changes over time in the proportion of
creased utilization of pre-operative CT imaging as well as patients who undergo surgery for aSBO and the timing and

Fig. 3 The proportion of patients

undergoing early procedures
among patients treated surgically
as a function of year. BEarly^
procedure = procedure performed
on the day of admission or on the
day following admission
J Gastrointest Surg
technique of those procedures. These changes affect a large
patient population and incur considerable healthcare re-
sources. In the USA alone, there are an estimated 350,000
operations performed annually for lysis of adhesions. These
procedures are associated with 960,000 inpatient days and
$2.3 billion.43,44 Consideration of shifting trends in manage-
ment may play an important role in resource allocation.
In this population-based cohort, we noted that patients who
lived in non-rural areas and those treated in larger hospitals
had a significantly greater likelihood of being managed oper-
atively, and those managed operatively underwent surgery
earlier in their admission. This finding may be a reflection of
the resources available to larger, urban hospitals, particularly
with respect to their ability to perform after-hours procedures.
In light of evidence that earlier surgical intervention may be
beneficial, resource allocation for the management of aSBO
may be an important consideration for healthcare systems.
Our study benefited from the single-payer universally ac-
cessible healthcare system in Ontario. The linked administra-
tive databases made available through the Ministry of Health
and Long-term Care and the Institute for Clinical Evaluative
Sciences allowed us to identify a cohort that captured almost
all admissions for aSBO across the entire population of
Ontario during our study period. The trends reported here
are representative of a large North American population with
minimal selection bias. However, using administrative data-
bases for research purposes has associated challenges. There is
the potential for misclassification bias in which patients other
than those admitted for their first episode of aSBO were in-
cluded in the cohort. Many patients who are managed non-
operatively for adhesive SBO may be attributed an ICD code
of BUnspecified bowel obstruction^, rather than BAdhesive
bowel obstruction^ if there is no operative documentation
specifically mentioning an adhesion. To address this, we in-
cluded patients with either diagnosis code, then excluded any
patients with concurrent diagnosis codes consistent with non-
adhesive etiologies of bowel obstruction. A similar method
has been used in population-based datasets for aSBO in the
past.15 Using this method, approximately 30% of patients who
were admitted with a diagnosis of bowel obstruction were
excluded for non-adhesive etiologies. This is consistent with
several published estimates that approximately 65–75% of
bowel obstructions are caused by adhesions.2
Additionally, since the health administrative data that we
used are not specifically collected for research purposes, they
lack much of the granularity for a detailed examination.
Certain clinically important factors that may play an important
role in the decision-making behind which patients to manage
operatively, the duration of the trial of non-operative manage-
ment, and the surgical approach were missing from our
dataset. These factors include clinical exam and subjective
patient findings, CT scan findings, the number of previous
abdominal operations, the existence of a ventral hernia, or
the presence of abdominal mesh. We were able to create a
relatively homogenous cohort by excluding some of these
factors, including a previous diagnosis of inflammatory bowel
disease, a history of abdominal radiation therapy, as well as
previous admission or surgery of aSBO; however, some im-
portant factors could not be ascertained.
Finally, our study was not able to identify admissions in
which patients underwent water-soluble contrast studies. These
studies can reliably predict which patients will require operative
intervention, with some studies showing an overall reduction in
the proportion of patients undergoing surgery.31,45,46 Water-
soluble contrast studies have become considerably more com-
mon since the end of our study period, with some recent guide-
lines including them as standard care.33 Future studies that can
evaluate the impact of these studies on operative trends at a
population level will be a valuable addition to the literature.
Conclusion
Patients admitted for their first episode of aSBO are increas-
ingly more likely to be managed by a surgical team and more
likely to undergo surgical management over the course of the
10 years examined. Among patients who are managed opera-
tively, surgery is more likely to be performed laparoscopically
and more likely to occur on the day of admission.
Author Contributions Study conception and design: Behman, Nathens,
Karanicolas.
Acquisition of data: Behman, Nathens, Karanicolas.
Analysis and interpretation of data: Behman, Nathens,
Pechlivanoglou, Karanicolas.
Drafting of manuscript: Behman, Nathens, Look Hong, Karanicolas.
Critical revision: Nathens, Look Hong, Pechlivanoglou, Karanicolas.
Compliance with Ethical Standards
Disclaimer The opinions, results, and conclusions reported in this paper
are those of the authors and are independent from the funding sources. No
endorsement by ICES or the Ontario MOHLTC is intended or should be
inferred.
Parts of this material are based on data and information compiled and
provided by the Canadian Institute for Health Information (CIHI).
However, the analyses, conclusions, opinions, and statements expressed
herein are those of the author, and not necessarily those of CIHI.
Sources of Support Physician Services Incorporated Resident Research
Grant, Ministry of Health and Long-term Care Clinician Investigator
Program, Canadian Institute of Health Research New Investigator
Award, Canada Research Chair for Systems in Trauma Care.
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