The outcome of IHE initiatives is providing better information for developing health policy and best medical practices. IHE disseminates information in many ways. In addition to publications in peer-reviewed journals, IHE produces books and a variety of reports synthesizing information in a particular field.
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| Angus Thompson, Maria Ospina, Liz Dennett, Arianna Waye, Philip Jacobs
Presenteeism, reduced productivity while working, has come into consideration as a major occupational health problem in many countries with serious consequences for both organizations and employees. Increasing evidence shows that presenteeism represents a significant source of productivity losses that can cost organizations much more than does absenteeism, and it can lead to an…
This report is from an Alberta Strategic Clinical Networks (SCN) exchange meeting with Mr. Neil Fraser. This event brought together SCNs and related health system stakeholders, and a leader in the Canadian medical technology industry, and recent member of a Federal Advisory Panel on Healthcare Innovation. The meeting had the objectives to help the SCNs to understand the Advisory…
Background: Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas.
The Institute of Health Economics held a roundtable on June 4, 2015, entitled Innovative Funding Models: Kidney Care Policy Options for the Future, to identify and discuss key issues in kidney care policy options. Prior to the roundtable, an Innovative Funding Models: Kidney Care Policy Options for the Future Steering Committee teleconference refined project objectives, and the…
The Institute of Health Economics (IHE), in partnership with Boehringer Ingelheim (Canada) Ltd./Ltée held an invitational forum on October 3, 2015, in Edmonton, Alberta. The purpose of this discussion was to bring together multiple stakeholders from across Canada to investigate the current state of evidence and information regarding idiopathic pulmonary fibrosis (IPF) and…
Objective: In this study, we estimate the impact of the new PCV13 immunization program on the burden of disease and related healthcare costs in Alberta.
OBJECTIVES: To examine differences in health services utilization (HSU) costs in the first year of life between low birth weight (LBW) and normal birth weight (NBW) infants, identify maternal and child characteristics associated with HSU costs, and estimate annual HSU cost of LBW infants for the province of Alberta, Canada.
| Bing Guo, Carmen Moga, Christa Harstall, Don Schopflocher
Objective: Because of a lack of a control group, a case-series study is considered one of the weaker study designs from which to obtain evidence on treatment effectiveness. Under certain circumstances, however, this is the only available evidence to inform health-care decisions. This study's intent was to develop and validate a quality appraisal checklist specifically for…
| Werner J Becker, Ted Findlay, Carmen Moga, Ann Scott, Christa Harstall, Paul Taenzer
Objective: To increase the use of evidence-informed approaches to diagnosis, investigation, and treatment of headache for patients in primary care.
Note: This is an Alberta Ambassador Guideline Adaptation Program related publication.
Alberta Health Services (AHS) has recently established a number of Strategic Clinical Networks (SCNs) in the province around specific health care topics (e.g., Cardiovascular Health & Stroke) and within areas where care is delivered (e.g., Surgery). The SCNs are the engines of innovation in the health system and have a mandate to find new and innovative ways of delivering care…
| Don Husereau, Larry Arshoff, Shahira Bhimani, Nicola Allen
This document describes the entry of new medical devices into the Canadian health system. It is intended to provide an accurate description of new medical device entry in Canada, and is intended to give patients, the public, private and public sector health system researchers, medical device companies, and private and public coverage bodies a general understanding of what regulatory,…
Written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report provides an assessment of how the adoption of fFN testing in Alberta impacted the clinical management of preterm labour and healty system resources. This was also an opportunity to retroactively use the Post Policy Implementation Framework to evaluate a specific policy developed within…
We reviewed literature to estimate the costs of Fetal Alcohol Spectrum Disorder (FASD) in the Canadian Criminal Justice System (CJS), and to update the total costs of FASD in Canada. The results suggest FASD is costlier than previous estimates. The costs of FASD associated with the CJS are estimated at $3.9 billion a year, with $1.2 billion for police, $0.4 billion for court,…
| Julie Polisena, John Lavis, Don Juzwishin, Pam McLean-Veysey, Ian Graham, Christa Harstall, Janet Martin
A perceived gap exists in how well Canadian health technology assessment (HTA) producers are supporting the use of their HTAs by decision-makers. The authors propose that the newly released HTA Database Canadian search interface incorporate structured decision-relevant summaries of HTAs that would be developed by participating Canadian HTA organizations. The registry would…
| Ann Scott, Dion Pasichnyk, Christa Harstall, Dagmara Chojecki
This Information Paper is an inventory and broad summary of factors affecting the adoption and diffusion of health technologies and of available models, strategies, tools, and processes for optimizing health technology diffusion.
| Braden Manns, Anderson Chuck, Eddy Nason, Lianne Barnieh, John Sproule, Jasmine Brown
This work, conducted by the Institute for Health Economics (IHE) and the University of Calgary (Health Economics group), was performed to better understand the unmet educational needs and health economics products that could support people in the province, and to determine the current capacity for conducting health economics in Alberta. This paper seeks to understand the needs…
Objectives: Economic evaluations, although not formally used in purchasing decisions for medical devices in Canada, are still being conducted and published. The aim of this study was to examine the way that prices have been included in Canadian economic evaluations of medical devices.
Economic surveillance and economic assessments are important sources of information to help administrators and policy makers to track current trends and evaluate policies and care patterns. The Institute of Health Economics, in partnership with Alberta Health, held a two-day Costing Methods Workshop which helped to review costing practices by bringing together economists and other…
| Deborah Marshall, Egon Jonsson, Liam Martin, Diane Mosher, Karen V. MacDonald
This White Paper discusses the concept of developing a comprehensive rheumatoid arthritis registry in Alberta, and the important health, social, and economic gains such a resource would generate for Alberta.
The Federal Minister of Health, the Honourable Rona Ambrose, announced the creation of the Advisory Panel on Healthcare Innovation (Panel) on June 24, 2014, to examine innovative health care ideas and approaches that exist in Canada and internationally. The Panel’s mandate is to identify promising innovations, here and internationally, which could help Canada reduce growth…
This book includes the plenary presentations made at the first international conference on prevention of FASD, which was attended by about 700 people from 35 countries around the globe. The issues addressed are FASD as a priority in health policy making; its prevalence and incidence; strategies for prevention; current applied and basic research in the field; the role of the medical…
Fetal alcohol spectrum disorder (FASD) is of growing concern around the world. A range of disabilities caused by prenatal exposure to alcohol, FASD is estimated to affect 2% to 5% of all newborns in the industrialized countries of Europe and North America, and the rates may be significantly higher in some developing countries and certain defined populations. Epidemiological studies…
| Maria Ospina, Liz Dennett, Arianna Waye, Philip Jacobs, Angus Thompson
Objectives: To assess and compare the measurement properties (ie, validity, reliability, responsiveness) and the quality of the evidence of presenteeism instruments.
| Thanh Nguyen, Egon Jonsson, Jessica Moffatt, Liz Dennett, Anderson Chuck, Shelley Birchard
Abstract: Parent-Child Assistance Program (P-CAP) is a 3-year home visitation/harm reduction intervention to prevent alcohol exposed births, thereby births with fetal alcohol spectrum disorder, among high-risk women. This article used a decision analytic modelling technique to estimate the incremental cost-effectiveness ratio and the net monetary benefit of the P-CAP…
| Lindsay Wodinski, Kate Woodman, Margaret Wanke, Thanh Nguyen, Philip Jacobs
Abstract: Alberta's Primary Care Networks (PCNs) bring together family physicians and other health professionals to provide local, comprehensive, and readily accessible primary care services to patients. The Edmonton North PCN, one of the largest in the province, piloted the Resource in Clinic (RIC) Program with objectives to increase efficiencies in the use of physician…
| Sherilyn Houle, Finlay McAlister, Cynthia Jackevicius, Anderson Chuck, Ross Tsuyuki
BACKGROUND: Pay-for-performance (P4P) is increasingly touted as a means to improve health care quality.
PURPOSE: To evaluate the effect of P4P remuneration targeting individual health careproviders.
Value for Money in the Health System was the eighth in the series of Innovation Forums. The keynote speaker, Mr. Don Drummond, Matthews Fellow and Distinguished Visiting Scholar in the School of Policy Studies at Queens University, and a former Associate Deputy Minister of Finance in the Government of Canada, as well as a former Senior Vice President and Chief Economics at TD Financial…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report performs an evaluation of the scientific evidence on the safety, performance, and effectiveness of universal and targeted preschool hearing screening (PHS) to inform the Infant and Preschool Screening Framework being developed by the Community and Public Health (CPH)…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This review focused on the best evidence available on the use of PSVS to detect vision conditions in asymptomatic preschool children (aged from birth to 6 years; not necessarily considered at risk for developing visual impairment) to determine the safety and efficacy/effectiveness…
The EQ-5D is a standardized instrument developed by the EuroQol group for use as a measure of health outcome. It considers five dimensions of health-related quality of life: mobility, self-care, usual activities, pain/discomfort, anxiety/depression. When the need for greater collaboration around implementation and use of the EQ-5D in Alberta was recognized in eary 2012, colleagues…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report is an update of a 2007 report. Permanent congenital hearing impairment/loss (PCHI/PCHL) is one of the most common congenital anomalies found at birth which can lead to delays and deficits in the development of speech, language, cognition, and learning, as well as…
This project is concerned with describing a comprehensive set of HTA products, not the methods used to produce them. The report describes various products produced by HTA agencies and provides a summary of the basic elements of these products, but an in-depth analysis of, or comparison between, the various products in terms of their methodology is beyond its scope. Information…
Background: The aim of this study was to extend an earlier retrospective cohort study of schizophrenia via a prospective study to a follow-up of 34 years, with an emphasis on describing the life-course of the illness.
| Thanh Nguyen, Anderson Chuck, Arto Ohinmaa, Philip Jacobs
Background: The benefits of pharmaceutical innovations are widely diffused; they accrue to the healthcare providers, patients, employers, and manufacturers. We estimate the societal monetary benefits of simvastatin in Canada and its distribution among different beneficiaries overtime.
| Mel Slomp, Philip Jacobs, Arto Ohinmaa, Roger Bland, Ray Block, Carolyn Dewa, Carina Wang
OBJECTIVES: In Canada, most mental health services are embedded in the publichealth care system. Little is known of the cost distribution within the mental healthpopulation. Our study aims to estimate the depression care costs of patients with adepression diagnosis, ranking them by the increasing total depression health carecosts.
| Logan McLeod, JoAnn Kingston-Riechers, Egon Jonsson
Abstract: The potential risks to patient safety in a primary care setting are different than the risks to patient safety in an acute care setting. The main differences arise from the organisational structures of primary care delivery and the greater involvement of patients in their care. To account for these differences, we present the Patient Safety in Primary Care Framework…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report provides an epidemiological profile of fetal aneuploidy and open neural tube defects (ONTD); describes the patterns of care, utilization trends, and factors affecting the provision of first and second trimester screening (FASTs) services for fetal aneuploidy and…
The concept of “personalized medicine” in health is garnering increased attention. Personalized medicine can be defined as the tailoring of preventive, diagnostic, or therapeutic interventions to the characteristics of an individual or population. This may involve genetic or laboratory biomarker information. As personalized medicine promises to increasingly change the…
For which strategies of suicide prevention is there evidence of effectiveness? This report aims to synthesize research findings from existing systematic reviews to address two questions: What types of preventive interventions have been evaluated in the published literature? Which strategies have good-quality evidence to support them? Limited evidence - as well as variability by…
| Sherilyn Houle, Anderson Chuck, Finlay McAlister, Ross Tsuyuki
STUDY OBJECTIVE: To quantify the potential cost savings of a community pharmacy-basedhypertension management program based on the results of the Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN) study in terms of avoided cardiovascular events-myocardial infarction, stroke, and heart failure hospitalization, and to compare these cost savings…
| Bach Tran, Arto Ohinmaa, Anh Duong, Nhan Do, Long Nguyen, Quoc Nguyen, Steve Mills, Philip Jacobs, Stan Houston
PURPOSE: This longitudinal study assessed the changes in drug use patterns and health-related quality of life (HRQL) among HIV-positive drug users in the first methadonemaintenance treatment (MMT) cohort in Vietnam.
| Paula Corabian, Dagmara Chojecki, Christa Harstall
This exploratory report provides a summary of some of the published information on the current status of research in and potential future sphere of activity of nanomedicine (Part I) and an inventory of resources on nanotechnology and nanomedicine (Part II). Over the next 5 to 10 years it is expected that the overall impact of nanomedicine will be multifaceted, with significant…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report summarizes available key information on the use of bariatric treatments for adult obesity in Alberta and North America (mainly Canada). This analysis was intended to describe the profile of adult obesity (definition, progression, epidemiology, and population dynamics…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report examines the research evidence on the safety and efficacy of insulin pump therapy, as compared to multiple daily insulin injections, in the treatment of children, adults, and pregnant women diagnosed with type 1 diabetes. The report also analyses the economic impact…
| Carmen Moga, Bing Guo, Don Schopflocher, Christa Harstall
This Methodology Paper summarizes the process, a modified Delphi approach, used to develop a specific checklist for the quality appraisal of case series studies. This work was supplemented with a review of other published checklists and an initial pilot test of the newly developed quality appraisal checklist. Researchers at the Institute of Health Economics with researchers from…
| Anne-Marie Boström, Susan E Slaughter, Dagmara Chojecki, Carole Estabrooks
OBJECTIVES: The recent emphasis on knowledge translation (KT) in health care is based on the premise that quality of care improves when research findings are translated into practice. This study aimed to identify the extent, nature, and settings of KT research pertaining to the care of older adults.
This report describes a framework for evaluating policies developed within the Alberta Health Technologies Decision Process (AHTDP) to strengthen the link between policy development and evidence. The framework was designed as a foundation upon which to build a more detailed and contextualized evaluative process in consultation with all stakeholders who are likely to be affected…
In February 2012, the Canadian Institute for Health Information (CIHI) in partnership with the Institute of Health Economics (IHE) sponsored a two day meeting of content, administrative and research experts to identify the breadth of diagnostic imaging studies that CIHI might feasibly undertake with its data or with data that could be easily obtained. The purpose of this report…
Sponsored by the Institute of Health Economics (IHE) – Methodology Forum Series. Presented at the Health Canada and Canadian Institutes of Health Research Personalised Medicine in Canada: A Multi-Stakeholder Workshop to Examine the Canadian Perspective, January 12, 2012. The specific objectives of this session/workshop were to: Explore issues relevant to economic evaluation…
| Bing Guo, Christa Harstall, Thomas Louie, Sander Veldhuyzen van Zanten, Levinus Dieleman
Aim: To critically appraise the clinical research evidence on the safety and effectiveness of FT compared with standard care in the treatment of patients with CDAD.
From the Introduction: Until four or five decades ago, the clinical consensus about childhood depression was that it did not, and perhaps could not, occur (Lefkowitz & Burton, 1978; Rie, 1966; Rochlin, 1965; Wolfenstein, 1966). In fact, prior to 1960, childhood depression was rarely mentioned in the literature (Cytryn, 2003; Tisher, 2007). A number of studies and conceptualizations…
| Carissa Escober-Doran, Philip Jacobs, Carolyn Dewa
This study measures the return on investment for parent training at the pre- or early childhood stage. The purpose is to prevent conduct disorders in childhood, and mental health problems in adolescence and adulthood. The program studied is the Triple P program. The context is a one year birth cohort in Alberta. The costs are for a universal parental training program. The downstream…
Rationale, aims and objectives: The Appraisal of Guidelines Research and Evaluation (AGREE) instrument is a generic tool for assessing guideline quality. This feasibility study aimed to reduce the ambiguity and subjectivity associated with AGREE item scoring, and to augment the tool's capacity to differentiate between good- and poor-quality guidelines. Note: This is an Alberta…
Emceed by Tom Feasby, the University of Calgary’s Dean of Medicine, this third session considered the following theme: Maximizing Health System Performance: Cost Containment and Improved Efficiency. Speakers from all sectors provided a range of perspectives on Cost Containment and Improved Efficiency.
The Consensus Statement on Fetal Alcohol Spectrum Disorder (FASD) - Across the Lifespan was produced by a panel of experts led by the Hon. Anne McLellan, former Deputy Prime Minister of Canada. This consensus statement on fetal alcohol spectrum disorder is the product of a unique conference: The IHE Consensus Development Conference on Fetal Alcohol Spectrum Disorder - Across the…
Le présent énoncé consensuel a été préparé par un panel indépendant de professionnels de la santé et de représentants du milieu universitaire et du public en se fondant sur: les études publiées pertinentes réunies par le Comité scientifique de la conférence pour l’établissement…
The Alberta Diabetes Surveillance System (ADSS) was created in 2006 in a partnership between Alberta Health and Wellness (AHW) and the Institute of Health Economics (IHE). The purpose of the ADSS is to provide information about diabetes within the province of Alberta. This information includes the incidence, prevalence and use of health care services for people with diabetes, along…
Written by health policy experts, the book gives a comprehensive overview of 8 different national health care systems and focuses in particular on the different approaches to maintain efficiency and to contain overall healthcare costs. Each chapter identifies the 4-5 specific policies with the highest impact for the respective country over the past 20-30 years and the current policy…
The Institute of Health Economics (IHE) Innovation Forum series reflects one of the key goals of the Institute to promote open debate and dialogue on important issues in the health care system among academia, government, health service executives and industry. The Institute believes that the significant challenges facing the health system will only be addressed if all partners…
The objective of this report is to assess research evidence on the safety and prognostic value of exercise testing (including electrocardiogram exercise testing and cardiopulmonary exercise testing) for the prediction of cardiac events in patients with chronic diseases including diabetes, chronic obstructive pulmonary disease (COPD), and arthritis. Information Specialist: Trish…
Alberta STE Report written under contract with the Alberta Health Technologies Decision Process (AHTDP). This report is about testing for Human Papillomavirus (HPV). HPV is one of the most common sexually transmitted infections and can also cause cervical cancer. Cervical screening aims to reduce cervical cancer incidence and mortality by detecting precancerous lesions early. Until…
Les estimations indiquent que un canadien sur trois aura un problème de santé mentale durant sa vie. Peu de canadiens réalisent l’impact que la mauvaise santé mentale a sur les familles, les communautés, les systèmes de santé et l’économie. La santé mentale est aussi importante que la santé physique…
| Charles Yan, JoAnn Kingston-Riechers, Anderson Chuck
This report provides information regarding the impact of physician reimbursement models on five dimensions specified in the Provincial Alternate Relationship Plan Program Evaluation. The impact of physician reimbursement models were assessed on the following five dimensions: Health service utilization Access to care Quality of services Patient satisfaction Physician satisfaction…
The use of the term “comparative effectiveness” (CE) has attracted considerable attention, particularly in the United States. This booklet examines the concept of CE and its relationship to other assessment frameworks.
Background: Although many programs targeting fetal alcohol spectrum disorder (FASD) are implemented, the province of Alberta is still lacking information on costs of FASD.
Objectives: To estimate the costs of FASD in Alberta based on available US and Canadian research on costs of FASD, and Alberta data.
| Lisa Bergerman, Paula Corabian, Christa Harstall
The purpose of this report is to advance the area of workplace mental health through a comprehensive synthesis of published research evidence. More specifically, this report examines the evidence on the effectiveness of organizational-level interventions for the prevention of stress in the workplace for adult employees without diagnosed mental illness. The main effectiveness outcomes…
This report on assisted reproductive technologies (ARTs) is a literature review and secondary analyses of administrative health data conducted to provide information on the direct health care costs associated with multiple pregnancies and the potential cost impact of ARTs in Alberta. It examines the impact of multiple pregnancies and Assistive Reproductive Technologies on health…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #17. The present report has been prepared as a follow up to the previous assessment because of continued interest in the technology by the health ministry and others. It considers studies that have been reported in the literature since completion of the earlier assessment (1997-1999) and focuses on the efficacy…
| Jennifer Simpson, Sandra Doze, Douglas Urness, David Hailey, Philip Jacobs
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #20. This report presents data from the telepsychiatry program subsequent to the pilot project. The assessment of telepsychiatry beyond the pilot project stage had two primary focuses: a) to develop and document information collection systems initiated during the pilot project evaluation, and b) to assess the operation…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #19. A request for information about the use of low level laser therapy (LLLT) to assist wound healing was received from the Capital Health Authority (CHA). This technology has been increasingly used within the Edmonton area, with somewhat different approaches being taken by individual operators. The concern was…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #16. This report has been prepared in view of the continuing interest in positron emission tomography and other functional diagnostic imaging (FDI) methods within the Alberta health care system. It also continues the work at the Alberta Heritage Foundation for Medical Research in developing approaches to assessment…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #16. This is the second volume of an assessment of functional diagnostic imaging methods in imaging of the myocardium. Volume 1 included an overview of the assessment findings and provided comments on the place of the FDI techniques in this application. In this volume, further details are given of the assessment…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #15. The present health technology assessment report has been prepared following a request by Alberta Health and Wellness for additional information on the use of stereotactic radiosurgery (SRS) in the treatment of acoustic neuroma, one of the applications considered in an earlier publication on SRS. Two main issues…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #14. This report has been prepared because of the interest by the Consumers' Association of Canada and the Health Ministry in the increasing use of newer types of intraocular lenses (IOLs) and in their comparative advantage. The focus of the report is on the safety, efficacy and effectiveness of the three types…
| Maureen Yunkap Kwankam, David Hailey, Philip Jacobs
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #13. This assessment has been prepared in view of the interest at the University of Alberta Hospital in developing a cord blood banking facility in the province and to provide information to decision makers on the current status of cord blood transplantation (CBT). The principal purpose of the assessment was to…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #12. This report has been prepared following a request from the provincial Clinical Practice Guidelines Program for information on the accuracy of diagnostic tests for the detection of bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomoniasis in females of reproductive age. The intention of this…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #11. This report has been prepared in view of the increasing interest in ultrasound technology for diagnosis of osteoporosis. Until recently, quantitative ultrasound (QUS) was mainly being used in research settings. This procedure is still not covered by provincial fee schedules. The recent FDA pre-marketing approvals…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #10. This report has been prepared as part of a project to assess the role of high cost functional diagnostic imaging (FDI) and related methods in routine health care. In the present paper, the potential application of four FDI methods to the management of epilepsy is considered. The assessment considered the current…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #8. This report has been prepared to provide information to health authorities and others on the available evidence on effectiveness of HBOT and the possible economic impact on health care should a second HBO facility be established in the province. Issues addressed in the report include: Whether HBOT has been…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #9. The present report has been prepared following a request by Alberta Health in relation to referral of patients outside the province for treatment with stereotactic radiosurgery (SRS). There was interest by the department in the comparative effectiveness of the two main approaches to SRS (GK and LINAC) and in…
Alberta Heritage Foundation for Medical Research (AHFMR) HTA Report #7. This assessment was undertaken at the request of a Regional Health Authority to provide input into a funding decision on a computerized dynamic posturography (CDP) system for use by a rehabilitation department. The focus of this study was restricted to the clinical use of CDP by the rehabilitation community.…