Identifying patients with physician-diagnosed asthma in health administrative databases

The association between cirrhosis and outcomes among female patients undergoing surgery for breast cancer in Ontario: a population-based study

BACKGROUND

The association between cirrhosis and post-operative breast cancer outcomes has not been explored. We evaluated the association between cirrhosis and surgical outcomes in female patients with breast cancer.

METHODS

We performed a retrospective population-based cohort study of female patients undergoing surgery for breast cancer between 2007 and 2018 using health administrative data from Ontario, Canada. Patients were stratified by cirrhosis status. Overall survival (OS) was described using the Kaplan-Meier method and the association between cirrhosis and long-term cancer-specific mortality (CSM) was evaluated using adjusted competing risks regression and subdistribution hazard ratios (sHR).

RESULTS

A total of 902 patients with breast cancer and cirrhosis were compared to 81,514 patients with breast cancer without cirrhosis. The median age at diagnosis was 65 years vs 61 years in patients with and without cirrhosis, respectively (p < .001). The most common etiologies of cirrhosis were metabolic dysfunction-associated steatotic liver disease (n = 595, 66%) and alcohol-associated (n = 143, 16%) liver disease. The median model for end-stage liver disease sodium score was 8 (IQR 6-11, n = 215). Furthermore, cirrhosis was associated with a twofold higher 90-day rate of post-operative mortality (RR 2.82; 95% CI 1.49-5.33). OS was lower in patients with cirrhosis (HR 1.41, 95% CI 1.26-1.58); however, there was no association with CSM (sHR 1.11, 95% CI 0.93-1.32).

CONCLUSION

This large population-based study demonstrates that patients with cirrhosis have lower OS compared to those without cirrhosis; however, there is no difference in CSM. Their outcomes remain favorable, and they should be considered for curative-intent therapies.

Occupational Exposure to Low Dose Ionizing Radiation and the Incidence of Surgically Removed Cataracts and Glaucoma in a Cohort of Ontario Nuclear Power Plant Workers

Ionizing radiation is a human carcinogen and has been shown to increase the risk of non-cancerous ocular disorders. Specifically, findings from epidemiological studies suggest that ionizing radiation leads to the development of cataracts and to a lesser extent glaucoma, however, there are uncertainties of these risks at lower exposures. We analyzed data from a cohort of 60,874 Ontario Nuclear Power Plant (NPP) workers within the Canadian National Dose Registry (NDR). These workers were monitored for whole-body exposure to ionizing radiation using dosimeters, with exposure estimates derived for each year of employment. Incident cases of surgically removed cataracts and glaucoma were identified through the record linkage of occupational histories to administrative health data for Ontario between 1991 and 2022. We compared the incidence of surgically removed cataracts and glaucoma in the cohort to Ontario's general population using indirect age- and sex-standardization with matching by place of residence. We evaluated exposure-response relationships with internal cohort comparisons using age-, sex-, and calendar-period-adjusted Poisson regression. The relative risks of cataract and glaucoma were estimated across categorical measures of whole-body dose [Hp(10)] from exposure to radiation (lagged 5 years). In total, 32,855 of the 60,874 workers (58%) had a positive cumulative dose exceeding the minimum reportable threshold. Among these workers, the mean cumulative whole-body lifetime dose at end of follow-up was 23.7 mSv (interquartile range: 1.1-26.4 mSv, maximum = 959.3 mSv). Overall, 4,401 (7.2%) of workers developed glaucoma, while 2,939 (4.8%) underwent cataract-removal surgery. There was no evidence of a dose-response relationship between cumulative whole-body dose ionizing radiation (lagged 5 years) and glaucoma, but some for surgically removed cataracts. Specifically, among workers with a cumulative exposure of greater than 50 mSv relative to those with an exposure of less than 0.25 mSv, the relative risks of incident glaucoma and cataract removal surgery were 0.91 (95% CI: 0.81-1.05) and 1.13 (95% CI: 0.97-1.33), respectively. The linear excess risks per 100 mSv (lagged 5 years) for cataract removal surgery was 0.055 (95% CI: -0.042 to 0.163). Our findings provide some evidence that ionizing radiation increases the risk of cataracts but not glaucoma in an occupational cohort whose lifetime cumulative dose rarely exceeded 30 mSv.

Trends in the Cost and Utilization of Publicly Dispensed Respiratory Inhalers in Ontario, Canada: A Repeated Cross-Sectional Study

PURPOSE

Several new respiratory inhalers have recently entered the market, including combination therapy products and generic alternatives. Therefore, we examined the cost and utilization of publicly dispensed respiratory inhalers in Ontario, Canada, and the impact of new market entrants on these trends.

METHODS

We conducted a repeated cross-sectional study among provincial drug program beneficiaries dispensed a respiratory inhaler between January 1, 2003, and March 31, 2023. We estimated per-beneficiary spending on respiratory inhalers per quarter, defined as the cost (2022 Canadian dollars) of respiratory inhalers reimbursement divided by the number of beneficiaries dispensed a respiratory inhaler. Joinpoint regression models were used to characterize changes in the trend.

RESULTS

Between Q1 of 2003 and Q1 of 2023, public payer spending rose 160% ($26 206 322 to $68 054 816), while the number of beneficiaries dispensed a respiratory inhaler increased 92% (155 893 to 299 418). Reimbursement of ICS/LABA inhalers accounted for half the cost ($33 844 484 in Q1 of 2023). The trend for per-beneficiary spending was marked by six joinpoints, with periods of increasing and decreasing quarterly costs. Between 2003 and 2015, per-beneficiary spending increased, reaching $248/beneficiary in Q1 of 2015. In Q2 of 2015, the trend decreased for the first time and continued to decline until Q2 of 2018 ($206/beneficiary). The trend increased again after Q3 of 2018 and reached a plateau in Q3 of 2019 ($216/beneficiary).

CONCLUSIONS

Public formulary listing of combination therapy inhalers, namely LAMA/LABA in Q2 of 2015, coincided with a significant decline in per-beneficiary spending on respiratory inhalers.

Machine learning prediction of premature death from multimorbidity among people with inflammatory bowel disease: a population-based retrospective cohort study

BACKGROUND

Multimorbidity, the co-occurrence of 2 or more chronic conditions, is important in patients with inflammatory bowel disease (IBD) given its association with complex care plans, poor health outcomes, and excess mortality. Our objectives were to describe premature death (age < 75 yr) among people with IBD and to identify patterns between multimorbidity and premature death among decedents with IBD.

METHODS

Using the administrative health data of people with IBD who died between 2010 and 2020 in Ontario, Canada, we conducted a population-based, retrospective cohort study. We described the proportion of premature deaths among people with IBD. We developed statistical and machine learning models to predict premature death from the presence of 17 chronic conditions and the patients' age at diagnosis. We evaluated models using accuracy, positive predictive value, sensitivity, F1 scores, area under the receiver operating curve (AUC), calibration plots, and explainability plots.

RESULTS

All models showed strong performance (AUC 0.81-0.95). The best performing was the model that incorporated age at diagnosis for each chronic condition developed at or before age 60 years (AUC 0.95, 95% confidence interval 0.94-0.96). Salient features for predicting premature death were young ages of diagnosis for mood disorder, osteo-and other arthritis types, other mental health disorders, and hypertension, as well as male sex.

INTERPRETATION

By comparing results from multiple approaches modelling the impact of chronic conditions on premature death among people with IBD, we showed that conditions developed early in life (age ≤ 60 yr) and their age of onset were important for predicting their health trajectory. Clinically, our findings emphasize the need for models of care that ensure people with IBD have access to high-quality, multidisciplinary health care.

Healthcare utilization trends in adults with asthma or COPD during the first year of COVID-19 pandemic in comparison to pre-pandemic: A population-based study

OBJECTIVES

To assess how changes in outpatient services during the first year of the COVID-19 pandemic were related to acute healthcare use (emergency department or hospitalizations) for individuals with asthma or chronic obstructive pulmonary disease (COPD).

METHODS

We conducted an observational study using health administrative data in Ontario (Canada) from January 2016 to March 2021 on all adults with diagnosed asthma or COPD. We used monthly time series auto-regressive integrated moving-average (ARIMA) and pre-pandemic monthly rates (January 2016 to February 2020) to calculate projected rates (i.e., a pandemic had not occurred) during the pandemic (March 2020 to March 2021), and Quasi-Poisson models with two-way interaction to estimate crude and adjusted rate ratios.

RESULTS

In the first pandemic year, in individuals with asthma or COPD, outpatient visit rates started lower than projected (Mar-May 2020), returned to projected in the middle of the year (Jun-Aug 2020) and then rose to higher than projected between Sep 2020 and Mar 2021: observed rates of 80,293 per 100,000 persons vs. projected 74,192 (95% CI: 68,926-79,868) in individuals with asthma, and 92,651 vs. projected 85,871 (95% CI: 79,975-92,207) in individuals with COPD. Acute care rates remained below projected during the first pandemic year. While pulmonary function test (PFT) rates remained below projected during the first pandemic year, in both populations, a decrease in acute care visits during the pandemic, compared to pre-pandemic, was noted during months with the highest PFT rates (interaction p-values < 0.0001).

CONCLUSIONS

Despite asthma and COPD being ambulatory-care sensitive conditions, lower rates of outpatient visits during the beginning of the pandemic were not associated with increased rates of acute care use. Lower PFT rates were associated with higher acute care visit rates, suggesting that access to PFT during pandemic is likely important for individuals with asthma or COPD.

The association between total social exposure and incident multimorbidity: A population-based cohort study

Background

Multimorbidity, the co-occurrence of two or more chronic conditions, is associated with the social determinants of health. Using comprehensive linked population-representative data, we sought to understand the combined effect of multiple social determinants on multimorbidity incidence in Ontario, Canada.

Methods

Ontario respondents aged 20-55 in 2001-2011 cycles of the Canadian Community Health Survey were linked to administrative health data ascertain multimorbidity status until 2022. Additive total social exposure (TSE) was generated by summing 12 measures of social disadvantage captured from the survey. Weighted-additive TSE included 15 measures of social disadvantage summed across 5 equally weighted domains. Hazard ratios for the association between each TSE measure and multimorbidity were estimated using competing risk Cox-proportional hazards models. All analyses were sex-stratified.

Results

Both additive and weighted-additive TSE were associated with an increased risk of multimorbidity among females and males. A social gradient was observed for multimorbidity risk in all models. While adjusted models were attenuated, an increased risk of multimorbidity was observed among those experiencing the most social disadvantage, compared to those with the least social disadvantage in additive (HR Females = 2.16; 95%CI = 1.63, 2.86; HR Males = 1.90; 95%CI = 1.52, 2.38) and weighted-additive (HR Females = 1.94; 95%CI = 1.49, 2.53; HR Males = 1.72; 95%CI = 1.41, 2.10) models. The observed social gradient was retained.

Conclusions

These findings demonstrate the importance of considering the cumulative effects of multiple social determinants of health on multimorbidity.

Chronic disease prevalence and preventive care among Ontario social housing residents compared with the general population: a population-based cohort study

BACKGROUND

Older adults living in social housing report poor health and access to healthcare services. This study aimed to estimate the prevalence of chronic diseases, influenza vaccination and cancer screenings among social housing residents versus non-residents in Ontario, Canada.

METHODS

We conducted a population-based cohort study for all health-insured Ontarians alive and aged 40 or older as of 1 January 2020. Social housing residents were identified using postal codes. Validated health administrative data case definitions were used to identify individuals with diabetes, hypertension, chronic obstructive pulmonary disease, asthma, congestive heart failure and cardiovascular disease. Influenza vaccination and mammography, Pap and colorectal cancer screenings were identified among screen-eligible residents using health administrative data.

RESULTS

The prevalence of all chronic diseases was higher among social housing residents across all age groups: 40-59, 60-79 and 80+ years. Influenza vaccination rates in 2018-2019 were lower among social housing residents aged 60-79 and 80+ years. Mammography rates for women aged 50-69 years in 2018-2019 were 10-11% lower among social housing residents across all age groups compared with non-residents. Pap screening rates for women aged 40-69 in 2018-2019 were 6-8% lower among social housing residents. The percentage of colorectal screening in both women and men aged 52-74 was lower (9-10% in men and 6-7% in women) in social housing compared with the general population in 2019-2020.

CONCLUSION

There is a higher prevalence of chronic diseases and lower cancer screening rates among the growing population of older adults in social housing in Ontario, Canada.

Association between maternal schizophrenia and risk of serious asthma exacerbations in childhood

BACKGROUND AND HYPOTHESIS

While maternal schizophrenia is linked to chronic childhood medical conditions, little is known about the risk of acute asthma exacerbations among children whose mothers have schizophrenia. This population-based study used health data for all of Ontario, Canada to evaluate whether having a mother with schizophrenia was associated with increased risk of asthma exacerbations.

STUDY DESIGN

The study cohort included 385,989 children diagnosed with asthma from age 2 years onward, followed from the time of their asthma diagnosis up to a maximum of age 19 years. Children whose biological mother was diagnosed with schizophrenia prior to the child's asthma diagnosis (n = 1407) were compared children whose mother was not (n = 384,582). Study outcomes were asthma-related hospitalization, and separately, asthma-related emergency department (ED) visit, each up to a maximum child age of 19 years. First exacerbations were evaluated using Cox proportional hazards models, and recurrent exacerbations by Andersen-Gill regression, adjusted for covariates.

STUDY RESULTS

First hospitalization for an asthma exacerbation occurred in 76 (6.9 per 1000 person-years) vs. 19,679 (5.4 per 1000 person-years) children with and without maternal schizophrenia (adjusted hazard ratio [aHR] 1.21, 95 % CI 0.97-1.51). For first asthma-related ED exacerbations, the rates were 25.1 vs. 20.7 per 100 person-years (aHR 1.06, 95 % CI 0.93-1.21). The adjusted rate ratio (aRR) for recurrent hospitalizations for asthma exacerbations was 1.27 (95 % CI 0.98-1.66), and 1.11 (95 % CI 0.94-1.31) for recurrent asthma-related ED exacerbations.

CONCLUSIONS

This study did not observe meaningful differences in acute care utilization for asthma exacerbations among children whose biological mothers had schizophrenia.

Associations of Diabetes, Mental Health, and Asthma with Hypertensive Disorders of Pregnancy: A Population-based Case-Control Study in Alberta, Canada

OBJECTIVE

To explore direct and indirect associations of diabetes, mental health, and asthma diagnosed before or during pregnancy with gestational hypertension (GH) or preeclampsia (PE).

STUDY DESIGN

This population-based case-control study conducted in Alberta, Canada, analyzed perinatal registry data from primiparous pregnant women aged 16 years and above, with no prior hypertension history, during the period 2010 to 2013. Cases of GH and PE were matched on gestational age with a random sample of controls at a 1:3 ratio.

MAIN OUTCOME MEASURES

We examined the presence of type 2 diabetes mellitus (T2DM) or gestational diabetes, depression, anxiety, and asthma diagnoses within five years before and during pregnancy. To estimate direct and indirect associations between these diagnoses and GH and PE, we used multivariable logistic and mediation models, adjusting for covariates.

RESULTS

The analysis included 18,381 women (3,443 GH cases, 1,152 PE cases, and 13,786 controls). We found a direct association between anxiety during pregnancy and GH (adjusted Odds Ratio [aOR] 2.18, 95 % confidence interval (CI) 1.43-3.31). Depression before pregnancy increased the odds of anxiety during pregnancy (aOR 4.78, 95 % CI 2.89-7.92) resulting in an indirect effect on GH (aOR 3.63, 95 % CI 1.67--7.87). For PE, we observed direct associations with pre-pregnancy T2DM (aOR 1.58, 95 % CI 1.12-2.24), gestational diabetes (aOR 1.28, 95 % CI 1.04-1.56), and asthma during pregnancy (aOR 2.23, 95 % CI 1.41-3.51).

CONCLUSION

These findings highlight the interplay of mental health factors in influencing GH and underscore the clinical importance of diabetes and asthma in the pathogenesis of PE.

The Impact of Eliminating Out-of-Pocket Payments on Asthma Medication Use

Rationale: High costs of controller therapies may be a barrier to guideline-recommended asthma treatment. Objectives: We determined whether eliminating out-of-pocket (OOP) payments among low-income patients with asthma impacted controller medication use. Methods: We applied a controlled interrupted time series design to administrative claims data in British Columbia, Canada from 2017 to 2020. Cases were individuals with an annual household income <$13,750 in whom copays were eliminated in January 2019; there was no change in public coverage for the control group with annual income >$45,000. We evaluated trends in asthma medication costs, use, the ratio of inhaled corticosteroid-containing medications to all asthma medications, excessive use of short-acting β-agonists (more than one canister per month), and the proportion of days covered by controller therapies. Results: There were 12,940 cases (62% female; mean age, 30.3 yr; standard deviation [SD], 14.9) and 71,331 controls (55% female; mean age, 31.3 yr; SD, 16.3). Removal of OOP payments increased monthly mean medication costs by $3.32 (95% confidence interval [CI], $0.08 to $6.56, 2020 Canadian dollars), days' supply of controller medications by 1.50 days (95% CI, 0.61 to 2.40 d), and the ratio of inhaled corticosteroid-containing medications to total medications by 4.20% (95% CI, 0.73% to 7.66%) compared with the control group. The policy had no effect on the proportion of days covered by controller therapies (0.01; 95% CI, -0.01 to 0.04), but nonsignificantly decreased the percentage of patients with excessive short-acting β-agonist use (-6.37%; 95% CI, -12.90% to 0.16%). Conclusions: Removal of OOP payments increased the dispensation of controller therapies, suggesting cost-related nonadherence could impair optimal asthma management.

Quantifying the magnitude of the general contextual effect in a multilevel study of SARS-CoV-2 infection in Ontario, Canada: application of the median rate ratio in population health research

BACKGROUND

Regional variations in SARS-CoV-2 infection were observed in Canada and other countries. Studies have used multilevel analyses to examine how a context, such as a neighbourhood, can affect the SARS-CoV-2 infection rates of the people within it. However, few multilevel studies have quantified the magnitude of the general contextual effect (GCE) in SARS-CoV-2 infection rates and assessed how it may be associated with individual- and area-level characteristics. To address this gap, we will illustrate the application of the median rate ratio (MRR) in a multilevel Poisson analysis for quantifying the GCE in SARS-CoV-2 infection rates in Ontario, Canada.

METHODS

We conducted a population-based, two-level multilevel observational study where individuals were nested into regions (i.e., forward sortation areas [FSAs]). The study population included community-dwelling adults in Ontario, Canada, between March 1, 2020, and May 1, 2021. The model included seven individual-level variables (age, sex, asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease) and four FSA census-based variables (household size, household income, employment, and driving to work). The MRR is a median value of the rate ratios comparing two patients with identical characteristics randomly selected from two different regions ordered by rate. We examined the attenuation of the MRR after including individual-level and FSA census-based variables to assess their role in explaining the variation in rates between regions.

RESULTS

Of the 11 789 128 Ontario adult community-dwelling residents, 343 787 had at least one SARS-CoV-2 infection during the study period. After adjusting for individual-level and FSA census-based variables, the MRR was attenuated to 1.67 (39% reduction from unadjusted MRR). The strongest FSA census-based associations were household size (RR = 1.88, 95% CI: 1.71-1.97) and driving to work (RR = 0.68, 95% CI: 0.65-0.71).

CONCLUSIONS

The individual- and area-level characteristics in our study accounted for approximately 40% of the between-region variation in SARS-CoV-2 infection rates measured by MRR in Ontario, Canada. These findings suggest that population-based policies to address social determinants of health that attenuate the MRR may reduce the observed between-region heterogeneity in SARS-CoV-2 infection rates.

Alpha-1 adrenergic antagonists and the risk of hospitalization or death in non-hospitalized patients with COVID-19: A population-based study

BACKGROUND

Alpha-1 receptor antagonists may interfere with IL-6 signaling and could therefore be a potential treatment for COVID-19. However, the effectiveness of these drugs in mitigating the risk of clinical deterioration among non-hospitalized patients with COVID-19 is unknown.

OBJECTIVES

The aim of this study is to examine the association between alpha-1 antagonist exposure and the 30-day risk of a hospital encounter or death in nonhospitalized patients with COVID-19.

METHODS

We conducted a population-based cohort study of Ontario residents aged 35 years and older who were eligible for public drug coverage and who had a positive test for SARS-CoV-2 between January 1, 2020, and March 1, 2021. We matched each individual receiving an alpha-1 antagonist at the time of their positive test with two non-exposed individuals using propensity scores. Our outcome was a composite of a hospital admission, emergency department visit, or death, 1 to 30 days following the positive test.

RESULTS

We matched 3289 alpha-1 antagonist exposed patients to 6189 unexposed patients. Overall, there was no difference in the 30-day risk of the primary outcome among patients exposed to alpha-1 antagonists at the time of their diagnosis relative to unexposed individuals (28.8% vs. 28.0%; OR 1.00, 95% CI 0.91 to 1.11). In a secondary analysis, individuals exposed to alpha-1 antagonists had a lower risk of death in the 30 days following a COVID diagnosis (OR 0.79; 95% CI 0.66 to 0.93).

CONCLUSION

Alpha-1 antagonists did not mitigate the 30-day risk of clinical deterioration in non-hospitalized patients with COVID-19. Our findings do not support the general repurposing of alpha-1 antagonists as a treatment for such patients, although there may be subgroups of patients in whom further research is warranted.

What happened to the patients? Care trajectories for persons with a delayed hospital discharge during wave 1 of COVID-19 in Ontario, Canada; a population-based retrospective cohort study

During the initial wave of coronavirus disease of 2019 (COVID-19), patients were rapidly discharged from acute hospitals in anticipation of an expected influx of patients with COVID-19. Patients that were no longer receiving acute medical care but were waiting for their next destination (i.e., delayed hospital discharge) were particularly affected. The objectives of this study were to examine the impact of COVID-19 onset on healthcare utilization and mortality among those who experienced delayed discharge from acute care. We conducted a population-based retrospective cohort study using linked administrative data. We included persons discharged from acute care who experienced a delayed hospital stay between April 1, 2019 and September 30, 2020. The onset of COVID-19 was the exposure (March 1, 2020), while the period of April 1, 2019 to February 29, 2020 was considered as a comparator. Primary outcomes included healthcare utilization and mortality following discharge, stratified by care setting (homecare, inpatient rehabilitation or long-term care). Multivariable logistic, zero-inflated Poisson regressions, and Cox proportional hazard models were used to examine the impact of COVID-19 on outcomes while adjusting for covariates. Those discharged home were more likely to receive homecare and physician visits within 30 days during COVID-19. The type of visits examined included both in-person as well as virtual visits. Individuals discharged to inpatient rehabilitation experienced lower rates of general physician visits but higher rates of specialist and homecare visits. Patients discharged to long-term care were significantly less likely to receive a physician visit following COVID-19, and significantly more likely to be readmitted within 7-days. There were no significant differences in mortality irrespective of discharge destination during the two time periods. Overall, the onset of the initial wave of COVID-19 significantly impacted healthcare utilization among those with a delayed discharge but varied depending on destination, with those in long-term care being most impacted.

The PSY-SIM Model: Using Real-World Data to Inform Health Care Policy for Individuals With Chronic Psychotic Disorders

BACKGROUND AND HYPOTHESIS

Few microsimulation models have been developed for chronic psychotic disorders, severe and disabling mental disorders associated with poor medical and psychiatric outcomes, and high costs of care. The objective of this work was to develop a microsimulation model for individuals with chronic psychotic disorders and to use the model to examine the impact of a smoking cessation initiative on patient outcomes.

STUDY DESIGN

Using health records and survey data from Ontario, Canada, the PSY-SIM model was developed to simulate health and cost outcomes of individuals with chronic psychotic disorders. The model was then used to examine the impact of the Smoking Treatment for Ontario Patients (STOP) program from Ontario on the development of chronic conditions, life expectancy, quality of life, and lifetime health care costs.

STUDY RESULTS

Individuals with chronic psychotic disorders had a lifetime risk of 63% for congestive heart failure and roughly 50% for respiratory disease, cancer and diabetes, and a life expectancy of 76 years. The model suggests the STOP program can reduce morbidity and lead to survival and quality of life gains with modest increases in health care costs. At a long-term quit rate of 4.4%, the incremental cost-effectiveness ratio of the STOP program was $41,936/QALY compared with status quo.

CONCLUSIONS

Smoking cessation initiatives among individuals with chronic psychotic disorders can be cost-effective. These findings will be relevant for decision-makers and clinicians looking to improving health outcomes among this patient population.

Identification of homelessness using health administrative data in Ontario, Canada following a national coding mandate: a validation study

OBJECTIVES

Conducting longitudinal health research about people experiencing homelessness poses unique challenges. Identification through administrative data permits large, cost-effective studies; however, case validity in Ontario is unknown after a 2018 Canada-wide policy change mandating homelessness coding in hospital databases. We validated case definitions for identifying homelessness using Ontario health administrative databases after introduction of this coding mandate.

STUDY DESIGN AND SETTING

We assessed 42 case definitions in a representative sample of people experiencing homelessness in Toronto (n = 640) from whom longitudinal housing history (ranging from 2018 to 2022) was obtained, and a randomly selected sample of presumably housed people (n = 128,000) in Toronto. We evaluated sensitivity, specificity, positive and negative predictive values, and positive likelihood ratios to select an optimal definition, and compared the resulting true positives against false positives and false negatives to identify potential causes of misclassification.

RESULTS

The optimal case definition included any homelessness indicator during a hospital-based encounter within 180 days of a period of homelessness (sensitivity = 52.9%; specificity = 99.5%). For periods of homelessness with ≥1 hospital-based healthcare encounter, the optimal case definition had greatly improved sensitivity (75.1%) while retaining excellent specificity (98.5%). Review of false positives suggested that homeless status is sometimes erroneously carried forward in healthcare databases after an individual transitioned out of homelessness.

CONCLUSION

Case definitions to identify homelessness using Ontario health administrative data exhibit moderate to good sensitivity and excellent specificity. Sensitivity has more than doubled since the implementation of a national coding mandate. Mandatory collection and reporting of homelessness information within administrative data present invaluable opportunities for advancing research on the health and healthcare needs of people experiencing homelessness.

Uptake and cardiac events of COVID-19 vaccinations among Canadian youth and young adults

Few studies have examined population-level data of the COVID-19 original and bivalent vaccine on its uptake and potential side effects. We used population-based health administrative data from Jan 2021-Feb 2023 to identify Ontario residents aged 12-35 years old to calculate their rates of COVID-19 vaccine uptake and vaccine-related cardiac events (myocarditis and pericarditis). Multivariable Cox, logistic, and negative binomial regression analyses were used to adjust for covariates. Hazard ratios (HR) were reported with 95% confidence intervals (CI). The study population included 5,012,721 individuals. Comparing to the general population, those with chronic diseases were associated with 13-37% higher rates of vaccine uptake and 1.39-2.27 times higher odds of receiving booster doses. Overall, post-vaccination cardiac event incidence rates ranged from 3-12 per 100,000 persons. Compared to the general population, the incidence rate of cardiac events among those with asthma and allergic diseases was significantly higher, 3.7 events per 100,000 persons. Compared to the general population, those with asthma and/or allergic diseases had significantly higher associated likelihoods of a cardiac event (HR = 1.31, 95% CI: 1.08-1.57). Females, adults, and those with prior COVID-19 infections had decreased odds of cardiac events after 2nd vaccine doses. No significant differences in post-vaccine cardiac events were detected between original and bivalent doses. This Canadian population-based study reported substantially higher rates of vaccine uptake and a very rare incidence of temporally associated post-vaccination cardiac events. While substantially smaller than the benefits of vaccination, our results indicated a continued small risk of cardiac side effects from bivalent COVID-19 vaccines in individuals with comorbidities.

Patterns of inpatient acute care and emergency department utilization within one year post-initial amputation among individuals with dysvascular major lower extremity amputation in Ontario, Canada: A population-based retrospective cohort study

INTRODUCTION

Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology.

OBJECTIVE

To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits.

DESIGN

Retrospective cohort study using population-level administrative data.

SETTING

Ontario, Canada.

POPULATION

Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Acute care hospitalizations and ED visits within one year post-initial discharge.

RESULTS

A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting.

CONCLUSION

Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk.

Uptake of COVID-19 vaccination among community-dwelling individuals receiving healthcare for substance use disorder and major mental illness: a matched retrospective cohort study

Introduction

Patients with major mental illness (MMI) and substance use disorders (SUD) face barriers in accessing healthcare. In this population-based retrospective cohort study, we investigated the uptake of COVID-19 vaccination in Ontario, Canada among community-dwelling individuals receiving healthcare for major mental illness (MMI) and/or substance use disorders (SUD), comparing them to matched general population controls.

Methods

Using linked health administrative data, we identified 337,290 individuals receiving healthcare for MMI and/or SUD as of 14 December 2020, matched by age, sex, and residential geography to controls without such healthcare. Follow-up extended until 31 December 2022 to document vaccination events.

Results

Overall, individuals receiving healthcare for MMI and/or SUD (N = 337,290) had a slightly lower uptake of first (cumulative incidence 82.45% vs. 86.44%; hazard ratio [HR] 0.83 [95% CI 0.82-0.83]) and second dose (78.82% vs. 84.93%; HR 0.77 [95% CI 0.77-0.78]) compared to matched controls. Individuals receiving healthcare for MMI only (n = 146,399) had a similar uptake of first (87.96% vs. 87.59%; HR 0.97 [95% CI 0.96-0.98]) and second dose (86.09% vs. 86.05%, HR 0.94 [95% CI 0.93-0.95]). By contrast, individuals receiving healthcare for SUD only (n = 156,785) or MMI and SUD (n = 34,106) had significantly lower uptake of the first (SUD 78.14% vs. 85.74%; HR 0.73 [95% CI 0.72-0.73]; MMI & SUD 78.43% vs. 84.74%; HR 0.76 [95% CI 0.75-0.77]) and second doses (SUD 73.12% vs. 84.17%; HR 0.66 [95% CI 0.65-0.66]; MMI & SUD 73.48% vs. 82.93%; HR 0.68 [95% CI 0.67-0.69]).

Discussion

These findings suggest that effective strategies to increase vaccination uptake for future COVID-19 and other emerging infectious diseases among community-dwelling people with SUD are needed.

Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design

INTRODUCTION

The growth and complexity of diabetes are exceeding the capacity of family physicians, resulting in the demand for community-based, interprofessional, primary care-led transition clinics. The Primary Care Diabetes Support Programme (PCDSP) in London, Ontario, is an innovative approach to diabetes care for high-risk populations, such as medically or socially complex and unattached patients. In this study, we will employ a quadruple-aim approach to evaluate the health system impacts of the PCDSP.

METHODS AND ANALYSIS

We will use multiple methods through a convergent parallel design in this project across five unique studies: a case study, a patient study, a provider study, a complications study and a cost-effectiveness study. The project will be conducted in a dedicated stand-alone clinic specialising in chronic disease management, specifically focusing on diabetes care. Participants will include clinic staff, administrators, family physicians, specialists and patients with type 1 or type 2 diabetes who received care at the clinic between 2011 and 2023. The project design will define the intervention, support replication at other sites or for other chronic diseases and address each of the quadruple aims and equity. Following the execution of the five individual studies, we will build a business case by integrating the results. Data will be analysed using both qualitative (content analysis and thematic analysis) and quantitative techniques (descriptive statistics and multiple logistic regression).

ETHICS AND DISSEMINATION

We received approval from the research ethics boards at Western University (reference ID: 2023-1 21 766; 2023-1 22 326) and Lawson Health Research Institute (reference ID: R-23-202). A privacy review was completed by St. Joseph's Healthcare Corporation. The findings will be shared among PCDSP staff and patients, stakeholders, academic researchers and the public through stakeholder sessions, conferences, peer-reviewed publications, infographics, posters, media interviews, social media and online discussions. For the patient and provider study, all participants will be asked to provide consent and are free to withdraw from the study, without penalty, until the data are combined. Participants will not be identified in any report or presentation except in the case study, for which, given the number of PCDSP providers, we will seek explicit consent to identify them.

Evaluating the Association between the Implementation of the PoET (Prevention of Error-Based Transfers) Southwest Spread Project and Palliative Care Provision: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

The PoET (Prevention of Error-based Transfers) project seeks to align long-term care (LTC) home informed consent practices to existing legislation, thereby reducing consent-related error-based transfers to acute care. We sought to measure changes in resident-level palliative care provision after participating in the PoET Southwest Spread Project (PSSP), and to identify patient and LTC home characteristics associated with palliative care provision.

DESIGN

Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data.

SETTING

Sixty LTC homes (PSSP = 30; Control = 30) in Ontario, Canada, from November 2019 to December 2021.

METHODS

We matched 30 PSSP to 30 control homes and described incidence rates for resident-level palliative care provision (ie, physician palliative care encounters and palliative medication prescriptions) during the 7-month postimplementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and palliative care provision during the postimplementation period. We adjusted for resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent subcohort to measure palliative care provision patterns during the last 2 months of life.

RESULTS

We captured a matched cohort of 8894 residents (PSSP = 4103; Control = 4791). Incidence rates of palliative care encounters increased during the postimplementation period for PSSP (82.6 to 85.4 per 100 person-months) but not for control residents (68.8 to 65.3 per 100 person-months). After adjusting for key covariates, PSSP exposure was associated increased palliative care provision (incidence rate ratio 2.47, 95% CI 2.31-2.64) and palliative care medication prescription (1.16, 95% CI 1.12-1.20). Larger home size, certain health regions, and higher number of comorbidities were associated with increased physician palliative care encounters.

CONCLUSIONS AND IMPLICATIONS

By promoting correct informed consent practices in LTC, PSSP participation increased palliative care provision for PSSP LTC residents across all settings.

Mode of delivery and birth outcomes before and during COVID-19 -A population-based study in Ontario, Canada

There is lack of clarity on whether pregnancies during COVID-19 resulted in poorer mode of delivery and birth outcomes in Ontario, Canada. We aimed to compare mode of delivery (C-section), birth (low birthweight, preterm birth, NICU admission), and health services use (HSU, hospitalizations, ED visits, physician visits) outcomes in pregnant Ontario women before and during COVID-19 (pandemic periods). We further stratified for pre-existing chronic diseases (asthma, eczema, allergic rhinitis, diabetes, hypertension). Deliveries before (Jun 2018-Feb 2020) and during (Jul 2020-Mar 2022) pandemic were from health administrative data. We used multivariable logistic regression analyses to estimate adjusted odds ratios (aOR) of delivery and birth outcomes, and negative binomial regression for adjusted rate ratios (aRR) of HSU. We compared outcomes between pre-pandemic and pandemic periods. Possible interactions between study periods and covariates were also examined. 323,359 deliveries were included (50% during pandemic). One in 5 (18.3%) women who delivered during the pandemic had not received any COVID-19 vaccine, while one in 20 women (5.2%) lab-tested positive for COVID-19. The odds of C-section delivery during the pandemic was 9% higher (aOR = 1.09, 95% CI: 1.08-1.11) than pre-pandemic. The odds of preterm birth and NICU admission were 15% (aOR = 0.85, 95% CI: 0.82-0.87) and 10% lower (aOR = 0.90, 95% CI: 0.88-0.92), respectively, during COVID-19. There was a 17% reduction in ED visits but a 16% increase in physician visits during the pandemic (aRR = 0.83, 95% CI: 0.81-0.84 and aRR = 1.16, 95% CI: 1.16-1.17, respectively). These aORs and aRRs were significantly higher in women with pre-existing chronic conditions. During the pandemic, healthcare utilization, especially ED visits (aRR = 0.83), in pregnant women was lower compared to before. Ensuring ongoing prenatal care during the pandemic may reduce risks of adverse mode of delivery and the need for acute care during pregnancy.

Emergency Colorectal Surgery in Those with Cirrhosis: A Population-based Study Assessing Practice Patterns, Outcomes and Predictors of Mortality

Background

Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality.

Methods

This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality.

Results

Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2-2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16-0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9-10.9; score 10-19 HR 1.8, 95%CI 1.1-3.0; score <10 [ref]).

Conclusion

Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.

Association Between Surgeon/Anesthesiologist Sex Discordance and 1-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study

OBJECTIVE

To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery.

BACKGROUND

Evidence suggests different practice patterns exist among female and male physicians. However, the influence of physician sex on team-based practices in the operating room and subsequent patient outcomes remains unclear in the context of noncardiac surgery.

METHODS

We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. The primary exposure was physician sex discordance (ie, the surgeon and anesthesiologist were of the opposite sex). The primary outcome was 1-year mortality. The association between physician sex discordance and patient outcomes was modeled using multivariable Cox proportional hazard regression with adjustment for relevant physician, patient, and hospital characteristics.

RESULTS

Of 541,209 patients, 158,084 (29.2%) were treated by sex-discordant physician teams. Physician sex discordance was associated with a lower rate of mortality at 1 year [5.2% vs. 5.7%; adjusted HR: 0.95 (0.91-0.99)]. Patients treated by teams composed of female surgeons and male anesthesiologists were more likely to be alive at 1 year than those treated by all-male physician teams [adjusted HR: 0.90 (0.81-0.99)].

CONCLUSIONS

Noncardiac surgery patients had a lower likelihood of 1-year mortality when treated by sex-discordant surgeon-anesthesiologist teams. The likelihood of mortality was further reduced if the surgeon was female. Further research is needed to explore the underlying mechanisms of these observations and design strategies to diversify operating room teams to optimize performance and patient outcomes.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis

BACKGROUND

Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce.

OBJECTIVES

To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC.

METHODS

We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit.

RESULTS

Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus.

CONCLUSIONS

MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Impact of income-based public drug coverage deductibles on adherence to asthma medications

BACKGROUND

Cost-related nonadherence to medications can be a barrier to asthma management.

OBJECTIVE

To quantify the impact of public drug plan deductibles on adherence to asthma medications.

METHODS

We used a quasi-experimental regression discontinuity analysis to determine whether thresholds in deductibles for public drug coverage, determined on the basis of annual household income, decreased medication use among lower-income children and adults with asthma in British Columbia from 2013 to 2018. Using dispensed medication records, we evaluated deductible thresholds at annual household incomes of $15,000 (a deductible increase from 0% to 2% of annual household income), and $30,000 (a deductible increase from 2% to 3% annual household income). We evaluated medication costs, use, the ratio of inhaled corticosteroids-containing controller medications to total medications, excessive use of short-acting β-agonists, and the proportion of days covered by controller therapies. All costs are reported in 2020 Canadian dollars.

RESULTS

Overall, 88,935 individuals contributed 443,847 person-years of follow-up (57% of female sex, mean age 31 years). Public drug subsidy decreased by -$41.74 (95% CI, -$28.34 to -$55.13) at the $15,000-deductible threshold, a 28% reduction, and patient costs increased by $48.45 (95% CI, $35.37-$61.53). The $30,000 deductible threshold did not affect public drug costs (P = .31), but patient costs increased by $27.65 (95% CI, $15.22-$40.09), which is an 11% increase. Asthma-related medication use, inhaled corticosteroids-to-total medication ratio, excessive use of short-acting β-agonists, and proportion of days covered by controller therapies were not impacted by deductible thresholds.

CONCLUSION

Income-based deductibles reduced public drug costs with no effect on asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use in lower-income individuals with asthma.

Acute health care use among children during the first 2.5 years of the COVID-19 pandemic in Ontario, Canada: a population-based repeated cross-sectional study

BACKGROUND

The effects of the decline in health care use at the start of the COVID-19 pandemic on the health of children are unclear. We sought to estimate changes in rates of severe and potentially preventable health outcomes among children during the pandemic.

METHODS

We conducted a repeated cross-sectional study of children aged 0-17 years using linked population health administrative and disease registry data from January 2017 through August 2022 in Ontario, Canada. We compared observed rates of emergency department visits and hospital admissions during the pandemic to predicted rates based on the 3 years preceding the pandemic. We evaluated outcomes among children and neonates overall, among children with chronic health conditions and among children with specific diseases sensitive to delays in care.

RESULTS

All acute care use for children decreased immediately at the onset of the pandemic, reaching its lowest rate in April 2020 for emergency department visits (adjusted relative rate [RR] 0.28, 95% confidence interval [CI] 0.28-0.29) and hospital admissions (adjusted RR 0.43, 95% CI 0.42-0.44). These decreases were sustained until September 2021 and May 2022, respectively. During the pandemic overall, rates of all-cause mortality, admissions for ambulatory care-sensitive conditions, newborn readmissions or emergency department visits or hospital admissions among children with chronic health conditions did not exceed predicted rates. However, after declining significantly between March and May 2020, new presentations of diabetes mellitus increased significantly during most of 2021 (peak adjusted RR 1.49, 95% CI 1.28-1.74 in July 2021) and much of 2022. Among these children, presentations for diabetic ketoacidosis were significantly higher than expected during the pandemic overall (adjusted RR 1.14, 95% CI 1.00-1.30). We observed similar time trends for new presentations of cancer, but we observed no excess presentations of severe cancer overall (adjusted RR 0.91, 95% CI 0.62-1.34).

INTERPRETATION

In the first 30 months of the pandemic, disruptions to care were associated with important delays in new diagnoses of diabetes but not with other acute presentations of select preventable conditions or with mortality. Mitigation strategies in future pandemics or other health system disruptions should include education campaigns around important symptoms in children that require medical attention.

Previous Ischemic Stroke Significantly Alters Stroke Risk in Newly Diagnosed Cancer Patients

BACKGROUND

Previous ischemic stroke (IS) is a risk factor for subsequent IS in the general population; it is unclear if this relationship remains true in patients with cancer. Our objective was to examine the association between previous IS and risk for future IS in individuals newly diagnosed with cancer.

METHODS

We conducted a retrospective population-based matched cohort study of newly diagnosed adult cancer patients (excluding nonmelanoma skin cancers and primary central nervous system tumors) in Ontario, Canada from 2010 to 2020; those with prior IS were matched (1:4) by age, sex, year of cancer diagnosis, cancer stage, and cancer site to those without a history of stroke. Cumulative incidence function curves were created to estimate the incidence of IS. Subdistribution adjusted hazard ratios (aHRs) and 95% CIs were calculated, where death was treated as a competing event. Multivariable analysis was adjusted for imbalanced baseline characteristics.

RESULTS

We examined 65 525 individuals with cancer, including 13 070 with a history of IS. The median follow-up duration was 743 days (interquartile range, 177-1729 days). The incidence of IS following cancer diagnosis was 261.3/10 000 person-years in the cohort with prior IS and 75.3/10 000 person-years in those without prior IS. Individuals with prior IS had an increased risk for IS after cancer diagnosis compared with those without a history (aHR, 2.68 [95% CI, 2.41-2.98]); they also had more prevalent cardiovascular risk factors. The highest risk for stroke compared with those without a history of IS was observed in the gynecologic cancer (aHR, 3.84 [95% CI, 2.15-6.85]) and lung cancer (aHR, 3.18 [95% CI, 2.52-4.02]) subgroups. The risk of IS was inversely correlated with lag time of previous stroke; those with IS 1 year before their cancer diagnosis had the highest risk (aHR, 3.68 [95% CI, 3.22-4.22]).

CONCLUSIONS

Among individuals with newly diagnosed cancer, those with IS history were almost 3× more likely to experience a stroke after cancer diagnosis, especially if the prediagnosis stroke occurred within 1 year preceding cancer diagnosis.

Evaluating the Association between the Implementation of the PoET Southwest Spread Project and Reductions in Acute Care Transfers from Long-Term Care: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

To measure changes in resident-level acute care transfer rates after the PoET Southwest Spread Project (PSSP), and to identify patient and long-term care (LTC) home characteristics associated with acute care transfers after program launch.

DESIGN

Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data.

SETTING

Sixty publicly funded LTC homes (PSSP = 30; control = 30) in Ontario, Canada, from November 2019 to December 2021.

METHODS

We matched 30 PSSP homes to 30 control homes with similar characteristics and described incidence rates for resident-level acute care transfers during the 7-month post-implementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and acute care transfers during the post-implementation period. We adjusted resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent sub-cohort to measure transfer patterns during the last 2 months of life.

RESULTS

A matched cohort of 8894 residents (PSSP = 4103; control = 4791) was captured. Incidence rates of transfers increased during the post-implementation period for both PSSP (78.8 to 80.9 transfers per 1000 person-months) and control residents (66.9 to 67.9 transfers per 1000 person-months). After adjusting for covariates of interest, PSSP exposure was associated with a reduction in acute care transfers during the post-implementation period after adjusting for covariates (incidence rate ratio, 0.73; 95% CI, 0.62-0.87; P = .0002). Older age and select health regions were associated with reduced transfers, whereas higher comorbidity status and higher COVID-19 outbreak days were associated with increases. Similar patterns persisted for transfers during the last 2 months of life.

CONCLUSIONS AND IMPLICATIONS

This study systematically evaluated the impact of an ethics-based health care intervention in LTC using health care utilization databases. PoET implementation is associated with reduced acute care transfer rates, especially in the last 2 months of life in LTC.

Estimating Cumulative Health Care Costs of Childhood and Adolescence Autism Spectrum Disorder in Ontario, Canada: A Population-Based Incident Cohort Study

BACKGROUND

Few studies have estimated cumulative health care costs post-diagnosis for individuals with autism spectrum disorder (ASD).

OBJECTIVES

Using an incidence-based approach, the objective of this analysis was to estimate cumulative costs of ASD to the Ontario health care system of children and adolescents.

METHODS

Using administrative health records from Ontario, Canada's most populous province, a retrospective, population-based, incident cohort study of children and adolescents aged 0-19 years old diagnosed with ASD was undertaken to estimate cumulative health care costs of ASD to the health care system from 2010 to 2019. Cumulative health care costs in 2021 Canadian dollars (CAD) from diagnosis to death or end of observation period were estimated using a consistent estimator based on the inverse probability weighting technique. Cumulative health care costs (and respective 95% confidence intervals [CI]) were estimated for 1, 5 and 10 years post-diagnosis by sex, age group and health service.

RESULTS

In 2010, there were 2867 diagnosed cases of ASD; in 2019, the number of incident cases had risen to 6072. The first year (i.e., 1-year) post-diagnosis cost of ASD was $4710.18 CAD (95% CI 4560.28-4860.08); just under a third of costs were for physician services. Total cumulative 5- and 10-year discounted costs were $16,025.95 CAD (15,371.64-16,680.26) and $32,635.76 CAD (28,906.94-36,364.58), respectively. Mean costs were higher for females and older age groups.

CONCLUSIONS

These results suggest that costs of ASD are high in the year of diagnosis and then increase at a steady rate thereafter. This information will help with future resource planning within the health care sector to ensure individuals with ASD are supported once their diagnosis is established.

Colorectal Cancer in Individuals with Cirrhosis: A Population-Based Study Assessing Practice Patterns, Outcomes, and Predictors of Survival

Those with cirrhosis who develop colorectal cancer (CRC) are an understudied group who may tolerate treatments poorly and are at risk of worse outcomes. This is a retrospective cohort study of 842 individuals from Ontario, Canada, with a pre-existing diagnosis of cirrhosis who underwent surgery for CRC between 2009 and 2017. Practice patterns, overall survival, and short-term morbidity and mortality were assessed. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (52%) and alcohol-associated liver disease (29%). The model for end-stage liver disease score (MELD-Na) was available in 42% (median score of 9, IQR7-11). Preoperative radiation was used in 62% of Stage II/III rectal cancer patients, while postoperative chemotherapy was used in 42% of Stage III colon cancer patients and 38% of Stage II/III rectal cancer patients. Ninety-day mortality following surgery was 12%. Five-year overall survival was 53% (by Stages I-IV, 66%, 55%, 50%, and 11%, respectively). Those with alcohol-associated cirrhosis (HR 1.8, 95% CI 1.5-2.2) had lower survival than those with NAFLD. Those with a MELD-Na of 10+ did worse than those with a lower MELD-Na score (HR 1.9, 95% CI 1.4-2.6). This study reports poor survival in those with cirrhosis who undergo treatment for CRC. Caution should be taken when considering aggressive treatment.

Asthma-related emergency admissions and associated healthcare resource use in Alberta, Canada

BACKGROUND

There is a lack of real-world research assessing asthma management following asthma-related emergency department (ED) discharges. The objective of this study was to characterise follow-up care, healthcare resource use (HCRU) and medical costs following ED admissions in Alberta, Canada.

METHODS

A retrospective cohort study was conducted on adults with asthma using longitudinal population-based administrative data from Alberta Health Services. Adult patients with asthma and ≥1 ED admission from 1 April 2015 to 31 March 2020 were included. ED admissions, outpatient visits, hospitalisations and asthma-specific medication use were measured in the 30 days before and up to 90 days after each asthma-related ED admission. Mean medical costs attributable to each type of HCRU were summarised. All outcomes were stratified by patient baseline disease severity.

RESULTS

Among 128 063 patients incurring a total of 20 142 asthma-related ED visits, a substantial rate of ED readmission was observed, with 10% resulting in readmissions within 7 days and 35% within 90 days. Rates increased with baseline asthma severity. Despite recommendations for patients to be followed up with an outpatient visit within 2-7 days of ED discharge, only 6% were followed up within 7 days. The mean total medical cost per patient was $C8143 in the 30 days prior to and $C5407 in the 30 days after an ED admission.

CONCLUSIONS

Despite recommendations regarding follow-up care for patients after asthma-related ED admissions, there are still low rates of outpatient follow-up visits and high ED readmission rates. New or improved multidimensional approaches must be integrated into follow-up care to optimise asthma control and prevent readmissions.

Sex-specific differences in physical health and health services use among Canadian Veterans: a retrospective cohort study using healthcare administrative data

INTRODUCTION

Military occupations have historically been, and continue to be, male dominated. As such, female military Veteran populations tend to be understudied, and comparisons of the physical health status and patterns of health services use between male and female Veterans are limited outside of US samples. This study aimed to compare the physical health and health services use between male and female Veterans residing in Ontario, Canada.

METHODS

A retrospective cohort of 27 058 male and 4701 female Veterans residing in Ontario whose military service ended between 1990 and 2019 was identified using routinely collected administrative healthcare data. Logistic and Poisson regression models were used to assess sex-specific differences in the prevalence of select physical health conditions and rates of health services use, after multivariable adjustment for age, region of residence, rurality, neighbourhood median income quintile, length of service in years and number of comorbidities.

RESULTS

The risk of rheumatoid arthritis and asthma was higher for female Veterans compared with male Veterans. Female Veterans had a lower risk of myocardial infarction, hypertension and diabetes. No sex-specific differences were noted for chronic obstructive pulmonary disease. Female Veterans were also more likely to access all types of health services than male Veterans. Further, female Veterans accessed primary, specialist and emergency department care at greater rates than male Veterans. No significant differences were found in the sex-specific rates of hospitalisations or home care use.

CONCLUSIONS

Female Veterans residing in Ontario, Canada have different chronic health risks and engage in health services use more frequently than their male counterparts. These findings have important healthcare policy and programme planning implications, in order to ensure female Veterans have access to appropriate health services.

Ascertaining asthma status in epidemiologic studies: a comparison between administrative health data and self-report

BACKGROUND

Studies have suggested that agreement between administrative health data and self-report for asthma status ranges from fair to good, but few studies benefited from administrative health data over a long period. We aimed to (1) evaluate agreement between asthma status ascertained in administrative health data covering a period of 30 years and from self-report, and (2) identify determinants of agreement between the two sources.

METHODS

We used administrative health data (1983-2012) from the Quebec Birth Cohort on Immunity and Health, which included 81,496 individuals born in the province of Quebec, Canada, in 1974. Additional information, including self-reported asthma, was collected by telephone interview with 1643 participants in 2012. By design, half of them had childhood asthma based on health services utilization. Results were weighted according to the inverse of the sampling probabilities. Five algorithms were applied to administrative health data (having ≥ 2 physician claims over a 1-, 2-, 3-, 5-, or 30-year interval or ≥ 1 hospitalization), to enable comparisons with previous studies. We estimated the proportion of overall agreement and Kappa, between asthma status derived from algorithms and self-reports. We used logistic regression to identify factors associated with agreement.

RESULTS

Applying the five algorithms, the prevalence of asthma ranged from 49 to 55% among the 1643 participants. At interview (mean age = 37 years), 49% and 47% of participants respectively reported ever having asthma and asthma diagnosed by a physician. Proportions of agreement between administrative health data and self-report ranged from 88 to 91%, with Kappas ranging from 0.57 (95% CI: 0.52-0.63) to 0.67 (95% CI: 0.62-0.72); the highest values were obtained with the [≥ 2 physician claims over a 30-year interval or ≥ 1 hospitalization] algorithm. Having sought health services for allergic diseases other than asthma was related to lower agreement (Odds ratio = 0.41; 95% CI: 0.25-0.65 comparing ≥ 1 health services to none).

CONCLUSIONS

These findings indicate good agreement between asthma status defined from administrative health data and self-report. Agreement was higher than previously observed, which may be due to the 30-year lookback window in administrative data. Our findings support using both administrative health data and self-report in population-based epidemiological studies.

Association of Different Prescribing Patterns for Oral Corticosteroids With Fracture Preventive Care Among Older Adults in the UK and Ontario

Importance

Identifying and mitigating modifiable gaps in fracture preventive care for people with relapsing-remitting conditions such as eczema, asthma, and chronic obstructive pulmonary disease who are prescribed high cumulative oral corticosteroid doses may decrease fracture-associated morbidity and mortality.

Objective

To estimate the association between different oral corticosteroid prescribing patterns and appropriate fracture preventive care, including treatment with fracture preventive care medications, among older adults with high cumulative oral corticosteroid exposure.

Design, Setting, and Participants

This cohort study included 65 195 participants with UK electronic medical record data from the Clinical Practice Research Datalink (January 2, 1998, to January 31, 2020) and 28 674 participants with Ontario, Canada, health administrative data from ICES (April 1, 2002, to September 30, 2020). Participants were adults 66 years or older with eczema, asthma, or chronic obstructive pulmonary disease receiving prescriptions for oral corticosteroids with cumulative prednisolone equivalent doses of 450 mg or higher within 6 months. Data were analyzed October 22, 2020, to September 6, 2022.

Exposures

Participants with prescriptions crossing the 450-mg cumulative oral corticosteroid threshold in less than 90 days were classified as having high-intensity prescriptions, and participants crossing the threshold in 90 days or more as having low-intensity prescriptions. Multiple alternative exposure definitions were used in sensitivity analyses.

Main Outcomes and Measures

The primary outcome was prescribed fracture preventive care. A secondary outcome was major osteoporotic fracture. Individuals were followed up from the date they crossed the cumulative oral corticosteroid threshold until their outcome or the end of follow-up (up to 1 year after index date). Rates were calculated for fracture preventive care and fractures, and hazard ratios (HRs) were estimated from Cox proportional hazards regression models comparing high- vs low-intensity oral corticosteroid prescriptions.

Results

In both the UK cohort of 65 195 participants (mean [IQR] age, 75 [71-81] years; 32 981 [50.6%] male) and the Ontario cohort of 28 674 participants (mean [IQR] age, 73 [69-79] years; 17 071 [59.5%] male), individuals with high-intensity oral corticosteroid prescriptions had substantially higher rates of fracture preventive care than individuals with low-intensity prescriptions (UK: 134 vs 57 per 1000 person-years; crude HR, 2.34; 95% CI, 2.19-2.51, and Ontario: 73 vs 48 per 1000 person-years; crude HR, 1.49; 95% CI, 1.29-1.72). People with high- and low-intensity oral corticosteroid prescriptions had similar rates of major osteoporotic fractures (UK: crude rates, 14 vs 13 per 1000 person-years; crude HR, 1.07; 95% CI, 0.98-1.15 and Ontario: crude rates, 20 vs 23 per 1000 person-years; crude HR, 0.87; 95% CI, 0.79-0.96). Results from sensitivity analyses suggested that reaching a high cumulative oral corticosteroid dose within a shorter time, with fewer prescriptions, or with fewer or shorter gaps between prescriptions, increased fracture preventive care prescribing.

Conclusions

The results of this cohort study suggest that older adults prescribed high cumulative oral corticosteroids across multiple prescriptions, or with many or long gaps between prescriptions, may be missing opportunities for fracture preventive care.

Perinatal and early life factors and asthma control among preschoolers: a population-based retrospective cohort study

BACKGROUND

Preventing poor childhood asthma control is crucial for short-term and long-term respiratory health. This study evaluated associations between perinatal and early-life factors and early childhood asthma control.

METHODS

This retrospective study used administrative health data from mothers and children born 2010-2012 with a diagnosis of asthma before age 5 years, in Alberta, Canada. The outcome was asthma control within 2 years after diagnosis. Associations between perinatal and early-life factors and risk of partly and uncontrolled asthma were evaluated by multinomial logistic regression.

RESULTS

Of 7206 preschoolers with asthma, 52% had controlled, 37% partly controlled and 12% uncontrolled asthma 2 years after diagnosis. Compared with controlled asthma, prenatal antibiotics (adjusted risk ratio (aRR): 1.19; 95% CI 1.06 to 1.33) and smoking (aRR: 1.18; 95% CI 1.02 to 1.37), C-section delivery (aRR: 1.11; 95% CI 1.00 to 1.25), summer birth (aRR: 1.16; 95% CI 1.00 to 1.34) and early-life hospitalisation for respiratory illness (aRR: 2.24; 95% CI 1.81 to 2.76) increased the risk of partly controlled asthma. Gestational diabetes (aRR: 1.41; 95% CI 1.06 to 1.87), C-section delivery (aRR: 1.18; 95% CI 1.00 to 1.39), antibiotics (aRR: 1.32; 95% CI 1.08 to 1.61) and hospitalisation for early-life respiratory illness (aRR: 1.65; 95% CI 1.19 to 2.27) were associated with uncontrolled asthma.

CONCLUSION

Maternal perinatal and early-life factors including antibiotics in pregnancy and childhood, gestational diabetes, prenatal smoking, C-section and summertime birth, and hospitalisations for respiratory illness are associated with partly or uncontrolled childhood asthma. These results underline the significance of perinatal health and the lasting effects of early-life experiences on lung development and disease programming.

Burden of illness associated with Respiratory Syncytial Virus (RSV)-related hospitalizations among adults in Ontario, Canada: A retrospective population-based study

BACKGROUND

Globally, RSV is a common viral pathogen that causes 64 million acute respiratory infections annually. Our objective was to determine the incidence of hospitalization, healthcare resource use and associated costs of adults hospitalized with RSV in Ontario, Canada.

METHODS

To describe the epidemiology of adults hospitalized with RSV, we used a validated algorithm applied to a population-based healthcare utilization administrative dataset in Ontario, Canada. We created a retrospective cohort of incident hospitalized adults with RSV between September 2010 and August 2017 and followed each person for up to two years. To determine the burden of illness associated with hospitalization and post-discharge healthcare encounters each RSV-admitted patient was matched to two unexposed controls based on demographics and risk factors. Patient demographics were described and mean attributable 6-month and 2-year healthcare costs (2019 Canadian dollars) were estimated.

RESULTS

There were 7,091 adults with RSV-associated hospitalizations between 2010 and 2019 with a mean age of 74.6 years; 60.4 % were female. RSV-coded hospitalization rates increased from 1.4 to 14.6 per 100,000 adults between 2010-2011 and 2018-2019. The mean difference in healthcare costs between RSV-admitted patients and matched controls was $28,260 (95 % CI: $27,728 - $28,793) in the first 6 months and $43,721 over 2 years (95 % CI: $40,383 - $47,059) post-hospitalization.

CONCLUSIONS

RSV hospitalizations among adults increased in Ontario between 2010/11 to 2018/19 RSV seasons. RSV hospitalizations in adults were associated with increased attributable short-term and long-term healthcare costs compared to matched controls. Interventions that could prevent RSV in adults may reduce healthcare burden.

Incidence of chronic disease following smoking cessation treatment: A matched cohort study using linked administrative healthcare data in Ontario, Canada

Scarce evidence is available on the impact of real-world smoking cessation treatment on subsequent health outcomes, such as incidence of chronic disease. This study compared two cohorts of people that smoke-those that enrolled in a smoking cessation program, and a matched control that had not accessed the program-to assess the incidence of cancer, chronic obstructive pulmonary disease, diabetes, hypertension, and major cardiovascular events over a 5-year follow-up period. We selected five sub-cohorts with matched treatment-control pairs in which both individuals were at risk of the five chronic diseases. Incident chronic disease from index date until December 31, 2017, was determined through linkage with routinely collected healthcare data. The cumulative incidence of each chronic disease was estimated using the cumulative incidence function with death as a competing risk. Gray's test was used to test for a difference between matched treatment and control groups in the chronic disease-specific cumulative incidence function over follow-up. Analyses were stratified by sex. Among females, cumulative incidence of diabetes was higher over follow-up for the treatment group (5-year cumulative incidence 5.8% vs 4.2%, p = 0.004), but did not differ for the four other chronic diseases. Among males, cumulative incidence of chronic obstructive pulmonary disease (12.2% vs 9.1%, p < 0.001) and diabetes (6.7% vs 4.8%, p < 0.001) both had higher 5-year cumulative incidence for the treated versus control groups but did not differ for the other three chronic diseases. We conclude that accessing primary-care based smoking cessation treatment is associated with increased incidence of diabetes for both sexes, and chronic obstructive pulmonary disease for males (possibly due to under diagnosis prior to treatment), within 5 years of treatment. The associations detected require further research to understand causal relationships.

Association between COPD and Stage of Lung Cancer Diagnosis: A Population-Based Study

Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of lung cancer; however, the association between COPD and stage of lung cancer diagnosis is unclear. We conducted a population-based cross-sectional analysis of lung cancer patients (2008-2020) in Ontario, Canada. Using estimated propensity scores and inverse probability weighting, logistic regression models were developed to assess the association between COPD and lung cancer stage at diagnosis (early: I/II, advanced: III/IV), accounting for prior chest imaging. We further examined associations in subgroups with previously diagnosed and undiagnosed COPD. Over half (55%) of all lung cancer patients in Ontario had coexisting COPD (previously diagnosed: 45%, undiagnosed at time of cancer diagnosis: 10%). Compared to people without COPD, people with COPD had 30% lower odds of being diagnosed with lung cancer in the advanced stages (OR = 0.70, 95% CI: 0.68 to 0.72). Prior chest imaging only slightly attenuated this association (OR = 0.77, 95% CI: 0.75 to 0.80). The association with lower odds of advanced-stage diagnosis remained, regardless of whether COPD was previously diagnosed (OR = 0.68, 95% CI: 0.66 to 0.70) or undiagnosed (OR = 0.77, 95% CI: 0.73 to 0.82). Although most lung cancers are detected in the advanced stages, underlying COPD was associated with early-stage detection. Lung cancer diagnostics may benefit from enhanced partnership with COPD healthcare providers.

An interrupted time series study using administrative health data to examine the impact of the COVID-19 pandemic on alternate care level acute hospitalizations in Ontario, Canada

BACKGROUND

Many health systems struggle with delayed discharges (known as alternate level of care [ALC] in Canada). Our objectives were to describe and compare patient and hospitalization characteristics by ALC status, and to examine the impact of the initial period of the COVID-19 pandemic on ALC rates in Ontario, Canada.

METHODS

We conducted an interrupted time series using linked administrative data for acute care hospital discharges in Ontario between Feb. 28, 2018, and Nov. 30, 2020. We measured the monthly ALC rate among discharges before and after the onset of the COVID-19 pandemic (Mar. 1, 2020). We used interrupted time series regressions to examine the association between the onset of the pandemic and average ALC monthly rates.

RESULTS

We identified no meaningful differences in patient and admission characteristics, irrespective of time; however, differences were identified by ALC status. The overall average monthly rate of ALC discharges before the COVID-19 pandemic was 4.9% and after the onset of the pandemic was 5.0%. These discharges dropped to 4.3% (n = 3558) in March 2020 but then rebounded to their peak of 5.8% (n = 3915). There was no significant change in the average level of ALC rates per month after the onset of the pandemic (increase of 0.36% average per month, 95% confidence interval [CI] -0.11% to 0.83%) or monthly rate of change (slope) after the onset of the pandemic (-0.08%, 95% CI -0.15 to 0).

INTERPRETATION

We identified a continued high rate of hospital discharges with an ALC component despite the considerable efforts in hospital to reduce hospital occupancy during the COVID-19 pandemic. Future research should examine why ALC rates remain high despite hospital efforts.

Multimorbidity at time of death among persons with type 2 diabetes: a population-based study in Ontario, Canada

OBJECTIVE

Individuals with Type 2 Diabetes are likely to experience multimorbidity and accumulate multiple chronic conditions over their life. We aimed to identify causes of death and chronic conditions at the time of death in a population-based cohort, and to analyze variations in the presence of diabetes at the time of death overall and across income and immigrant status.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of 2,199,801 adult deaths from 1992 to 2017 in Ontario, Canada. We calculated the proportion of decedents with chronic conditions at time of death and causes of death. The risk of diabetes at the time of death was modeled across sociodemographic variables with a log binomial regression adjusting for sex, age, immigrant status, area-level income. comorbiditiesand time.

RESULTS

The leading causes of death in the cohort were cardiovascular and cancer. Decedents with diabetes had a higher prevalence of most chronic conditions than decedents without diabetes, including hypertension, osteo and other arthritis, chronic coronary syndrome, mood disorder, and congestive heart failure. The risk of diabetes at the time of death was 19% higher in immigrants (95%CI 1.18-1.20) and 15% higher in refugees (95%CI 1.12-1.18) compared to long-term residents, and 19% higher in the lowest income quintile (95%CI 1.18-1.20) relative to the highest income quintile, after adjusting for other covariates.

CONCLUSIONS

Individuals with diabetes have a greater multimorbidity burden at the time of death, underscoring the importance of multiple chronic disease management among those living with diabetes and further considerations of the social determinants of health.

New Hypertension After Pregnancy in Patients With Heart Disease

Background After pregnancy, patients with preexisting heart disease are at high risk for cardiovascular complications. The primary objective was to compare the incidence of new hypertension after pregnancy in patients with and without heart disease. Methods and Results This was a retrospective matched-cohort study comparing the incidence of new hypertension after pregnancy in 832 patients who are pregnant with congenital or acquired heart disease to a comparison group of 1664 patients who are pregnant without heart disease; matching was by demographics and baseline risk for hypertension at the time of the index pregnancy. We also examined whether new hypertension was associated with subsequent death or cardiovascular events. The 20-year cumulative incidence of hypertension was 24% in patients with heart disease, compared with 14% in patients without heart disease (hazard ratio [HR], 1.81 [95% CI, 1.44-2.27]). The median follow-up time at hypertension diagnosis in the heart disease group was 8.1 years (interquartile range, 4.2-11.9 years). The elevated rate of new hypertension was observed not only in patients with ischemic heart disease, but also in those with left-sided valve disease, cardiomyopathy, and congenital heart disease. Pregnancy risk prediction methods can further stratify risk of new hypertension. New hypertension was associated with an increased rate of subsequent death or cardiovascular events (HR, 1.54 [95% CI, 1.05-2.25]). Conclusions Patients with heart disease are at higher risk for developing hypertension in the decades after pregnancy when compared with those without heart disease. New hypertension in this young cohort is associated with adverse cardiovascular events highlighting the importance of systematic and lifelong surveillance.

Variations in all-cause mortality, premature mortality and cause-specific mortality among persons with diabetes in Ontario, Canada

INTRODUCTION

Patients with diabetes have a higher risk of mortality compared with the general population. Large population-based studies that quantify variations in mortality risk for patients with diabetes among subgroups in the population are lacking. This study aimed to examine the sociodemographic differences in the risk of all-cause mortality, premature mortality, and cause-specific mortality in persons diagnosed with diabetes.

RESEARCH DESIGN AND METHODS

We conducted a population-based cohort study of 1 741 098 adults diagnosed with diabetes between 1994 and 2017 in Ontario, Canada using linked population files, Canadian census, health administrative and death registry databases. We analyzed the association between sociodemographics and other covariates on all-cause mortality and premature mortality using Cox proportional hazards models. A competing risk analysis using Fine-Gray subdistribution hazards models was used to analyze cardiovascular and circular mortality, cancer mortality, respiratory mortality, and mortality from external causes of injury and poisoning.

RESULTS

After full adjustment, individuals with diabetes who lived in the lowest income neighborhoods had a 26% (HR 1.26, 95% CI 1.25 to 1.27) increased hazard of all-cause mortality and 44% (HR 1.44, 95% CI 1.42 to 1.46) increased risk of premature mortality, compared with individuals with diabetes living in the highest income neighborhoods. In fully adjusted models, immigrants with diabetes had reduced risk of all-cause mortality (HR 0.46, 95% CI 0.46 to 0.47) and premature mortality (HR 0.40, 95% CI 0.40 to 0.41), compared with long-term residents with diabetes. Similar HRs associated with income and immigrant status were observed for cause-specific mortality, except for cancer mortality, where we observed attenuation in the income gradient among persons with diabetes.

CONCLUSIONS

The observed mortality variations suggest a need to address inequality gaps in diabetes care for persons with diabetes living in the lowest income areas.

Mental Health Care Use Among Children and Adolescents With High Health Care Costs in Ontario, Canada

Importance

Research on patients with high health care costs has examined mainly adults, with little focus on mental health care use.

Objective

To examine the characteristics and costs of children and adolescents with high health care costs who use mostly mental health care and whether and why they persist in the high-cost state.

Design, Setting, and Participants

This population-based, retrospective cohort study used health care records from Ontario, Canada, on all children and adolescents (age 0-17 years) covered under a universal health care system from January 1, 2012, to December 31, 2019. All children and adolescents in and above the 90th percentile of the cost distribution in 2012 for whom costs related to mental health care accounted for 50% or more of their costs were defined as patients with high mental health care costs. Data were analyzed from August 2019 to December 2022.

Exposures

High health care costs.

Main Outcomes and Measures

Patients with high mental health care costs were characterized in terms of their sociodemographic characteristics; chronic physical health, mental health, and behavioral conditions; and health care costs (in 2021 Canadian dollars) by health service and type of care (mental health care vs non-mental health care). Patients were followed up until 2019 to assess whether they persisted in the high-cost state and to examine factors associated with persisting in that state.

Results

In 2012, there were 273 490 children and adolescents with high health care costs (mean [SD] age, 6.43 [5.99] years; 55.8% male; mean cost, $7936.40; 95% CI, $7850.30-$8022.40). Of these, 20 463 (7.5%) were classified as having high mental health care costs (mean cost, $10 040.20; 95% CI, $9822.80-$10 257.50). Asthma (30.3%), attention-deficit/hyperactivity disorder (35.8%), and mood and/or anxiety disorders (94.9%) were the most common chronic physical, behavioral, or mental health conditions. Few patients with high mental health care costs persisted in the high-cost state beyond 3 years (19.0%). Mood and/or anxiety disorders (relative risk ratio [RRR], 6.17; 95% CI, 3.19-11.96) and schizophrenia spectrum disorders (RRR, 2.98; 95% CI, 2.14-4.14) were identified as the main factors associated with persistence in the high-cost state.

Conclusions and Relevance

In this cohort study of children and adolescents with high health care costs, some patients had high levels of mental health care use and high costs of care, but few of these persisted in the high-cost state for 3 or more years. These findings may help inform the development of care coordination interventions and service delivery models, such as youth integrated services, to reduce costs and improve outcomes for children and adolescents.

Outcomes of COVID-19 Infection and Vaccination Among Individuals With Myasthenia Gravis

Importance

There are limited data regarding COVID-19 outcomes and vaccine uptake and safety among people with myasthenia gravis (MG).

Objective

To investigate COVID-19-related outcomes and vaccine uptake among a population-based sample of adults with MG.

Design, Setting, and Participants

This population-based, matched cohort study in Ontario, Canada, used administrative health data from January 15, 2020, and August 31, 2021. Adults with MG were identified using a validated algorithm. Each patient was matched by age, sex, and geographic area of residence to 5 controls from the general population and from a cohort of individuals with rheumatoid arthritis (RA).

Exposure

Patients with MG and matched controls.

Main Outcomes and Measures

Main outcomes were COVID-19 infection and related hospitalizations, intensive care unit admissions, and 30-day mortality among patients with MG vs controls. Secondary outcomes were uptake of COVID-19 vaccination among patients with MG vs controls.

Results

Among 11 365 233 eligible Ontario residents, 4411 patients with MG (mean [SD] age, 67.7 [15.6] years; 2274 women [51.6%]) were matched to 22 055 general population controls (mean [SD] age, 67.7 [15.6] years; 11 370 women [51.6%]) and 22 055 controls with RA (mean [SD] age, 67.7 [15.6] years; 11 370 women [51.6%]). In the matched cohort, 38 861 of 44 110 individuals (88.1%) were urban residents; in the MG cohort, 3901 (88.4%) were urban residents. Between January 15, 2020, and May 17, 2021, 164 patients with MG (3.7%), 669 general population controls (3.0%), and 668 controls with RA (3.0%) contracted COVID-19. Compared with general population controls and controls with RA, patients with MG had higher rates of COVID-19-associated emergency department visits (36.6% [60 of 164] vs 24.4% [163 of 669] vs 29.9% [200 of 668]), hospital admissions (30.5% [50 of 164] vs 15.1% [101 of 669] vs 20.7% [138 of 668]), and 30-day mortality (14.6% [24 of 164] vs 8.5% [57 of 669] vs 9.9% [66 of 668]). By August 2021, 3540 patients with MG (80.3%) vs 17 913 general population controls (81.2%) had received 2 COVID-19 vaccine doses, and 137 (3.1%) vs 628 (2.8%), respectively had received 1 dose. Of 3461 first vaccine doses for patients with MG, fewer than 6 individuals were hospitalized for MG worsening within 30 days of vaccination. Vaccinated patients with MG had a lower risk than unvaccinated patients with MG of contracting COVID-19 (hazard ratio, 0.43; 95% CI, 0.30-0.60).

Conclusions and Relevance

This study suggests that adults with MG who contracted COVID-19 had a higher risk of hospitalization and death compared with matched controls. Vaccine uptake was high, with negligible risk of severe MG exacerbations after vaccination, as well as evidence of effectiveness. The findings support public health policies prioritizing people with MG for vaccination and new COVID-19 therapeutics.

The association between receipt of home care rehabilitation services and acute care hospital utilization in clients with multimorbidity following an acute care unit discharge: a retrospective cohort study

BACKGROUND

Individuals experiencing multimorbidity have more complex healthcare needs, use more healthcare services, and access multiple service providers across the healthcare continuum. They also experience higher rates of functional decline. Rehabilitation therapists are well positioned to address these functional needs; however, little is known about the influence of rehabilitation therapy on patient outcomes, and subsequent unplanned healthcare utilization for people with multimorbidity. The aims of this study were to: 1) describe and compare the characteristics of people with multimorbidity receiving: home care rehabilitation therapy alone, other home care services without rehabilitation therapy, and the combination of home care rehabilitation therapy and other home care services, and 2) determine the association between home care rehabilitation therapy and subsequent healthcare utilization among those recently discharged from an acute care unit.

METHODS

This retrospective cohort study used linked health administrative data housed within ICES, Ontario, Canada. The cohort included long-stay home care clients experiencing multimorbidity who were discharged from acute care settings between 2007-2015 (N = 43,145). Descriptive statistics, ANOVA's, t-tests, and chi-square analyses were used to describe and compare cohort characteristics. Multivariable logistic regression was used to understand the association between receipt of rehabilitation therapy and healthcare utilization.

RESULTS

Of those with multimorbidity receiving long-stay home care services, 45.5% had five or more chronic conditions and 46.3% required some assistance with ADLs. Compared to people receiving other home care services, those receiving home care rehabilitation therapy only were less likely to be readmitted to the hospital (OR = 0.78; 95% CI: 0.73-0.83) and use emergency department services (OR = 0.73; 95% CI: 0.69-0.78) within the first 3-months following hospital discharge.

CONCLUSIONS

Receipt of rehabilitation therapy was associated with less unplanned healthcare service use when transitioning from hospital to home among persons with multimorbidity. These findings suggest rehabilitation therapy may help to reduce the healthcare burden for individuals and health systems. Future research should evaluate the potential cost savings and health outcomes associated with providing rehabilitation therapy services for people with multimorbidity.

Incidence of cardiovascular disease and mortality in childhood solid organ transplant recipients: a population-based study

BACKGROUND

With improved survival among children after transplantation, our understanding of the risk for developing other comorbidities is improving, yet little is known about the long-term risk of cardiovascular events and mortality after solid organ transplantation.

METHODS

In a cohort study using health administrative data, we compared cardiovascular events in children (n = 615) with liver, lung, kidney, small bowel, or multi-organ transplant at the Hospital for Sick Children, Toronto, Canada, with asthmatic children (n = 481,697) between 1996 and 2014. Outcomes included non-fatal cardiovascular events, cardiovascular death, all-cause mortality, and a composite of non-fatal and fatal cardiovascular events. Time-stratified Cox proportional hazards models were used.

RESULTS

Among 615 children, 317 (52%) were recipients of kidneys, 253 (41%) of livers, and the remaining 45 (7%) had lung, small bowel, or multi-organ transplants. Median follow-up was 12.1 [7.2, 16.7] years. Non-fatal incident cardiovascular events were 34 times higher among solid organ transplant recipients than non-transplanted children (incidence rate ratio (IRR) 34.4, 95% CI: 25.5, 46.4). Among transplant recipients, the cumulative incidence of non-fatal and fatal cardiovascular events was 2.3% and 13.0%, 5 and 15 years after transplantation, respectively.

CONCLUSIONS

Increased rate of cardiovascular events in children after transplantation highlights the need for surveillance during transition into adulthood and beyond. A higher resolution version of the Graphical abstract is available as Supplementary information.

An inverse relationship between asthma prevalence and medication dispensation trend: a 12-year spatial analysis of electronic health record data in Alberta, Canada

Despite guideline-based asthma management in Alberta, an inverse trend between asthma prevalence and dispensation of asthma medications in the past 12 years possibly underscores the reason for a large number of emergency department visits https://bit.ly/3HQsBo8.

Understanding the scope of preventable acute care spending among patients with eating disorders

OBJECTIVE

The economic burden of eating disorders is substantial. One potential way to reduce costs, without sacrificing care, may be to target preventable (i.e., potentially unnecessary) acute care. This study sought to determine the amount and proportion of preventable and non-preventable acute care spending among individuals with eating disorders.

METHOD

We undertook a population-based, cross-sectional study of all individuals over the age of 17 with eating disorders (diagnosed through hospitalization) in Ontario, Canada, to determine potentially preventable and non-preventable acute care spending. Preventable acute care (i.e., preventable emergency department visits and hospitalizations) was defined using previously validated algorithms. We undertook analyses for the full sample, by sex and by eating disorder diagnosis (anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified, multiple).

RESULTS

Among 7547 individuals with eating disorders, 15% of all acute care spending (i.e., $1.33 million) was considered preventable; this figure was higher for females (14%) and those with bulimia nervosa (21%). Among emergency department visits, 25% of visits were considered preventable; the largest proportions were for non-emergent (11%) and primary care treatable (10%) conditions. Among hospitalizations, 9% were considered preventable; the highest proportions of preventable care spending were for short-term diabetes complications (1.8%) and urinary tract infections (1.8%).

DISCUSSION

Although the economic burden of eating disorders is substantial, there is some scope to decrease acute care spending among this patient population. Care coordination and improved access to primary care and disease prevention, particularly related to diabetes, may help prevent the occurrence of some acute care episodes.

PUBLIC SIGNIFICANCE

Many jurisdictions have implemented strategies to reduce costs and improve the quality of care among patients with high health care needs, such as those with eating disorders; however, it is unclear whether any costs can be reduced and, if so, which costs. Cost-savings resulting from the reduction of unnecessary care could provide further economic justification for increased investment in outpatient care for individuals with eating disorders.