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Young S, Gomes T, Kolla G, McCormack D, Dodd Z, Raboud J, Bayoumi AM. Initiations of safer supply hydromorphone increased during the COVID-19 pandemic in Ontario: An interrupted time series analysis. PLoS One 2023; 18:e0295145. [PMID: 38113220 PMCID: PMC10729949 DOI: 10.1371/journal.pone.0295145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/14/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS Calls to prescribe safer supply hydromorphone (SSHM) as an alternative to the toxic drug supply increased during the COVID-19 pandemic but it is unknown whether prescribing behaviour was altered. We aimed to evaluate how the number of new SSHM dispensations changed during the pandemic in Ontario. METHODS We conducted a retrospective interrupted time-series analysis using provincial administrative databases. We counted new SSHM dispensations in successive 28-day periods from March 22, 2016 to August 30, 2021. We used segmented Poisson regression methods to test for both a change in level and trend of new dispensations before and after March 17, 2020, the date Ontario's pandemic-related emergency was declared. We adjusted the models to account for seasonality and assessed for over-dispersion and residual autocorrelation. We used counterfactual analysis methods to estimate the number of new dispensations attributable to the pandemic. RESULTS We identified 1489 new SSHM dispensations during the study period (434 [mean of 8 per 28-day period] before and 1055 [mean of 56 per 28-day period] during the pandemic). Median age of individuals initiating SSHM was 40 (interquartile interval 33-48) with 61.7% (N = 919) male sex. Before the pandemic, there was a small trend of increased prescribing (incidence rate ratio [IRR] per period 1.002; 95% confidence interval [95CI] 1.001-1.002; p<0.001), with a change in level (immediate increase) at the pandemic date (relative increase in IRR 1.674; 95CI 1.206-2.322; p = 0.002). The trend during the pandemic was not statistically significant (relative increase in IRR 1.000; 95CI 1.000-1.001; p = 0.251). We estimated 511 (95CI 327-695) new dispensations would not have occurred without the pandemic. CONCLUSION The pandemic led to an abrupt increase in SSHM prescribing in Ontario, although the rate of increase was similar before and during the pandemic. The absolute number of individuals who accessed SSHM remained low throughout the pandemic.
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Affiliation(s)
- Samantha Young
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Addiction Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Tara Gomes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | | | - Zoë Dodd
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed M. Bayoumi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health, Toronto, Ontario, Canada
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Paradise RK, Desmarais J, O'Malley SE, Hoyos-Cespedes A, Nurani A, Walley AY, Clarke J, Taylor S, Dooley D, Bazzi AR, Kimmel SD. Perspectives and recommendations of opioid overdose survivors experiencing unsheltered homelessness on housing, overdose, and substance use treatment in Boston, MA. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104127. [PMID: 37523844 DOI: 10.1016/j.drugpo.2023.104127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/04/2023] [Accepted: 07/07/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Opioid overdose causes one in four deaths among people experiencing homelessness in Boston, MA. To reduce overdose risks, the experience and perspectives of people experiencing homelessness should be incorporated into housing, overdose prevention, and substance use treatment efforts. METHODS In 2021, we conducted qualitative interviews with 59 opioid overdose survivors to inform equitable access to treatment services. In response to policy debate surrounding a public drug scene near a key recruitment site, we conducted a targeted thematic analysis of transcribed interview data from a subset of participants experiencing unsheltered homelessness (n=29) to explore their perspectives and recommendations on housing, overdose prevention, and substance use treatment. RESULTS Among 29 participants who identified as non-Hispanic Black (n=10), Hispanic/Latinx (n=10), or as non-Hispanic White (n=9), the median number of self-reported opioid overdoses in the past three months was 2.0 (SD 3.7). Three themes emerged from this targeted analysis: (1) Participants described inadequate housing resources and unwelcoming shelter environments. (2) Participants near a large public drug scene explained how unsheltered homelessness was chaotic, dangerous, and disruptive to recovery goals. (3) Participants provided recommendations for improving housing and addiction treatment systems and including their perspectives in the development of solutions to the intersecting housing and opioid overdose crises. CONCLUSIONS The overdose prevention, housing and substance use treatment systems must address the needs of opioid overdose survivors experiencing unsheltered homelessness. Overdose survivors experiencing unsheltered homelessness described a chaotic public drug scene but resorted to residing in nearby encampments because the existing shelter, housing, and addiction treatment systems were unwelcoming, difficult to navigate, or unaffordable. Despite efforts to provide low-threshold housing in Boston, additional low-barrier housing services (i.e., including harm reduction resources and without "sobriety" requirements) could promote the health and safety of people who use drugs and are experiencing homelessness.
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Affiliation(s)
- Ranjani K Paradise
- Institute for Community Health, 350 Main Street, Malden, MA 02148, United States; Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA 02111, United States
| | - Jeffrey Desmarais
- Institute for Community Health, 350 Main Street, Malden, MA 02148, United States
| | - Shannon E O'Malley
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | | | - Alykhan Nurani
- Boston Medical Center, 801 Massachusetts Avenue, 2(nd) Floor Crosstown Building, Boston MA 02118, United States
| | - Alexander Y Walley
- Boston Medical Center, 801 Massachusetts Avenue, 2(nd) Floor Crosstown Building, Boston MA 02118, United States; Boston University Chobanian and Avedisian School of Medicine, 801 Massachusetts Avenue, 2nd Floor Crosstown Building, Boston, MA 02118, United States
| | - Jaylen Clarke
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | - Sunday Taylor
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | - Daniel Dooley
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | - Angela R Bazzi
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States; Boston University School of Public Health, 801 Massachusetts Avenue, 4(th) Floor Crosstown Building, Boston, MA 02118, United States
| | - Simeon D Kimmel
- Boston Medical Center, 801 Massachusetts Avenue, 2(nd) Floor Crosstown Building, Boston MA 02118, United States; Boston University Chobanian and Avedisian School of Medicine, 801 Massachusetts Avenue, 2nd Floor Crosstown Building, Boston, MA 02118, United States.
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Garg R, Kitchen SA, Men S, Campbell TJ, Bozinoff N, Tadrous M, Antoniou T, Wyman J, Werb D, Munro C, Gomes T. Impact of the COVID-19 pandemic on the prevalence of opioid agonist therapy discontinuation in Ontario, Canada: A population-based time series analysis. Drug Alcohol Depend 2022; 236:109459. [PMID: 35489179 PMCID: PMC9008980 DOI: 10.1016/j.drugalcdep.2022.109459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/19/2022] [Accepted: 04/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND We assessed the impact of COVID-19, which includes the declaration of a state of emergency and subsequent release of pandemic-specific OAT guidance (March 17, 2020 to March 23, 2020) on the prevalence of OAT discontinuation. METHODS We conducted a population-based time series analysis using interventional autoregressive integrated moving average models among Ontario residents who were stable (>60 days of continuous use) and not yet stable on OAT. Specifically, we examined whether COVID-19 impacted the weekly percentage of individuals who discontinued OAT, overall and stratified by treatment type (methadone vs. buprenorphine/naloxone). Additionally, we compared demographic characteristics and patient outcomes among people stable on OAT who discontinued treatment during (March 17, 2020 to November 30, 2020) and prior (July 3, 2019 to March 16, 2020) to the pandemic. RESULTS The weekly prevalence of OAT discontinuation across the study period ranged between 0.6% and 1.1%, among those stable on treatment compared to 7.3% and 16.6%, among those not stable on treatment. Following COVID-19, there was no significant change in the percentage of Ontarians who discontinued OAT, regardless of whether they were stabilized on treatment. Among those stable on OAT, a similar proportion of patients restarted therapy and experienced opioid-related harm following an OAT discontinuation. However, mortality following OAT discontinuation must be noted, as approximately 1.4% and 0.8% of people who discontinued methadone and buprenorphine/naloxone respectively, died within 30 days of discontinuation. CONCLUSIONS Trends in the prevalence of OAT discontinuation did not significantly change during the first eight months of the COVID-19 pandemic.
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Affiliation(s)
- Ria Garg
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Sophie A. Kitchen
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Siyu Men
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Tonya J. Campbell
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| | - Nikki Bozinoff
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, Ontario M5G 1V7, Canada
| | - Mina Tadrous
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario M5S 3M2, Canada,Women’s College Hospital, 76 Grenville St, Toronto, Ontario M5S 1B2, Canada
| | - Tony Antoniou
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada,Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, Ontario M5G 1V7, Canada,Department of Family and Community Medicine, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Jennifer Wyman
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario M5S 3M2, Canada,Women’s College Hospital, 76 Grenville St, Toronto, Ontario M5S 1B2, Canada
| | - Dan Werb
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada,Department of Family and Community Medicine, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada,Division of Infectious Diseases & Global Public Health at the University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Charlotte Munro
- Ontario Drug Policy Research Network Lived Experience Advisory Group, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario M5S 3M2, Canada; Institute of Health Policy, Management & Evaluation at the University of Toronto, 155 College St, Toronto, Ontario M5T 3M6, Canada.
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Brothers TD, Leaman M, Bonn M, Lewer D, Atkinson J, Fraser J, Gillis A, Gniewek M, Hawker L, Hayman H, Jorna P, Martell D, O'Donnell T, Rivers-Bowerman H, Genge L. Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness. Drug Alcohol Depend 2022; 235:109440. [PMID: 35461084 PMCID: PMC8988445 DOI: 10.1016/j.drugalcdep.2022.109440] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program. METHODS We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol. RESULTS Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day). CONCLUSIONS COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events.
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Affiliation(s)
- Thomas D Brothers
- Department of Medicine (General Internal Medicine & Clinician-Investigator Program), Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, UK.
| | - Malcolm Leaman
- North End Community Health Centre, Halifax, Nova Scotia, Canada
| | - Matthew Bonn
- Canadian Association of People who Use Drugs, Dartmouth, Nova Scotia, Canada
| | - Dan Lewer
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, UK
| | | | - John Fraser
- North End Community Health Centre, Halifax, Nova Scotia, Canada; Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Anesthesia, Pain Management & Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amy Gillis
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Gniewek
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
| | - Leisha Hawker
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
| | - Heather Hayman
- North End Community Health Centre, Halifax, Nova Scotia, Canada
| | | | - David Martell
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
| | | | | | - Leah Genge
- North End Community Health Centre, Halifax, Nova Scotia, Canada; Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
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Shariff SZ, Richard L, Hwang SW, Kwong JC, Forchuk C, Dosani N, Booth R. COVID-19 vaccine coverage and factors associated with vaccine uptake among 23 247 adults with a recent history of homelessness in Ontario, Canada: a population-based cohort study. Lancet Public Health 2022; 7:e366-e377. [PMID: 35278362 PMCID: PMC8906815 DOI: 10.1016/s2468-2667(22)00037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND People experiencing homelessness face a high risk of SARS-CoV-2 infection and transmission, as well as health complications and death due to COVID-19. Despite being prioritised for receiving the COVID-19 vaccine in many regions, little data are available on vaccine uptake in this vulnerable population. Using population-based health-care administrative data from Ontario, Canada-a region with a universal, publicly funded health system-we aimed to describe COVID-19 vaccine coverage (ie, the estimated percentage of people who have received a vaccine) and determinants of vaccine receipt among individuals with a recent history of homelessness. METHODS We conducted a retrospective, population-based cohort study of adults (aged ≥18 years) with a recent experience of homelessness, inadequate housing, or shelter use as recorded in routinely collected health-care databases between June 14, 2020, and June 14, 2021 (a period within 6 months of Dec 14, 2020, when COVID-19 vaccine administration was initiated in Ontario). Participants were followed up from Dec 14, 2020, to Sept 30, 2021, for the receipt of one or two doses of a COVID-19 vaccine using the province's real-time centralised vaccine information system. We described COVID-19 vaccine coverage overall and within predefined subgroups. Using modified Poisson regression, we further identified sociodemographic factors, health-care usage, and clinical factors associated with receipt of at least one dose of a COVID-19 vaccine. FINDINGS 23 247 individuals with a recent history of homelessness were included in this study. Participants were predominantly male (14 752 [63·5%] of 23 247); nearly half were younger than 40 years (11 521 [49·6%]) and lived in large metropolitan regions (12 123 [52·2%]); and the majority (18 226 [78·4%]) visited a general practitioner for an in-person consultation during the observation period. By Sept 30, 2021, 14 271 (61·4%; 95% CI 60·8-62·0) individuals with a recent history of homelessness had received at least one dose of a COVID-19 vaccine and 11 082 (47·7%; 47·0-48·3) had received two doses; in comparison, over the same period, 86·6% of adults in the total Ontario population had received a first dose and 81·6% had received a second dose. In multivariable analysis, factors positively associated with COVID-19 uptake were one or more outpatient visits to a general practitioner (adjusted risk ratio [aRR] 1·37 [95% CI 1·31-1·42]), older age (50-59 years vs 18-29 years: 1·18 [1·14-1·22], ≥60 years vs 18-29 years: 1·27 [1·22-1·31]), receipt of an influenza vaccine in either of the two previous influenza seasons (1·25 [1·23-1·28]), being identified as homeless via a visit to a community health centre versus exclusively a hospital-based encounter (1·13 [1·10-1·15]), receipt of one or more SARS-CoV-2 tests between March 1, 2020, and Sept 30, 2021 (1·23 [1·20-1·26]), and the presence of chronic health conditions (one condition: 1·05 [1·03-1·08]; two or more conditions: 1·11 [1·08-1·14]). By contrast, living in a smaller metropolitan region (aRR 0·92 [95% CI 0·90-0·94]) or rural location (0·93 [0·90-0·97]) versus large metropolitan regions were associated with lower uptake. INTERPRETATION In Ontario, COVID-19 vaccine coverage among adults with a recent history of homelessness has lagged and, as of Sept 30, 2021, was 25 percentage points lower than that of the general adult population in Ontario for a first dose and 34 percentage points lower for a second dose. With high usage of outpatient health services among individuals with a recent history of homelessness, better utilisation of outpatient primary care structures might offer an opportunity to increase vaccine coverage in this population. Our findings underscore the importance of leveraging existing health and service organisations that are accessed and trusted by people who experience homelessness for targeted vaccine delivery. FUNDING The Public Health Agency of Canada. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Salimah Z Shariff
- ICES (formerly the Institute for Clinical Evaluative Sciences), London, ON, Canada; Lawson Health Research Institute, London, ON, Canada; Arthur Labatt Family School of Nursing, Western University, London, ON, Canada.
| | - Lucie Richard
- ICES (formerly the Institute for Clinical Evaluative Sciences), London, ON, Canada,MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
| | - Stephen W Hwang
- ICES (formerly the Institute for Clinical Evaluative Sciences), London, ON, Canada,MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jeffrey C Kwong
- ICES (formerly the Institute for Clinical Evaluative Sciences), London, ON, Canada,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada,Public Health Ontario, Toronto, ON, Canada,University Health Network, Toronto, ON, Canada
| | - Cheryl Forchuk
- Lawson Health Research Institute, London, ON, Canada,Arthur Labatt Family School of Nursing, Western University, London, ON, Canada
| | - Naheed Dosani
- Division of Palliative Care, Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Richard Booth
- ICES (formerly the Institute for Clinical Evaluative Sciences), London, ON, Canada,Lawson Health Research Institute, London, ON, Canada,Arthur Labatt Family School of Nursing, Western University, London, ON, Canada
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