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Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman GA, Kirkwood D, Costa AP. Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study. J Am Med Dir Assoc 2023; 24:1341-1348. [PMID: 37549887 DOI: 10.1016/j.jamda.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios. RESULTS There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada.
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Natasha E Lane
- ICES, Toronto, ON, Canada; Department of Internal Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paula A Rochon
- ICES, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Samir K Sinha
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; National Institute on Ageing, Toronto Metropolitan University, Toronto, ON, Canada
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada; Schlegel Research Institute for Aging, Waterloo, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman GA, Kirkwood D, Costa AP. Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study. J Am Med Dir Assoc 2023; 24:1356-1360. [PMID: 37507099 DOI: 10.1016/j.jamda.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019. RESULTS There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019. CONCLUSIONS AND IMPLICATIONS Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Natasha E Lane
- ICES, Toronto, Ontario, Canada; Department of Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paula A Rochon
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir K Sinha
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; National Institute on Ageing, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada; Schlegel Research Institute for Aging, Waterloo, Ontario, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Manis DR, Bronskill SE, Rochon PA, Sinha SK, Boscart V, Tanuseputro P, Poss JW, Rahim A, Tarride JÉ, Abelson J, Costa AP. Defining the Assisted Living Sector in Canada: An Environmental Scan. J Am Med Dir Assoc 2022; 23:1871-1877.e1. [PMID: 36007545 DOI: 10.1016/j.jamda.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/24/2022] [Accepted: 07/16/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVES In this study, we (1) identify the terms used to describe the assisted living sector and the legislation governing operation in all Canadian provinces and territories; (2) identify the cost estimates associated with residency in these homes; and (3) quantify the growth of the sector. DESIGN Environmental scan. SETTING AND PARTICIPANTS Internet searches of Canadian provincial and territorial government websites and professional associations were conducted in 2021 to retrieve publicly accessible sources related to the assisted living sector. METHODS We synthesized data that identified the terms used to describe the sector in all provinces and territories, the legislation governing operation, financing, median fees per month for care, and growth of the sector from 2012 to 2020. Counts and proportions were calculated for some extracted variables. All data were narratively synthesized. RESULTS The terms used to describe the assisted living sector varied across Canada. The terms "assisted living," "retirement homes," and "supportive living" were prevalent. Ontario was the only province to regulate the sector through an independent, not-for-profit organization. Ontario, British Columbia, and Alberta had some of the highest median fees for room, board, and care per month (range: $1873 to $6726). The licensed assisted living sector in Ontario doubled in size (768 in 2020 vs 383 in 2012), and there was a threefold increase in the number of corporate-owned chain assisted living facilities (465 in 2020 vs 142 in 2012). CONCLUSIONS AND IMPLICATIONS The rapid growth of the assisted living sector that is primarily financed through out-of-pocket payments may indicate a rise in a two-tier system of housing and health care for older adults. Policymakers need better mechanisms, such as standardized reporting systems and assessments, to understand the needs of older adults who reside in assisted living facilities and inform the need for sector regulation and oversight.
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Affiliation(s)
- Derek R Manis
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Paula A Rochon
- ICES, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir K Sinha
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; National Institute on Ageing, Ryerson University, Toronto, Ontario, Canada
| | - Veronique Boscart
- Schlegel Research Institute for Aging, Waterloo, Ontario, Canada; Institute of Technology and Advanced Learning, Conestoga College, Kitchener, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jeffrey W Poss
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Ahmad Rahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Éric Tarride
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Julia Abelson
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada; Schlegel Research Institute for Aging, Waterloo, Ontario, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Manis DR, Poss JW, Jones A, Rochon PA, Bronskill SE, Campitelli MA, Perez R, Stall NM, Rahim A, Babe G, Tarride JÉ, Abelson J, Costa AP. Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study. CMAJ 2022; 194:E730-E738. [PMID: 35636759 PMCID: PMC9259419 DOI: 10.1503/cmaj.211883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults. METHODS We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits. RESULTS We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14). INTERPRETATION Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.
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Affiliation(s)
- Derek R Manis
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Jeffrey W Poss
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Aaron Jones
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Paula A Rochon
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Susan E Bronskill
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Michael A Campitelli
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Richard Perez
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Nathan M Stall
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Ahmad Rahim
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Glenda Babe
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Jean-Éric Tarride
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Julia Abelson
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Andrew P Costa
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.
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