Residential surrounding greenness and the incidence of childhood asthma: Findings from a population-based cohort in Ontario, Canada

Several epidemiological studies have investigated the possible role that living in areas with greater amounts of greenspace has on the incidence of childhood asthma. These findings have been inconsistent, and few studies explored the relevance of timing of exposure. We investigated the role of residential surrounding greenness on the risk of incident asthma using a population-based retrospective cohort study. We included 982,131 singleton births in Ontario, Canada between 2006 and 2013. Two measures of greenness, the Normalized Difference Vegetation Index (NDVI) and the Green View Index (GVI), were assigned to the residential histories of these infants from pregnancy through to 12 years of age. Longitudinally-based diagnoses of asthma were determined by using provincial administrative health data. The extended Cox hazards model was used to characterize associations between greenness measures and asthma (up to age 12 years) while adjusting for several risk factors. In a fully adjusted model, that included a term for traffic-related air pollution (NO2), we found no association between an interquartile range increase (0.08) of the NDVI during childhood and asthma incidence (HR = 0.99; 95 % CI = 0.99-1.01). In contrast, we found that an 0.08 increase in NDVI during childhood reduced the risk of asthma in children 7-12 years of age by 14 % (HR = 0.86, 95 % CI:0.79-0.95). Seasonal differences in the association between greenness and asthma were noted. Our findings suggest that residential proximity to greenness reduces the risk of asthma in children aged 7-12.

The relationship between the morningness-eveningness questionnaire and incident cancer: A historical clinical cohort study

OBJECTIVE

We conducted a retrospective cohort study to explore the relationship between chronotype measured by the total Morningness-Eveningness Questionnaire (MEQ) score and incident cancer.

METHODS

We used clinical and provincial health administrative data on consecutive adults who underwent a Level 1 Polysomnography (PSG) and completed the MEQ between 2010 and 2015 in an academic hospital (Ontario, Canada) and were cancer-free at baseline. Cancer status was derived from the Ontario Cancer Registry. Individuals were followed until death or March 31, 2020. We used multivariable Cox cause-specific regressions to address the research objective.

RESULTS

Of 3,004 individuals, 1,781 were analyzed: a median age of 54 years (IQR: 40-64) and 838 (47.1%) men. The median total MEQ score was 63 (IQR: 55-69); 61 (3.4%) were classified as evening (≤41), 536 (30.1%) as intermediate (42-58), and 1,184 (66.5%) as morning chronotypes (≥59). Over a median of 7 years (IQR: 5-8), 120 (6.7%) developed cancer. A U-shape relationship was found between the total MEQ score and an increased hazard of incident cancer, controlling for PSG measures of sleep apnea severity and sleep architecture, demographics, and comorbidities. Compared to the median of 63.0, a total MEQ score greater or less than the median was associated with an increased hazard of incident cancer, with the largest effect for those with a total score ≥76 (e.g., HR of a MEQ total score of 78 vs. 63: 2.01, 95% CI: 1.09-3.71).

CONCLUSION

The U-shaped curve may reflect deviations from a standard circadian tendency, which may stress biological systems and influence malignancy risk.

Obstructive Sleep Apnea and Mental Health Disorders in the Pediatric Population: A Retrospective Population-based Cohort Study

RATIONALE

Information is limited about the association between obstructive sleep apnea (OSA) and mental disorders in children.

OBJECTIVES

In children, (1) to evaluate the association between OSA and new mental healthcare encounters; (2) to compare mental healthcare encounters two years post- to pre-OSA treatment initiation.

METHODS

We conducted a retrospective longitudinal cohort study using Ontario health administrative data (Canada). Children (0-18 years) who underwent diagnostic polysomnography (PSG) 2009-2016 and met criteria for definition of moderate-severe OSA (PSG-OSA) were propensity score weighted by baseline characteristics and compared to children who underwent a PSG in the same period but did not meet the OSA definition (PSG-No-OSA). Children were followed until March 2021. Weighted cause-specific Cox Proportional Hazards and Modified Poisson regression models were used to compare time from PSG to first mental healthcare encounter and frequency of new mental healthcare encounters per person time, respectively. Among those who underwent adenotonsillectomy (AT) or were prescribed and claimed positive airway pressure therapy (PAP), we used age-adjusted conditional logistic regression models to compare two years post- to pre-treatment odds of mental healthcare encounters.

RESULTS

Of 32,791 children analyzed, 7,724 (23.6%) children met criteria for moderate-severe OSA. In PSG-OSA group, 7,080 (91.7%) were treated (AT or PAP). Compared to PSG-No-OSA, the PSG-OSA group had a shorter time from PSG to first mental healthcare encounter (HR: 1.08; 95%CI: 1.05-1.12), but less frequent mental healthcare encounters in follow-up (RR: 0.92; 95% CI: 0.87-0.97). OSA treatment (AT or PAP) was associated with lower odds of mental healthcare encounters two years post-treatment initiation compared to two years prior (OR: 0.69; 95% CI: 0.65-0.74).

CONCLUSION

In this large population-based study of children who underwent PSG for sleep disorder assessment, OSA diagnosis/treatment was associated with an improvement in some mental health indicators, such as fewer new mental healthcare encounters compared to no OSA, and lower odds of mental healthcare encounters compared to pre-OSA treatment.

Associations of preoperative anaemia with healthcare resource use and outcomes after colorectal surgery: a population-based cohort study

BACKGROUND

Preoperative anaemia is common in patient undergoing colorectal surgery. Understanding the population-level costs of preoperative anaemia will inform development and evaluation of anaemia management at health system levels.

METHODS

This was a population-based cohort study using linked, routinely collected data, including residents from Ontario, Canada, aged ≥18 yr who underwent an elective colorectal resection between 2012 and 2022. Primary exposure was preoperative anaemia (haemoglobin <130 g L-1 in males; <120 g L-1 in females). Primary outcome was 30-day costs in 2022 Canadian dollars (CAD), from the perspective of a publicly funded healthcare system. Secondary outcomes included red blood cell transfusion, major adverse events (MAEs), length of stay (LOS), days alive at home (DAH), and readmissions.

RESULTS

We included 54,286 patients, with mean 65.3 (range 18-102) years of age and 49.0% females, among which 21 264 (39.2%) had preoperative anaemia. There was an absolute adjusted cost increase of $2671 per person at 30 days after surgery attributable to preoperative anaemia (ratio of means [RoM] 1.05, 95% confidence interval [CI] 1.04-1.06). Compared with the control group, 30-day risks of transfusion (odds ratio [OR] 4.34, 95% CI 4.04-4.66), MAEs (OR 1.14, 95% CI 1.03-1.27), LOS (RoM 1.08, 95% CI 1.07-1.10), and readmissions (OR 1.16, 95% CI 1.08-1.24) were higher in the anaemia group, with reduced DAH (RoM 0.95, 95% CI 0.95-0.96).

CONCLUSIONS

Approximately $2671 CAD per person in 30-day health system costs are attributable to preoperative anaemia after colorectal surgery in Ontario, Canada.

Early life exposure to pollens and increased risks of childhood asthma: a prospective cohort study in Ontario children

Asthma is a disease characterised by wheeze, cough and shortness of breath, and constitutes the most prevalent chronic disease among children [1]. Various phenotypes have been specifically identified in the paediatric population, and include early transient wheeze, current wheeze/asthma, and mild or moderate asthma [2]. Lifestyle behaviours, genetics, maternal and paternal factors, and environment exposures have been identified as risk factors in the multifactorial aetiology of childhood asthma [3].

Increased exposure to tree canopy around the place of residence at birth prevented the risk of childhood asthma development, but this protective effect can be reduced when exposure to weed and tree pollen increases https://bit.ly/3Tboabo

A quasi-experimental evaluation of the association between implementation of Quality-Based Procedures funding for hip fractures and improvements in processes and outcomes for hip fracture patients in Ontario: an interrupted time series analysis

PURPOSE

In 2013, Ontario introduced a patient-based funding model for hip fracture care (Quality-Based Procedures [QBP]). The association of QBP implementation with changes in processes and outcomes has not been evaluated.

METHODS

We conducted a quasi-experimental study using linked health data for adult hip fractures as an interrupted time series. The pre-QBP period was from 2008 to 2012 and the post-QBP period was from 2014 to 2018; 2013 was excluded as a wash-in period. We used segmented regression analyses to estimate the association of QBP implementation with changes in processes (surgery in less than two days from admission, use of echocardiography, use of nerve blocks, and provision of geriatric care) and clinical outcomes (90-day mortality, 90-day readmissions, length of stay, and days alive at home). We estimated the immediate (level) change, trend (slope) postimplementation, and total counterfactual differences. Sensitivity analyses included case-mix adjustment and stratification by hospital type and procedure.

RESULTS

We identified 45,500 patients in the pre-QBP period and 41,256 patients in the post-QBP period. There was a significant total counterfactual increase in the use of nerve blocks (11.1%; 95% confidence interval [CI], 6.2 to 16.0) and a decrease in the use of echocardiography (-2.5%; 95% CI, -3.7 to -1.3) after QBP implementation. The implementation of QBP was not associated with a clinically or statistically meaningful change in 90-day mortality, 90-day readmission, length of stay, or number of days alive at home.

CONCLUSION

Evaluation of the QBP program is crucial to inform ongoing and future changes to policy and funding for hip fracture care. The introduction of the QBP Hip Fracture program, supported by evidence-based recommendations, was associated with improved application of some evidence-based processes of care but no changes in clinical outcomes. There is a need for ongoing development and evaluation of funding models to identify optimal strategies to improve the value and outcomes of hip fracture care.

STUDY REGISTRATION

Open Science Framework ( https://osf.io/2938h/ ); first posted 13 June 2022.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BACKGROUND

Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.

METHODS

We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.

RESULTS

Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).

CONCLUSIONS

We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Changes in Cannabis-Attributable Hospitalizations Following Nonmedical Cannabis Legalization in Canada

Importance

The impact of adult-use cannabis legalization and subsequent commercialization (ie, increasing store and product access) on hospitalizations in Canada is unclear.

Objectives

To examine changes in overall and subtypes of hospitalizations due to cannabis and associated factors following legalization in Canada and to compare changes between provinces.

Design, Setting, and Participants

This repeated cross-sectional analysis included all acute hospitalizations for individuals aged 15 to 105 years in Canada's 4 most populous provinces (Ontario, Quebec, Alberta and British Columbia, population 26.9 million individuals in 2018). Data were obtained from routinely collected health administrative databases. Immediate and gradual changes in the age- and sex-standardized rates of hospitalizations due to cannabis were compared using an interrupted time series design over 3 time periods: prelegalization (January 2015 to September 2018), legalization with product and store restrictions (October 2018 to February 2020), and commercialization, which overlapped with the COVID-19 pandemic (March 2020 to March 2021).

Main Outcomes and Measures

Rates of hospitalizations due to cannabis per 100 000 individuals and per 1000 all-cause hospital admissions.

Results

There were 105 203 hospitalizations due to cannabis over the 7-year study period, 69 192 of which (65.8%) were among male individuals, and 34 678 (33%) of which were among individuals aged 15 to 24 years. Overall, the age- and sex-standardized rate of hospitalizations increased 1.62 times between January 2015 (3.99 per 100 000 individuals) and March 2021 (6.46 per 100 000 individuals). The largest relative increase in hospitalizations was for cannabis-induced psychosis (rate ratio, 1.40; 95% CI, 1.34 to 1.47 during the commercialization period relative to the prelegalization period). Nationally, legalization with restrictions was associated with a gradual monthly decrease of -0.06 (95% CI -0.08 to -0.03) in hospitalizations due to cannabis per 100 000 individuals. Commercialization and the COVID-19 pandemic were associated with an immediate increase of 0.83 (95% CI, 0.30 to 1.30) hospitalizations due to cannabis per 100 000 individuals. There was provincial variation in changes, with provinces with less mature legal markets experiencing the greatest declines immediately following legalization.

Conclusions and Relevance

This cross-sectional study found that legalization with restrictions was not associated with an increase in hospitalizations due to cannabis but commercialization was. The findings suggest that commercialization of cannabis may be associated with increases in cannabis-related health harms, including cannabis-induced psychosis.

Long-Term Outcomes of Cardiogenic Shock Complicating Myocardial Infarction

BACKGROUND

Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short-term mortality; however, there are limited data on long-term outcomes and trends.

OBJECTIVES

This study sought to examine long-term outcomes of AMI-CS patients.

METHODS

This was a population-based, retrospective cohort study in Ontario, Canada of critically ill adult patients with AMI-CS who were admitted to hospitals between April 1, 2009 and March 31, 2019. Outcome data were captured using linked health administrative databases.

RESULTS

A total of 9,789 consecutive patients with AMI-CS from 135 centers were included. The mean age was 70.5 ± 12.3 years, and 67.7% were male. The incidence of AMI-CS was 8.2 per 100,000 person-years, and it increased over the study period. Critical care interventions were common, with 5,422 (55.4%) undergoing invasive mechanical ventilation, 1,425 (14.6%) undergoing renal replacement therapy, and 1,484 (15.2%) receiving mechanical circulatory support. A total of 2,961 patients (30.2%) died in the hospital, and 4,004 (40.9%) died by 1 year. Mortality at 5 years was 58.9%. Small improvements in short- and long-term mortality were seen over the study period. Among survivors to discharge, 2,870 (42.0%) required increased support in care from their preadmission baseline, 3,244 (47.5%) were readmitted to the hospital within 1 year, and 1,047 (15.3%) died within 1 year. The mean number of days at home in the year following discharge was 307.9 ± 109.6.

CONCLUSIONS

Short- and long-term mortality among patients with AMI-CS is high, with minimal improvement over time. AMI-CS survivors experience significant morbidity, with high risks of readmission and death. Future studies should evaluate interventions to minimize postdischarge morbidity and mortality among AMI-CS survivors.

Screening for postpartum depression and risk of suicidality with obstetrical patients: a cross-sectional survey

BACKGROUND

Pregnancy is a vulnerable time where the physical and social stress of the COVID-19 pandemic affects psychological health, including postpartum depression (PPD). This study is designed to estimate the prevalence and correlates of PPD and risk of suicidality among individuals who gave birth during the COVID-19 pandemic.

METHODS

We surveyed individuals who gave birth at The Ottawa Hospital and were ≥ 20 days postpartum, between March 17 and June 16, 2020. A PPD screen consisted of a score ≥ 13 using the Edinburgh Postnatal Depression Scale. A score of 1, 2, or 3 on item 10 ("The thought of harming myself has occurred to me") indicates risk of suicidality. If a participant scores greater than ≥ 13 or ≥ 1 on item 10 they were flagged for PPD, the Principal Investigator (DEC) was notified within 24 h of survey completion for a chart review and to assure follow-up. Modified Poisson multivariable regression models were used to identify factors associated with PPD and risk of suicidality using adjusted risk ratios (aRR) and 95% confidence intervals (CI).

RESULTS

Of the 216 respondents, 64 (30%) screened positive for PPD and 17 (8%) screened positive for risk of suicidality. The maternal median age of the total sample was 33 years (IQR: 30-36) and the infant median age at the time of the survey was 76 days (IQR: 66-90). Most participants reported some form of positive coping strategies during the pandemic (97%) (e.g. connecting with friends and family, exercising, getting professional help) and 139 (64%) reported negative coping patterns (e.g. over/under eating, sleep problems). In total, 47 (22%) had pre-pregnancy anxiety and/or depression. Negative coping (aRR:2.90, 95% CI: 1.56-5.37) and pre-existing anxiety/depression (aRR:2.03, 95% CI:1.32-3.11) were associated with PPD. Pre-existing anxiety/depression (aRR:3.16, 95% CI:1.28-7.81) was associated with risk of suicidality.

CONCLUSIONS

Almost a third of participants in this study screened positive for PPD and 8% for risk of suicidality. Mental health screening and techniques to foster positive coping skills/strategies are important areas to optimize postpartum mental health.

Association of clinically significant obstructive sleep apnoea with risks of contracting COVID-19 and serious COVID-19 complications: a retrospective population-based study of health administrative data

RATIONALE/OBJECTIVES

Despite plausible pathophysiological mechanisms, more research is needed to confirm the relationship between obstructive sleep apnoea (OSA) and the risk of COVID-19 infection or COVID-19-related serious complications.

METHODS

We conducted a retrospective population-based cohort study using provincial health administrative data (Ontario, Canada). Adults with physician-diagnosed OSA who received positive airway pressure therapy in the 5 years prepandemic (OSA group) were propensity score matched by baseline characteristics to individuals in the general population at low risk of OSA (non-OSA group) using inverse probability of treatment weighting. Weighted HRs of (1) a positive COVID-19 test and (2) COVID-19-related emergency department (ED) visits, hospitalisations, intensive care unit (ICU) admissions and mortality, within 12 months of pandemic onset, were compared between groups. We also evaluated the impact of comorbid cardiometabolic or chronic airways disease.

RESULTS

We identified and matched 324 029 individuals in the OSA group to 4 588 200 individuals in the non-OSA group. Compared with the non-OSA group, those in the OSA group were at a greater hazard of testing positive for COVID-19 (HR=1.17, 95% CI 1.13 to 1.21), having a COVID-19-related ED visit (HR=1.62, 95% CI 1.51 to 1.73), hospitalisation (HR=1.50, 95% CI 1.37 to 1.65) or ICU admission (HR=1.53, 95% CI 1.27 to 1.84). COVID-19-related 30-day mortality was not different (HR=0.98, 95% CI 0.82 to 1.16).We found that for the OSA group, comorbid airways disease but not cardiometabolic conditions increased the hazards of COVID-19-related outcomes, including mortality.

CONCLUSION

In this large population-based study, we demonstrated that a recent diagnosis of OSA requiring treatment was associated with an increased hazard of testing positive for COVID-19 and serious COVID-19-related complications, particularly in those with co-existing chronic airways disease.

Days alive and at home after hip fracture: a cross-sectional validation of a patient-centred outcome measure using routinely collected data

BACKGROUND

Days alive and at home (DAH) is a patient centered outcome measureable in routinely collected health data. The validity and minimally important difference (MID) in hip fracture have not been evaluated.

OBJECTIVE

We assessed construct and predictive validity and estimated a MID for the patient-centred outcome of DAH after hip fracture admission.

METHODS

This is a cross-sectional observational study using linked health administrative data in Ontario, Canada. DAH was calculated as the number of days alive within 90 days of admission minus the number of days hospitalised or institutionalised. All hospital admissions (2012-2018) for hip fracture in adults aged >50 years were included. Construct validity analyses used Bayesian quantile regression to estimate the associations of postulated patient, admission and process-related variables with DAH. The predictive validity assessed was the correlation of DAH in 90 days with the value from 91 to 365 days; and the association and discrimination of DAH in 90 days predicting subsequent mortality. MID was estimated by averaging distribution-based and clinical anchor-based estimates.

RESULTS

We identified 63 778 patients with hip fracture. The median number of DAH was 43 (range 0-87). In the 90 days after admission, 8050 (12.6%) people died; a further 6366 (10.0%) died from days 91 to 365. Associations between patient-level and admission-level factors with the median DAH (lower with greater age, frailty and comorbidity, lower if admitted to intensive care or having had a complication) supported construct validity. DAH in 90 days after admission was strongly correlated with DAH in 365 days after admission (r=0.922). An 11-day MID was estimated.

CONCLUSION

DAH has face, construct and predictive validity as a patient-centred outcome in patients with hip fracture, with an estimated MID of 11 days. Future research is required to include direct patient perspectives in confirming MID.

Polysomnographic Assessment of Sleep Disturbances in Cancer Development: A Historical Multicenter Clinical Cohort Study

BACKGROUND

Many cellular processes are controlled by sleep. Therefore, alterations in sleep might be expected to stress biological systems that could influence malignancy risk.

RESEARCH QUESTION

What is the association between polysomnographic measures of sleep disturbances and incident cancer, and what is the validity of cluster analysis in identifying polysomnography phenotypes?

STUDY DESIGN AND METHODS

We conducted a retrospective multicenter cohort study using linked clinical and provincial health administrative data on consecutive adults free of cancer at baseline with polysomnography data collected between 1994 and 2017 in four academic hospitals in Ontario, Canada. Cancer status was derived from registry records. Polysomnography phenotypes were identified by k-means cluster analysis. A combination of validation statistics and distinguishing polysomnographic features was used to select clusters. Cox cause-specific regressions were used to assess the relationship between identified clusters and incident cancer.

RESULTS

Among 29,907 individuals, 2,514 (8.4%) received a diagnosis of cancer over a median of 8.0 years (interquartile range, 4.2-13.5 years). Five clusters were identified: mild (mildly abnormal polysomnography findings), poor sleep, severe OSA or sleep fragmentation, severe desaturations, and periodic limb movements of sleep (PLMS). The associations between cancer and all clusters compared with the mild cluster were significant while controlling for clinic and year of polysomnography. When additionally controlling for age and sex, the effect remained significant only for PLMS (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.06-1.50) and severe desaturations (aHR, 1.32; 95% CI, 1.04-1.66). Further controlling for confounders, the effect remained significant for PLMS, but was attenuated for severe desaturations.

INTERPRETATION

In a large cohort, we confirmed the importance of polysomnographic phenotypes and highlighted the role that PLMS and oxygenation desaturation may play in cancer. Using this study's findings, we also developed an Excel (Microsoft) spreadsheet (polysomnography cluster classifier) that can be used to validate the identified clusters on new data or to identify which cluster a patient belongs to.

TRIAL REGISTRY

ClinicalTrials.gov; Nos.: NCT03383354 and NCT03834792; URL: www.

CLINICALTRIALS

gov.

Attributable perioperative cost of frailty after major, elective non-cardiac surgery: a population-based cohort study

BACKGROUND

Patients with frailty consistently experience higher rates of perioperative morbidity and mortality; however, costs attributable to frailty remain poorly defined. We sought to identify older patients with and without frailty using a validated, multidimensional frailty index and estimated the attributable costs in the year following major, elective non-cardiac surgery.

METHODS

We conducted a retrospective population-based cohort study of all patients >66 years having major, elective non-cardiac surgery between April 1, 2012 and March 31, 2018 using linked health data obtained from an independent research institute (ICES) in Ontario, Canada. All data were collected using standard methods from the date of surgery to the end of 1-year follow up. The presence or absence of preoperative frailty was determined using a multi-dimensional frailty index. Our primary outcome was total health system costs in the year following surgery using a validated patient-level costing method capturing direct and indirect costs. Secondary outcomes included costs to postoperative days 30 and 90 along with sensitivity analyses and evaluation of effect modifiers.

RESULTS

Of 171,576 patients, 23,219 (13.5%) were identified with preoperative frailty. Unadjusted costs were higher among patients with frailty (ratio of means (RoM) 1.79, 95% confidence interval (CI) 1.76 to 1.83). After adjusting for confounders, an absolute cost increase of $11,828 CAD (RoM 1.53; 95% CI 1.51 to 1.56) was attributable to frailty. This association was attenuated with additional control for comorbidities (RoM 1.24, 95% CI 1.22 to 1.26). Among contributors to total costs, frailty was most strongly associated with increased post-acute care costs.

CONCLUSIONS

For patients with preoperative frailty having elective surgery, we estimate that attributable costs are increased 1.5-fold in the year after major, elective non-cardiac surgery. These data inform resource allocation for patients with frailty.

Exploring disease perception in Behçet's syndrome: combining a quantitative and a qualitative study based on a narrative medicine approach

BACKGROUND

Behçet Syndrome (BS) has a significant psychological and social impact on patients, caregivers and families. The present study aims at exploring disease perception in BS patients, using both a co-designed survey and the narrative medicine (NM) approach.

METHODS

An ad-hoc questionnaire was co-designed by clinicians expert in BS, BS patients and caregivers and BS adult patients were invited to answer the online questionnaires. Cluster analysis was used to analyse data from the survey and to identify groups of patients with diverse disease perception. To further explore real-life perspectives, the stories of illness of a smaller group of adult BS patients were anonymously collected online and analysed by means of text, sentiment and qualitative analysis.

RESULTS

Two hundred and seven patients answered the survey and forty-three stories were collected. The cluster analysis highlighted that accepting or not the disease has a strong impact on the daily life, on how BS patients perceive themselves and in terms of hope for the future. The stories revealed that patients often address common issues, such as the long and complex journey faced from the disease onset until the BS diagnosis, which was strongly connected to the concept of time and perceived as an exhausting period of their lives.

CONCLUSION

To our knowledge, this is the first study that addressed disease perception also applying the NM principles in BS. The current perception that BS patients have of their disease should encourage the BS scientific and patient community in joining forces in order to improve the journey of BS patients.

Critical windows of exposure to air pollution and gestational diabetes: assessing effect modification by maternal pre-existing conditions and environmental factors

BACKGROUND

Ambient air pollution has been associated with gestational diabetes (GD), but critical windows of exposure and whether maternal pre-existing conditions and other environmental factors modify the associations remains inconclusive.

METHODS

We conducted a retrospective cohort study of all singleton live birth that occurred between April 1^st 2006 and March 31^st 2018 in Ontario, Canada. Ambient air pollution data (i.e., fine particulate matter with a diameter ≤ 2.5 μm (PM_2.5), nitrogen dioxide (NO₂) and ozone (O₃)) were assigned to the study population in spatial resolution of approximately 1 km × 1 km. The Normalized Difference Vegetation Index (NDVI) and the Green View Index (GVI) were also used to characterize residential exposure to green space as well as the Active Living Environments (ALE) index to represent the active living friendliness. Multivariable Cox proportional hazards regression models were used to evaluate the associations.

RESULTS

Among 1,310,807 pregnant individuals, 68,860 incident cases of GD were identified. We found the strongest associations between PM_2.5 and GD in gestational weeks 7 to 18 (HR = 1.07 per IQR (2.7 µg/m³); 95% CI: 1.02 - 1.11)). For O₃, we found two sensitive windows of exposure, with increased risk in the preconception period (HR = 1.03 per IQR increase (7.0 ppb) (95% CI: 1.01 - 1.06)) as well as gestational weeks 9 to 28 (HR 1.08 per IQR (95% CI: 1.04 -1.12)). We found that women with asthma were more at risk of GD when exposed to increasing levels of O₃ (p- value for effect modification = 0.04). Exposure to air pollutants explained 20.1%, 1.4% and 4.6% of the associations between GVI, NDVI and ALE, respectively.

CONCLUSION

An increase of PM_2.5 exposure in early pregnancy and of O₃ exposure during late first trimester and over the second trimester of pregnancy were associated with gestational diabetes whereas exposure to green space may confer a protective effect.

Pediatric Hospitalizations for Unintentional Cannabis Poisonings and All-Cause Poisonings Associated With Edible Cannabis Product Legalization and Sales in Canada

Importance

Canada legalized cannabis in October 2018 but initially prohibited the sale of edibles (eg, prepackaged candies). Starting in January 2020, some provinces permitted the sale of commercial cannabis edibles. The association of legalizing cannabis edibles with unintentional pediatric poisonings is uncertain.

Objective

To evaluate changes in proportions of all-cause hospitalizations for poisoning due to cannabis in children during 3 legalization policy periods in Canada's 4 most populous provinces (including 3.4 million children aged 0-9 years).

Design, Setting, and Participants

This repeated cross-sectional study included all hospitalizations in children aged 0 to 9 years in Ontario, Alberta, British Columbia, and Quebec between January 1, 2015, and September 30, 2021.

Exposures

Prelegalization (January 2015 to September 2018); period 1, in which dried flower only was legalized in all provinces (October 2018 to December 2019); and period 2, in which edibles were legalized in 3 provinces (exposed provinces) and restricted in 1 province (control province) (January 2020 to September 2021).

Main Outcomes and Measures

The primary outcome was the proportion of hospitalizations due to cannabis poisoning out of all-cause poisoning hospitalizations. Data analysis was performed using descriptive statistics and Poisson regression models.

Results

During the 7-year study period, there were 581 pediatric hospitalizations for cannabis poisoning (313 [53.9%] boys; 268 [46.1%] girls; mean [SD] age, 3.6 [2.5] years) and 4406 hospitalizations for all-cause poisonings. Of all-cause poisoning hospitalizations, the rate per 1000 due to cannabis poisoning before legalization was 57.42 in the exposed provinces and 38.50 in the control province. During period 1, the rate per 1000 poisoning hospitalizations increased to 149.71 in the exposed provinces (incidence rate ratio [IRR], 2.55; 95% CI, 1.88-3.46) and to 117.52 in the control province (IRR, 3.05; 95% CI, 1.82-5.11). During period 2, the rate per 1000 poisoning hospitalizations due to cannabis more than doubled to 318.04 in the exposed provinces (IRR, 2.16; 95% CI, 1.68-2.80) but remained similar at 137.93 in the control province (IRR, 1.18; 95% CI, 0.71-1.97).

Conclusions and Relevance

This cross-sectional study found that following cannabis legalization, provinces that permitted edible cannabis sales experienced much larger increases in hospitalizations for unintentional pediatric poisonings than the province that prohibited cannabis edibles. In provinces with legal edibles, approximately one-third of pediatric hospitalizations for poisonings were due to cannabis. These findings suggest that restricting the sale of legal commercial edibles may be key to preventing pediatric poisonings after recreational cannabis legalization.

Sleep quality in Behçet's disease: a systematic literature review

Behçet's Disease (BD) can be correlated with sleep impairment and fatigue, resulting in low quality of life (QoL); however, a comprehensive evaluation of this issue is still missing. We performed a systematic literature review (SLR) of existing evidence in literature regarding sleep quality in BD. Fifteen papers were included in the SLR. Two domains were mainly considered: global sleep characteristics (i) and the identification of specific sleep disorders (ii) in BD patients. From our analysis, it was found that patients affected by BD scored significantly higher Pittsburgh Sleep Quality Index (PSQI) compared to controls. Four papers out of 15 (27%) studied the relationship between sleep disturbance in BD and disease activity and with regards to disease activity measures, BD-Current Activity Form was adopted in all papers, followed by Behçet's Disease Severity (BDS) score, genital ulcer severity score and oral ulcer severity score. Poor sleep quality showed a positive correlation with active disease in 3 out of 4 studies. Six papers reported significant differences between BD patients with and without sleep disturbances regarding specific disease manifestations. Notably, arthritis and genital ulcers were found to be more severe when the PSQI score increased. Our work demonstrated lower quality of sleep in BD patients when compared to the general population, both as altered sleep parameters and higher incidence of specific sleep disorders. A global clinical patient evaluation should thereby include sleep assessment through the creation and adoption of disease-specific and accessible tests.

Initial treatment is associated with improved survival and end-of-life outcomes for patients with pancreatic cancer: a cohort study

Background

We describe the association between initial treatment and end-of-life (EOL) outcomes among patients with pancreatic ductal adenocarcinoma (PDAC).

Methods

This population-based cohort study included patients with PDAC who died from April 2010–December 2017 in Ontario, Canada using administrative databases. We used multivariable models to explore the association between index cancer treatment (no cancer-directed therapy, radiation, chemotherapy, surgery alone, and surgery and chemotherapy), and primary (mortality, healthcare encounters and palliative care) and secondary outcomes (location of death, hospitalizations, and receipt of chemotherapy within the last 30 days of life).

Results

In our cohort (N = 9950), 56% received no cancer-directed therapy, 5% underwent radiation, 27% underwent chemotherapy, 7% underwent surgery alone, and 6% underwent surgery and chemotherapy. Compared to no cancer-directed therapy, radiation therapy (HR = 0.63), chemotherapy (HR = 0.43) surgery alone (HR = 0.32), and surgery and chemotherapy (HR = 0.23) were all associated with decreased mortality. Radiation (AMD = − 3.64), chemotherapy (AMD = -6.35), surgery alone (AMD = -6.91), and surgery and chemotherapy (AMD = -6.74) were all associated with fewer healthcare encounters per 30 days in the last 6 months of life. Chemotherapy (AMD = -1.57), surgery alone (AMD = -1.65), and surgery and chemotherapy (AMD = -1.67) were associated with fewer palliative care visits (all p-values for estimates above < 0.05). Treatment groups were associated with lower odds of institutional death and hospitalization at EOL, and higher odds of chemotherapy at EOL.

Conclusions

Receiving cancer-directed therapies was associated with higher survival, fewer healthcare visits, lower odds of dying in an institution and hospitalization at EOL, fewer palliative care visits, and higher odds of receiving chemotherapy at EOL.

Population-Level Trends in Emergency Department Encounters for Sexual Assault Preceding and During the COVID-19 Pandemic Across Ontario, Canada

IMPORTANCE

Lockdown measures and the stress of the COVID-19 pandemic are factors associated with increased risk of violence, yet there is limited information on trends in emergency department (ED) encounters for sexual assault.

OBJECTIVE

To compare changes in ED encounters for sexual assault during the COVID-19 pandemic vs prepandemic estimates.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study used linked health administrative data from 197 EDs across Ontario, Canada, representing more than 15 million residents. Participants included all patients who presented to an ED in Ontario from January 11, 2019, to September 10, 2021. Male and female individuals of all ages were included. Data analysis was performed from March to October 2022.

EXPOSURES

Sexual assault, defined through 27 International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, procedure and diagnoses codes.

MAIN OUTCOMES AND MEASURES

Ten bimonthly time periods were used to compare differences in the frequency and rates of ED encounters for sexual assault between 2020 to 2021 (during the pandemic) compared with baseline prepandemic rates in 2019. Rate differences (RDs) and age adjusted rate ratios (aRRs) and Wald 95% CIs were calculated using Poisson regression.

RESULTS

From January 11, 2019, to September 10, 2021, there were 14 476 656 ED encounters, including 10 523 for sexual assault (9304 [88.4%] among female individuals). The median (IQR) age was 23 (17-33) years for female individuals and 15 (4-29) years for male individuals. Two months before the pandemic, ED encounters increased for sexual assault among female individuals (8.4 vs 6.9 cases per 100 000; RD, 1.51 [95% CI, 1.06 to 1.96]; aRR, 1.22 [95% CI, 1.09 to 1.38]) and male individuals (1.2 vs 1.0 cases per 100 000; RD, 0.19 [95% CI, 0.05 to 0.36]; aRR, 1.19 [95% CI, 0.87 to 1.64]). During the first 2 months of the pandemic, the rates decreased for female individuals (4.2 vs 8.3 cases per 100 000; RD, -4.07 [95% CI, -4.48 to -3.67]; aRR, 0.51 [95% CI, 0.44 to 0.58]) and male individuals (0.5 vs 1.2 cases per 100 000; RD, -0.72 [95% CI, -0.86 to -0.57]; aRR, 0.39 [95% CI, 0.26 to 0.58]). For the remainder of the study period, the rates of sexual assault oscillated, returning to prepandemic levels during the summer months and between COVID-19 waves.

CONCLUSIONS AND RELEVANCE

These findings suggest that lockdown protocols should evaluate the impact of limited care for sexual assault. Survivors should still present to EDs, especially when clinical care or legal interventions are needed.

Hospital-, Anesthesiologist-, Surgeon-, and Patient-Level Variations in Neuraxial Anesthesia Use for Lower Limb Revascularization Surgery: A Population-Based Cross-Sectional Study

BACKGROUND

Although neuraxial anesthesia may promote improved outcomes for patients undergoing lower limb revascularization surgery, its use is decreasing over time. Our objective was to estimate variation in neuraxial (versus general) anesthesia use for lower limb revascularization at the hospital, anesthesiologist, surgeon, and patient levels, which could inform strategies to increase uptake.

METHODS

Following protocol registration, we conducted a historical cross-sectional analysis of population-based linked health administrative data in Ontario, Canada. All adults undergoing lower limb revascularization surgery between 2009 and 2018 were identified. Generalized linear models with binomial response distributions, logit links and random intercepts for hospitals, anesthesiologists, and surgeons were used to estimate the variation in neuraxial anesthesia use at the hospital, anesthesiologist, surgeon, and patient levels using variance partition coefficients and median odds ratios. Patient- and hospital-level predictors of neuraxial anesthesia use were identified.

RESULTS

We identified 11,849 patients; 3489 (29.4%) received neuraxial anesthesia. The largest proportion of variation was attributable to the hospital level (50.3%), followed by the patient level (35.7%); anesthesiologists and surgeons had small attributable variation (11.3% and 2.8%, respectively). Mean odds ratio estimates suggested that 2 similar patients would experience a 5.7-fold difference in their odds of receiving a neuraxial anesthetic were they randomly sent to 2 different hospitals. Results were consistent in sensitivity analyses, including limiting analysis to patients with diagnosed peripheral artery disease and separately to those aged >66 years with complete prescription anticoagulant and antiplatelet usage data.

CONCLUSIONS

Neuraxial anesthesia use primarily varies at the hospital level. Efforts to promote use of neuraxial anesthesia for lower limb revascularization should likely focus on the hospital context.

Association of Extracorporeal Membrane Oxygenation With New Mental Health Diagnoses in Adult Survivors of Critical Illness

IMPORTANCE

Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in critically ill patients, but little is known regarding long-term psychiatric sequelae among survivors after ECMO.

OBJECTIVE

To investigate the association between ECMO survivorship and postdischarge mental health diagnoses among adult survivors of critical illness.

DESIGN, SETTING, AND PARTICIPANTS

Population-based retrospective cohort study in Ontario, Canada, from April 1, 2010, through March 31, 2020. Adult patients (N=4462; age ≥18 years) admitted to the intensive care unit (ICU), and surviving to hospital discharge were included.

EXPOSURES

Receipt of ECMO.

MAIN OUTCOMES AND MEASURES

The primary outcome was a new mental health diagnosis (a composite of mood disorders, anxiety disorders, posttraumatic stress disorder; schizophrenia, other psychotic disorders; other mental health disorders; and social problems) following discharge. There were 8 secondary outcomes including incidence of substance misuse, deliberate self-harm, death by suicide, and individual components of the composite primary outcome. Patients were compared with ICU survivors not receiving ECMO using overlap propensity score-weighted cause-specific proportional hazard models.

RESULTS

Among 642 survivors who received ECMO (mean age, 50.7 years; 40.7% female), median length of follow-up was 730 days; among 3820 matched ICU survivors who did not receive ECMO (mean age, 51.0 years; 40.0% female), median length of follow-up was 1390 days. Incidence of new mental health conditions among survivors who received ECMO was 22.1 per 100-person years (95% confidence interval [CI] 19.5-25.1), and 14.5 per 100-person years (95% CI, 13.8-15.2) among non-ECMO ICU survivors (absolute rate difference of 7.6 per 100-person years [95% CI, 4.7-10.5]). Following propensity weighting, ECMO survivorship was significantly associated with an increased risk of new mental health diagnosis (hazard ratio [HR] 1.24 [95% CI, 1.01-1.52]). There were no significant differences between survivors who received ECMO vs ICU survivors who did not receive ECMO in substance misuse (1.6 [95% CI, 1.1 to 2.4] per 100 person-years vs 1.4 [95% CI, 1.2 to 1.6] per 100 person-years; absolute rate difference, 0.2 per 100 person-years [95% CI, -0.4 to 0.8]; HR, 0.86 [95% CI, 0.48 to 1.53]) or deliberate self-harm (0.4 [95% CI, 0.2 to 0.9] per 100 person-years vs 0.3 [95% CI, 0.2 to 0.3] per 100 person-years; absolute rate difference, 0.1 per 100 person-years [95% CI, -0.2 to 0.4]; HR, 0.68 [95% CI, 0.21 to 2.23]). There were fewer than 5 total cases of death by suicide in the entire cohort.

CONCLUSIONS AND RELEVANCE

Among adult survivors of critical illness, receipt of ECMO, compared with ICU hospitalization without ECMO, was significantly associated with a modestly increased risk of new mental health diagnosis or social problem diagnosis after discharge. Further research is necessary to elucidate the potential mechanisms underlying this relationship.

Suicide and Self-Harm Among Physicians in Ontario, Canada

BACKGROUND

Studies of occupation-associated suicide suggest physicians may be at a higher risk of suicide compared to nonphysicians. We set out to assess the risk of suicide and self-harm among physicians and compare it to nonphysicians.

METHODS

We conducted a population-based, retrospective cohort study using registration data from the College of Physicians and Surgeons of Ontario from 1990 to 2016 with a follow-up to 2017, linked to Ontario health administrative databases. Using age- and sex-standardized rates and inverse probability-weighted, cause-specific hazards regression models, we compared rates of suicide, self-harm, and a composite of either event among all newly registered physicians to nonphysician controls.

RESULTS

Among 35,989 physicians and 6,585,197 nonphysicians, unadjusted suicide events (0.07% vs. 0.11%) and rates (9.44 vs. 11.55 per 100,000 person-years) were similar. Weighted analyses found a hazard ratio of 1.05 (95% confidence interval: 0.69 to 1.60). Self-harm requiring health care was lower among physicians (0.22% vs. 0.46%; hazard ratio: 0.65, 95% confidence interval: 0.52 to 0.82), as was the composite of suicide or self-harm (hazard ratio: 0.70, 95% confidence interval: 0.57 to 0.86). The composite of suicide or self-harm was associated with a history of a mood or anxiety disorder (odds ratio: 2.84, 95% confidence interval: 1.17 to 6.87), an outpatient mental health visit in the past year (odds ratio: 3.08, 95% confidence interval: 1.34 to 7.10) and psychiatry visit in the preceding year (odds ratio: 3.87, 95% confidence interval: 1.67 to 8.95).

INTERPRETATION

Physicians in Ontario are at a similar risk of suicide deaths and a lower risk of self-harm requiring health care relative to nonphysicians. Risk factors associated with suicide or self-harm may help inform prevention programs.

Anticoagulant use and associated outcomes in older patients receiving home palliative care: a retrospective cohort study

Background:

The benefits and harms of anticoagulants for people near the end of life are not well understood, nor is it known what proportion of patients discontinue these medications. We aimed to characterize anticoagulant use in older recipients of home palliative care and describe patient and provider characteristics, as well as outcomes associated with anticoagulant discontinuation in this group.

Methods:

Using linked administrative health databases, we conducted a population-based cohort study of patients aged 66 years and older who initiated home palliative care in Ontario from 2010 to 2018. We calculated the prevalence of anticoagulant use. We used multilevel logistic regression models to assess patient (e.g., sociodemographic, comorbidities) and physician (e.g., demographic, training, practice) factors associated with anticoagulant discontinuation after initiation of home palliative care. We defined discontinuation as either primary (no anticoagulant claim within 1.5 times the days’ supply of the previous prescription) or secondary (no subsequent anticoagulant claim at any time after the index date). In secondary analyses, we used cause-specific hazards regression to explore subsequent thrombotic and bleeding events associated with anticoagulant discontinuation, and multivariable logistic regression for location of death.

Results:

We identified 98 089 recipients of home palliative care, of whom 15.5% were taking anticoagulants at the time of the first palliative care visit. Depending on the definition of discontinuation, 18.0% to 24.4% of patients discontinued anticoagulants after the first home palliative care visit. Compared with warfarin, use of a direct oral anticoagulant (adjusted odds ratio [OR] 0.49, 95% confidence interval [CI] 0.43–0.56) and low-molecular-weight heparin (adjusted OR 0.56, 95% CI 0.47–0.66) were associated with a lower likelihood of discontinuation. Few patient or physician characteristics — and no comorbidities or indications for therapeutic anticoagulation — were associated with discontinuation. Anticoagulant discontinuation after beginning home palliative care was associated with similar rates of thrombosis (adjusted hazard ratio [HR] 1.06, 95% CI 0.81–1.39), lower rates of bleeding (adjusted HR 0.75, 95% CI 0.62–0.90) and a higher likelihood of a home death (adjusted OR 1.22, 95% CI 1.09–1.36) compared with continuing anticoagulation.

Interpretation:

Among recipients of home palliative care in Ontario, anticoagulant use is common, and discontinuation is not influenced by comorbidities or indication for anticoagulation. Physician preference may play an important role; patients should be made aware of their options toward the end of life and supported in shared decision-making.

Comparing the predictive accuracy of frailty instruments applied to preoperative electronic health data for adults undergoing noncardiac surgery

BACKGROUND

Preoperative frailty is associated with increased risk of postoperative mortality and complications. Routine preoperative frailty assessment is underperformed. Automation of preoperative frailty assessment using electronic health data could improve adherence to guideline-based care if an accurate instrument is identified.

METHODS

We conducted a retrospective cohort study of adults >65 yr undergoing elective noncardiac surgery between 2012 and 2018. Four frailty instruments were compared: Frailty Index, Hospital Frailty Risk Score, Risk Analysis Index-Administrative, and Adjusted Clinical Groups frailty-defining diagnoses indicator. We compared the predictive performance of each instrument added to a baseline model (age, sex, ASA physical status, and procedural risk) using discrimination, calibration, explained variance, net reclassification, and Brier score (binary outcomes); and explained variance, root mean squared error, and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes included 365-day mortality, length of stay, non-home discharge, days alive at home, and 365-day costs.

RESULTS

For this study, 171 576 patients met the inclusion criteria; 1370 (0.8%) died within 30 days. Compared with the baseline model predicting 30-day mortality (area under the curve [AUC] 0.85; R² 0.08), the addition of Hospital Frailty Risk Score led to the greatest improvement in discrimination (AUC 0.87), explained variance (R² 0.09), and net reclassification (Net Reclassification Index 0.65). Brier and calibration scores were comparable.

CONCLUSIONS

All four frailty instruments significantly improved discrimination and risk reclassification when added to typically assessed preoperative risk factors. Accurate identification of the presence or absence of preoperative frailty using electronic frailty instruments may improve perioperative risk stratification. Future research should evaluate the impact of automated frailty assessment in guiding surgical planning and patient-centred optimisation amongst older surgical patients.

Primary Care Physician Use and Frequency of Visits Among Physicians in Ontario, Canada

IMPORTANCE

Maintaining a healthy physician workforce includes the routine use of primary care physician (PCP) services; however, physicians may face barriers to attaining formal care.

OBJECTIVE

To analyze access to and frequency of visits to PCPs among physicians compared with nonphysicians.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study used registration data from the College of Physicians and Surgeons of Ontario, Canada, from January 1, 1990, to March 31, 2018. Data for all newly practicing physicians as of March 31, 2018, were linked to Ontario health administrative databases. Data were analyzed from August 25, 2020, to August 6, 2021.

MAIN OUTCOMES AND MEASURES

The main outcomes were enrollment in a PCP practice and visits with a PCP. Generalized estimating equations compared primary care visits between physicians and nonphysicians, matched 1:5 based on age, sex, neighborhood income quintile, and health region.

RESULTS

Among 19 581 physicians (mean [SD] age, 43.99 [8.94] years; 53.27% male) matched to 97 905 nonphysicians, physicians were less likely to be enrolled with a PCP than were nonphysicians (81.8% vs 86.4%; absolute difference, 4.6%; adjusted odds ratio [OR], 0.75; 95% CI, 0.72-0.79) and had fewer primary care visits during the preceding 2 years (median [IQR], 2 [0-4] vs 4 [1-7]; adjusted relative rate ratio [RRR], 0.59; 95% CI, 0.58-0.60). Physicians aged 40 years or older and male physicians were less likely to be rostered (ages 40-44 years: OR, 0.70 [95% CI, 0.64-0.77]; male: OR, 0.60 [95% CI, 0.57-0.63]) and more likely to have a lower frequency of PCP visits (ages 40-44 years: RRR, 0.53 [95% CI, 0.51-0.56]; male: RRR, 0.50 [95% CI, 0.50-0.51]) compared with nonphysicians.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, enrollment with a PCP practice and frequency of visits were lower among physicians compared with a matched general population of nonphysicians. Individual, system, and medical cultural factors associated with these results need to be better understood so that physicians can take better care of themselves and their patients.

Giving Birth in the Early Phases of the COVID-19 Pandemic: The Patient Experience

Objective

Obstetrical patients are at risk of complications from COVID-19 and face increased stress due to the pandemic and changes in hospital birth setting. The objective was to describe the perinatal care experiences of obstetrical patients who gave birth during the early phases of the COVID-19 pandemic.

Methods

A descriptive epidemiological survey was administered to consenting patients who gave birth at The Ottawa Hospital (TOH) between March 16th and June 16th, 2020. The participants reported on prenatal, in-hospital, and postpartum care experiences. COVID-19 pandemic related household stress factors were investigated. Frequencies and percentages are presented for categorical variables and median and interquartile range (IQR) for continuous variables.

Results

A total of 216 participants were included in the analyses. Median participants age was 33 years (IQR: 30–36). Collectively, 94 (43.5%) participants felt elevated stress for prenatal appointments and 105 (48.6%) for postpartum appointments because of COVID-19. There were 108 (50.0%) were scared to go to the hospital for delivery, 97 (44.9%) wore a mask during labour and 54 (25.0%) gave birth without a support person. During postpartum care, 125 (57.9%) had phone appointments (not offered prior to COVID-19), and 18 (8.3%) received no postpartum care at all.

Conclusion

COVID-19 pandemic and public health protocols created a stressful healthcare environment for the obstetrical population where many were fearful of accessing services, experienced changes to standard care, or no care at all. As the pandemic continues, careful attention should be given to the perinatal population to reduce stress and improve continuity of care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03495-2.

AB1152 COVID-19 mRNA VACCINE BOOSTER IN PATIENTS WITH SYSTEMIC AUTOIMMUNE DISEASES

Background

Patients with systemic autoimmune diseases (SADs) are often treated with drugs that interfere with the immune system and previous data showed a reduced seroconversion rate after anti-SARS-CoV2 vaccine in these subjects compared to healthy controls1. Administration of a booster dose of the vaccine could be particularly important in these patients, but data available to date are still scarce.

Objectives

To evaluate the antibody response to the booster dose of mRNA SARS-CoV2 vaccine in patients with SADs and to compare it to the response after completion of the first vaccination course. Secondly, to find possible correlations between a low antibody titre and patients’ clinical features, with special regard to ongoing immunosuppressive therapies.

Methods

Consecutive patients with an established diagnosis of SADs undergoing SARS-CoV2 vaccine were prospectively enrolled from January 2021; among them, we selected the patients who received the third vaccination dose between September and December 2021. Demographic and clinical data were collected at enrolment (sex, age, diagnosis, disease duration, ongoing therapies, previous SARS-CoV2 infection, presence of hypogammaglobulinemia); the last three elements were reassessed at each follow-up visit. Blood samples were collected 4 weeks both after the second (W4a) and the third (W4b) dose of the vaccine; a minority of patients was also tested 12 weeks after the second dose (W12). IgG antibodies to SARS-CoV2 receptor-binding domain (RBD) and neutralizing antibodies inhibiting the interaction between RBD and angiotensin converting enzyme 2 were evaluated. IgG anti-RBD were detected by solid phase assay on plates coated with recombinant RBD, while neutralising antibodies by using the kit SPIA (Spike Protein Inhibition Assay). Cut-off values were defined as the 97.5th percentile of a pre-vaccine healthy population. Statistical analysis was performed using IBM SPSS Statistics 20 and GraphPad Prism statistical packages. P values <0.05 were considered significant.

Results

Forty-five patients (95.6% female; mean age ±SD 55.6±14.1 years; mean disease duration 12.9±10.6 years) were enrolled. Diagnosis was in most cases connective tissue disease (31/45, 68.9%), followed by inflammatory arthritis (11/45, 24.4%) and systemic vasculitis (3/45, 6.7%). Two patients (4.4%) had a previous SARS-CoV2 infection and three had hypogammaglobulinemia (6.7%). At the time of the second dose, 18/45 patients were treated with glucocorticoids (GCs) [mean daily 6-methylprednisolone (6MP) dose 3.9 mg (min. 2, max. 14)], 17/45 with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and 12/45 with biologic DMARDs (bDMARDs). At the third dose administration, 19/45 patients were treated with GCs [mean daily 6MP dose 4.1 mg (min. 1.5, max. 10)], 18/45 with csDMARDs and 13/45 with bDMARDs. Anti-RBD IgG were positive in 42/45 patients (93.3%) at W4a, in 16/18 (88.9%) at W12 and in 42/45 (93.3%) at W4b. Neutralizing antibodies were present in 38/45 patients (84.4%) at W4a, in 14/18 (77.8%) at W12 and in 42/45 (93.3%) at W4b. Both anti-RBD IgG titers and neutralizing antibody titers significantly increased after the third dose if compared to W4a (p<0.0001 both) (Figure 1). Interestingly, of the 7 patients who had not developed an adequate neutralizing antibody response after the first vaccination course, 5 mounted an adequate titer after the booster. Two non-responder patients were both on combination therapy (one with low dose of GCs plus mycophenolate mofetil, the other with methotrexate and infliximab).

Conclusion

Our data suggest that in patients with SADs there is a decline in the antibody titers developed after COVID-19 vaccination, however the booster dose is effective in restoring an adequate antibody titre. These data consolidate the importance of a booster dose of COVID-19 vaccination in patients with SADs to aid in the generation of an immune response.

References

[1]Jena A et al. Response to SARS-CoV-2 vaccination in immune mediated inflammatory diseases: systematic review and meta-analysis. Autoimmun Rev. 2022

Acknowledgements

The authors would like to thank all the patients who participated in the study and the nurses Sabrina Gori, Rosanna Lo Coco, Lucia Pedrocco, Carla Puccini, Pasqualina Semeraro, Manuela Terachi, Maria Tristano, Valentina Venturini and Catiuscia Zoina who took care of the patients.

Disclosure of Interests

None declared

POS1232 LONG-TERM OUTCOMES OF COVID-19 VACCINATION IN PATIENTS WITH RARE AND COMPLEX CONNECTIVE TISSUE DISEASES: AN AD-INTERIM ANALYSIS OF ERN-ReCONNET VACCINATE STUDY

Background

Since the COVID-19 vaccination campaign was launched all over Europe, there has been general agreement on how benefits of SARS-CoV2 vaccines outweigh the risks in patients with rare connective tissue diseases (rCTDs). Yet, there is still limited evidence regarding safety and efficacy of such vaccines in these patients, especially in the long-term. For this reason, in the framework of ERN-ReCONNET, an observational long-term study (VACCINATE) was designed in order to explore the long-term outcome of COVID-19 vaccination in rCTDs patients. The consent form was developed thanks to the involvement of the ERN ReCONNET ePAG Advocates (European Patients Advocacy Group).

Objectives

To evaluate the safety profile of COVID-19 vaccination in rCTDs patients and the potential impact on disease activity. Primary endpoints were the prevalence of adverse events (AEs) and of disease exacerbations post-vaccination. Secondary endpoints were the proportion of serious adverse events (SAEs) and adverse events of special interest for COVID-19 (adapted from https://brightoncollaboration.us/wp-content/uploads/2021/01/SO2_D2.1.2_V1.2_COVID-19_AESI-update-23Dec2020-review_final.pdf)

Methods

The first ad-interim analysis of the VACCINATE study involved 9 ERN-ReCONNET Network centres. Patients over 18 years of age with a known rCTD and who received vaccine against COVID-19 were eligible for recruitment. Demographic data and diagnoses were collected at the time of enrolment, while the appearance of AEs and potential disease exacerbations were monitored after one week from each vaccination dose, and then after 4, 12 and 24 weeks from the second dose. A disease exacerbation was defined as at least one of the following: new manifestations attributable to disease activity, hospitalization, increase in PGA from previous evaluation, addition of corticosteroids or immunosuppressants.

Results

A cohort of 300 patients (261 females, mean age 52, range 18-85) was recruited. Systemic lupus erythematosus (44%) and systemic sclerosis (16%) were the most frequent diagnoses, followed by Sjogren’s syndrome (SS,12%), idiopathic inflammatory myositis (IMM,10%), undifferentiated connective tissue disease (UCTD,8%), mixed connective tissue disease (MCTD,4%), Ehlers-Danlos’s syndrome (EDS,4%), antiphospholipid syndrome (APS,2%). AEs appearing 7 days after the first and second doses were reported in 93 (31%) and 96 (32%) patients respectively, mainly represented by fatigue, injection site reaction, headache, fever and myalgia. Otitis, urticaria, Herpes Simplex-related rash, stomatitis, migraine with aura, vertigo, tinnitus and sleepiness were reported with very low frequency. Less than 2% of patients experienced AEs within 24 weeks from the second dose. No SAEs or AEs of special interest were observed in the study period. There were 25 disease exacerbations (8%), 7 of which severe. The highest number of exacerbations was observed after 4 weeks from the second dose (12 within week 4, 6 within week 12 and 7 within week 24). Disease exacerbation was most frequent in patients with EDS (33%) and MCTD (25%).

Conclusion

This preliminary analysis shows that COVID-19 vaccination is safe in rCTDs patients. AEs appear most often early after vaccination and are usually mild. Disease exacerbations are not frequent, but can be potentially severe and tend to occur most frequently within the first month after vaccination. Exacerbations can also occur 3-6 months after vaccination, although a causal relationship with the vaccination remains to be established. Our present data underline the importance of long-term observational studies.

Table 1.

AEs and disease exacerbations per disease

DiagnosisPatients enrolled (%) (n=300)EAs after 1st and 2nd dose (%)Exacerbations (%)APS25714EDS45033IIM10527MCTD44225SS12598SLE44698SSC16492UCTD850-

Acknowledgements

VACCINATE is a study promoted by the European Reference Network on rare and complex connective tissue diseases, ERN ReCONNET. This publication was funded by the European Union’s Health Programme (2014-2020)

Disclosure of Interests

None declared

AB0588 GIANT CELL ARTERITIS: DO DIFFERENT PHENOTYPES OF PRESENTATION MEAN DIFFERENT CLINICAL ENTITIES?

Background

Giant cell arteritis (GCA) represents the most common primary vasculitis of the elderly, affecting large and medium-sized arterial vessels. GCA often also involves the aorta and its major branches and may lead to aortic aneurysm/dissection as well as large artery stenoses; it seems that unrecognized extra-cranial involvement may be even more common.

Objectives

The primary aim of this study was to explore the different clinical entities in a large cohort of patients with GCA; a secondary aim was to evaluate long-term outcome of GCA patients with at least 5 years of follow-up.

Methods

A cohort of 278 GCA patients (54 males and 224 females, mean ± SD age 75 ± 6 years) were retrospectively studied. Clinical symptoms at disease onset and during the follow-up, time delay until diagnosis, as well as laboratory findings at the time of diagnosis and therapeutic approach were retrospective evaluated. In order to characterize the different clinical phenotypes, overall clinical symptoms were grouped for macro-area (cranial versus systemic). Moreover, long-term outcomes in patients with a minimum follow-up of 3 years were evaluated. A disease flare was defined as the presence of any further clinical manifestation compatible with the clinical spectrum of GCA and an increase of ESR ≥ 30 mm/hour, not otherwise justifiable, that required higher doses or new introduction of glucocorticoids (GC) therapy and/or the introduction of steroid sparing treatments (e.g. tocilizumab, methotrexate).

Results

The most frequent clinical manifestations presented at the onset included: constitutional symptoms 69%, new onset headache and/or scalp pain 64%, jaw claudicatio 32%, vision loss 30%, abnormal temporal artery on examination 19%, neuropsychiatric symptoms 17%, cough not otherwise justifiable 7%, cerebrovascular accidents 6% and hearing loss 3%. Irreversible (mono- or bilateral) blindness was reported in 7% of patients, mainly due to a latency period between onset and treatment of ≥ 3 months. Temporal artery biopsy was performed in 171 patients, resulting positive in 72%. Globally, about 38% of subjects (was characterized by a clinical profile compatible with extra-cranial GCA. In all cases, extra-cranial involvement was confirmed by (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET). Moreover, patients who presented symptoms compatible with large-vessel involvement were characterized by a more relapsing course compared with patients with cranial involvement GCA profile (both in terms of dose of corticosteroids and use of steroid-sparing agents).

Conclusion

According to the literature data, different phenotypes of GCA exist and they may probably represent different clinical entities, also in terms of prognosis and therapeutic approach. This is particularly crucial in order to plan a tailored therapy and prevent disease damage in the short and long-term follow-up.

Disclosure of Interests

None declared

P110 ACCIDENTAL FINDING OF COR TRIATRIUM SINISTER IN AN ADULT: DIAGNOSIS MANAGMENT

A 45–year old woman presented at the emergency department for palpitations and fever. The EKG, thoracic x–ray and troponins were normal, only a neutrophil leucocytosis was found. The echocardiography showed a normal bi–ventricular and valvular function and a mobile, linear, mass in the left atrium. In order to exclude an infective vegetation the patient underwent to a 2D and 3D transesophageal echocardiography (Figure 1 and 2) which showed a left ventricle concentric remodelling (iLVmass 62 g/m2; RWT 0.45), preserved left and right ventricle function (LVEF according to Simpson 70%; FAC 50%) and valves function; inter–atrial septum defects were excluded, too. The mass was described as a mobile membrane in the left atrium at 2.11 cm from the mitral valve anular plane, which divided the atrium into two separate chambers with a large fenestration without trans–mitralic flow obstruction, supporting a cor triatrium sinister. We excluded endocarditis (the blood cultures were negative, too) and supra–valvular mitral ring (since the left appendage position in the antero–inferior side of the left atrium). The cardiac MRI showed (Figure 3) (SSFP–FIESTA, IR–GRE T1, STIR T2) confirmed the finding of a left atrium divided in two chamber by a iso–intense membraine from the coumadin ridge between the left upper pulmonary vein and the left appendage to the inter–atrial septum fossa ovalis, incomplete in the infero–lateral part. Venous drenaige and other congenital abnormalities were excluded. Miocarditis was excluded since no fibrosis in IR–GRE T1 and no edema in Triple T2 sequences. Since the non–obstructive cor triatrium sinister, grading IA according the Lucas classification, was confirmed, no surgical treatment was proposed and the patient was discharged without complications.

The collapse of infectious disease diagnoses commonly due to communicable respiratory pathogens during the COVID-19 pandemic: A time series and hierarchical clustering analysis

Background

Nonpharmaceutical interventions such as physical distancing and mandatory masking were adopted in many jurisdictions during the coronavirus disease 2019 pandemic to decrease spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We determined the effects of these interventions on incidence of healthcare utilization for other infectious diseases.

Methods

Using a healthcare administrative dataset, we employed an interrupted time series analysis to measure changes in healthcare visits for various infectious diseases across the province of Ontario, Canada, from January 2017 to December 2020. We used a hierarchical clustering algorithm to group diagnoses that demonstrated similar patterns of change through the pandemic months.

Results

We found that visits for infectious diseases commonly caused by communicable respiratory pathogens (eg, acute bronchitis, acute sinusitis) formed distinct clusters from diagnoses that often originate from pathogens derived from the patient’s own flora (eg, urinary tract infection, cellulitis). Moreover, infectious diagnoses commonly arising from communicable respiratory pathogens (hierarchical cluster 1: highly impacted diagnoses) were significantly decreased, with a rate ratio (RR) of 0.35 (95% confidence interval [CI], .30–.40; P < .001) after the introduction of public health interventions in April–December 2020, whereas infections typically arising from the patient’s own flora (hierarchical cluster 3: minimally impacted diagnoses) did not demonstrate a sustained change in incidence (RR, 0.95 [95% CI, .90–1.01]; P = .085).

Conclusions

Public health measures to curtail the incidence of SARS-CoV-2 were widely effective against other communicable respiratory infectious diseases with similar modes of transmission but had little effect on infectious diseases not strongly dependent on person-to-person transmission.

Empowering rare disease patients through patient education: the new BehçeTalk programme

BACKGROUND

Educating patients and caregivers on their disease can improve their knowledge and promote the active involvement in the therapeutic decision-making process. Naturally, patient education programmes are critically important in rare systemic autoimmune diseases, where relevant knowledge and expertise still remain scattered. Behçet's disease (BD) represents a challenging rare condition, characterized by a variable spectrum of disease profile and a relapsing course.

RESULTS

Recently, BehçeTalk, an educational programme tailored for BD patients, families and caregivers with, was launched. BehçeTalk, entirely co-designed with BD patients, is offering educational on-line webinars on different aspects of the disease, as well support groups for patients and caregivers coordinated by a psychologist with specific expertise in BD.

CONCLUSIONS

The therapeutical management of BD is often challenging and frequently includes off-label treatments. Considering the specificities of BD, providing a specific education on the disease to patients will lead to empower them in being part of the decision-making processes, in the self-management and in improving their quality of life.

A257 PANCREATIC CANCER TREATMENT AND END OF LIFE OUTCOMES: A POPULATION BASED COHORT STUDY

Background

Patients with pancreatic cancer face challenging decisions regarding treatment choices following their diagnosis and often lack data on end-of-life (EOL) outcomes. Without the available information, older patients may be undertreated, dying earlier than they would have with treatment, while others may be overtreated and exposed to aggressive measures with harmful side effects.

Aims

To describe survival and EOL outcomes among pancreatic cancer patients based on index cancer treatment, disease stage, and patient characteristics.

Methods

We conducted a population based cohort study in Ontario, Canada of patients who died from April 2010 to December 2017 and were diagnosed with pancreatic cancer prior to death. We used administrative databases to collect data on demographics, baseline health status, treatments, and outcomes. The primary exposure was index cancer treatment (no treatment, radiation, chemotherapy alone, surgery alone, and surgery with chemotherapy). The primary outcomes were mortality, health care encounters per 30 days in the last six months of life, and palliative care visits per 30 days within the last six months of life. Secondary outcomes were location of death (institution vs. community), hospitalization within the last 30 days of life, and receipt of chemotherapy within the last 30 days of life. We estimated the association between the exposure and outcomes using multivariable models, adjusting for demographics, comorbidities, and cancer stage. Hazard ratios, adjusted mean differences, and odds ratios were reported with 95% confidence intervals.

Results

Our cohort included 9950 adults with a median age at diagnosis of 78. 56% received no index treatment, 5% underwent radiation, 27% underwent chemotherapy alone, 7% underwent surgery alone, and 6% underwent surgery and chemotherapy. In the multivariable regression (Table and Figure), radiation, chemotherapy alone, surgery alone, and surgery with chemotherapy were all associated with decreased mortality and fewer healthcare encounters. All groups except radiation were associated with fewer palliative care visits. All treatment groups were associated with lower odds of institutional death and hospitalization within the last 30 days of life, and higher odds of chemotherapy within the last 30 days of life.

Conclusions

Our data, the first to provide EOL outcome estimates based on index cancer treatment, can help patients make initial treatment decisions after a diagnosis of pancreatic cancer.

Multivariable regression analyses predicting primary and secondary outcomes

Funding Agencies

CIHR

Physician Health Care Visits for Mental Health and Substance Use During the COVID-19 Pandemic in Ontario, Canada

IMPORTANCE

Physicians self-report high levels of symptoms of anxiety and depression, and surveys suggest these symptoms have been exacerbated by the COVID-19 pandemic. However, it is not known whether pandemic-related stressors have led to increases in health care visits related to mental health or substance use among physicians.

OBJECTIVE

To evaluate the association between the COVID-19 pandemic and changes in outpatient health care visits by physicians related to mental health and substance use and explore differences across physician subgroups of interest.

DESIGN, SETTING, AND PARTICIPANTS

A population-based cohort study was conducted using health administrative data collected from the universal health system (Ontario Health Insurance Plan) of Ontario, Canada, from March 1, 2017, to March 10, 2021. Participants included 34 055 physicians, residents, and fellows who registered with the College of Physicians and Surgeons of Ontario between 1990 and 2018 and were eligible for the Ontario Health Insurance Plan during the study period. Autoregressive integrated moving average models and generalized estimating equations were used in analyses.

EXPOSURES

The period during the COVID-19 pandemic (March 11, 2020, to March 10, 2021) compared with the period before the pandemic.

MAIN OUTCOMES AND MEASURES

The primary outcome was in-person, telemedicine, and virtual care outpatient visits to a psychiatrist or family medicine and general practice clinicians related to mental health and substance use.

RESULTS

In the 34 055 practicing physicians (mean [SD] age, 41.7 [10.0] years, 17 918 [52.6%] male), the annual crude number of visits per 1000 physicians increased by 27%, from 816.8 before the COVID-19 pandemic to 1037.5 during the pandemic (adjusted incident rate ratio per physician, 1.13; 95% CI, 1.07-1.19). The absolute proportion of physicians with 1 or more mental health and substance use visits within a year increased from 12.3% before to 13.4% during the pandemic (adjusted odds ratio, 1.08; 95% CI, 1.03-1.14). The relative increase was significantly greater in physicians without a prior mental health and substance use history (adjusted incident rate ratio, 1.72; 95% CI, 1.60-1.85) than in physicians with a prior mental health and substance use history.

CONCLUSIONS AND RELEVANCE

In this study, the COVID-19 pandemic was associated with a substantial increase in mental health and substance use visits among physicians. Physician mental health may have worsened during the pandemic, highlighting a potential greater requirement for access to mental health services and system level change.

In-Hospital Patient Harm Across Linguistic Groups: A Retrospective Cohort Study of Home Care Recipients

OBJECTIVE

Research examining the impact of language barriers on patient safety is limited. We conducted a population-based study to determine whether patients whose primary language is not English are more likely to experience harm when admitted to hospitals in Ontario, Canada.

METHODS

We used linked administrative health records to establish a retrospective cohort of home care recipients (from 2010 to 2015) who were subsequently admitted to hospital. Patient language (obtained from home care assessments) was coded as English, French, or other. Harmful events were identified using the Hospital Harm Indicator developed by the Canadian Institute for Health Information.

RESULTS

We included 190,724 patients (156,186 Anglophones, 5,110 Francophones, and 29,428 Allophones). There was no significant difference in the unadjusted risk of harm for Francophones compared with Anglophones (relative risk [RR], 0.94; 95% confidence interval [CI], 0.87-1.02). However, Allophones were more likely to experience harm when compared with Anglophones (RR, 1.14; 95% CI, 1.10-1.18). The risk of harm was even greater for Allophones with low English proficiency (RR, 1.18; 95% CI, 1.13-1.24). After adjusting for potential confounders, Anglophones and Allophones were equally likely to experience harm of any type, but Allophones more likely to experience harm from infections and procedures.

CONCLUSIONS

Patients whose primary language was not English or French were more likely to experience harm after admission to hospital, especially if they had low English proficiency. For these patients, the risk of harm from infections and procedures persisted in the adjusted analysis, but the overall risk of harm did not.

Dying with Parkinson's Disease: Healthcare Utilization and Costs in the Last Year of Life

BACKGROUND

The end-of-life period is associated with disproportionately higher health care utilization and cost at the population level but there is little data in Parkinson's disease (PD).

OBJECTIVE

The goals of this study were to 1) compare health care use and associated cost in the last year of life between decedents with and without PD, and 2) identify factors associated with palliative care consultation and death in hospital.

METHODS

Using linked administrative datasets held at ICES, we conducted a retrospective, population-based cohort study of all Ontario, Canada decedents from 2015 to 2017. We examined demographic data, rate of utilization across healthcare sectors, and cost of health care services in the last year of life.

RESULTS

We identified 291,276 decedents of whom 12,440 (4.3%) had a diagnosis of PD. Compared to decedents without PD, decedents with PD were more likely to be admitted to long-term care (52% vs. 23%, p < 0.001) and received more home care (69.0 vs. 41.8 days, p < 0.001). Receipt of palliative homecare or physician palliative home consultation were associated with lower odds of dying in hospital (OR: 0.24, 95% CI: 0.19- 0.30, and OR: 0.38, 95% CI: 0.33- 0.43, respectively). Mean cost of care in the last year of life was greater for decedents with PD ($68,391 vs. $59,244, p < 0.001).

CONCLUSION

Compared to individuals without PD, individuals with PD have higher rates of long-term care, home care and higher health care costs in the last year of life. Palliative care is associated with a lower rate of hospital death.

Characteristics and resource utilization of high-cost users in the intensive care unit: a population-based cohort study

Background

Healthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns.

Methods

We conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups.

Results

Among 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval [CI] 22.0–22.7 days vs. 5.56 days, 95% CI 5.54–5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020–$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046–$45,264). High-cost users accounted for 37.0% of total healthcare costs.

Conclusion

High-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07318-y.

A systematic literature review of existing tools used to assess medication adherence in connective tissue diseases: the state of the art for the future development of co-designed measurement tools

Lack of medication adherence is frequent in chronic connective tissue diseases and is associated with poorer health outcomes, low quality of life and economic loss. This research is based on a systematic literature search and aims to identify the surveys and tools used for the assessment of medication adherence in patients with connective tissue diseases (CTDs) and in particular the tools co-designed with patients. A systematic literature review was performed in PubMed and Embase databases searching for studies concerning the application of surveys or tools designed for medication adherence assessment. A specific analysis was also performed to identify which of these existing tools were developed in co-design with patients affected by CTDs. 1958 references were identified, and 31 studies were finally included. Systemic lupus erythematosus was the most investigated disease, followed by the Behçet's disease. The tools used to assess adherence in CTDs were, in most cases, valid and useful. However, the results showed a certain degree of heterogeneity among the studies and the medication adherence assessment and measurement tools adopted, which were mostly based on selfreported questionnaire. No co-designed tools with patients were found. Low- and non-adherence were explored in some CTDs with valid and useful tools, while other CTDs still need to be assessed. Therefore, more efforts should be made to better understand the specific reasons for the low- and non-adherence in CTDs patients.

Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study

BACKGROUND

Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients.

METHODS

After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated.

RESULTS

Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35).

CONCLUSIONS

Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Comparison of End-of-Life Care Between Recent Immigrants and Long-standing Residents in Ontario, Canada

IMPORTANCE

Recent immigrants face unique cultural and logistical challenges that differ from those of long-standing residents, which may influence the type of care they receive at the end of life.

OBJECTIVE

To compare places of care among recent immigrants and long-standing residents in Canada in the last 90 days of life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study used linked health administrative data on individuals from Ontario, Canada, who died between January 1, 2013, and December 31, 2016, extracted on February 26, 2020. Individuals were categorized by immigration status: recent immigrants (since 1985) and long-standing residents. Data were analyzed from December 27, 2019, to February 26, 2020.

EXPOSURES

All decedents who immigrated to Canada between 1985 and 2016 were classified as recent immigrants. Subgroup analyses assessed the association of region of origin.

MAIN OUTCOMES AND MEASURES

The main outcome was place of care, including institutional and noninstitutional settings, in the last 90 days of life. Descriptive statistics were used to compare characteristics and health service utilization among recent immigrants and long-standing residents. Negative binomial regression models estimated the rate ratios (RR) of using acute care and long-term care in the last 90 days of life.

RESULTS

A total of 376 617 deceased individuals (median [IQR] age, 80 [68-88] years; 187 439 [49.8%] women and 189 178 [50.2%] men) were identified, among whom 22 423 (6.0%) were recent immigrants; recent immigrants were younger than long-standing residents (median [IQR] age, 76 [60-85] years vs 81 [69-88] years; P < .001), more likely to be living in lower income neighborhoods (12 357 immigrants [55.1%] vs 166 017 long-standing residents [46.9%] in the lower 2 income quintiles; P < .001), and had a higher Charlson Index score (score ≥5, 6294 immigrants [28.1%] vs 74 809 long-standing residents [21.1%]; P < .001). In the last 90 days of life, recent immigrants spent more days in intensive care units than long-standing residents (mean [SD], 2.64 [8.73] days vs 1.47 [5.70] days; P < .001), while long-standing residents spent more days using long-term care than recent immigrants (mean [SD], 19.49 [35.81] days vs 10.45 [27.42] days; P < .001). Being a recent immigrant was associated with a greater likelihood of acute inpatient care use (RR, 1.21; 95% CI, 1.18-1.24) and lower likelihood of long-term care use (RR, 0.66; 95% CI, 0.63-0.70), after adjusting for covariates.

CONCLUSIONS AND RELEVANCE

These findings suggest that at the end of life, recent immigrants were significantly more likely to receive inpatient and intensive care unit services and die in acute care settings compared with long-standing residents. Further research is needed to examine differences in care preference and disparities for immigrant groups of different origins.

Sociodemographic changes in emergency department visits due to alcohol during COVID-19

INTRODUCTION

Little detailed sociodemographic information is available about how alcohol use and associated health care visits have changed during COVID-19. Therefore, we assessed how rates of emergency department (ED) visits due to alcohol have changed during COVID-19 by age and sex and for individuals living in urban and rural settings and low and high-income neighborhoods.

METHODS

Our cohort included 13,660,516 unique Ontario residents between the ages of 10-105. We compared rates and characteristics of ED visits due to alcohol, identified using ICD-10 codes, from March 11-August 31 2020 to the same period in the prior 3 years. We used negative binomial regressions to examine to examine changes is visits during COVID-19 after accounting for temporal and seasonal trends.

RESULTS

During COVID-19, the average monthly rate of ED visits due to alcohol decreased by 17.2 % (95 % CI -22.7, -11.3) from 50.5-40.9 visits per 100,000 individuals. In contrast, the proportion of all-cause ED visits due to alcohol increased by 11.4 % (95 % CI 7.7, 15.3) from 15.0 visits to 16.3 visits per 1000 all cause ED visits. Changes in ED visits due to alcohol were similar for men in women. Decreases in visits were larger for younger adults compared to older adults and pre-COVID-19 disparities in rates of ED visits due to alcohol between urban and rural settings and low and high-income neighborhoods widened. ED visits related to harms from acute intoxication showed the largest declines during COVID-19, particularly in younger adults and urban and high-income neighborhoods.

CONCLUSION

ED visits due to alcohol decreased during the first six months of COVID-19, but to a lesser extent than decreases in all-cause ED visits. Our data suggest a widening of geographic and income-based disparities in alcohol harms in Ontario during COVID-19 which may require immediate and long-term interventions to mitigate.

Predicting death in home care users: derivation and validation of the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT)

BACKGROUND:

Prognostication tools that report personalized mortality risk and survival could improve discussions about end-of-life and advance care planning. We sought to develop and validate a mortality risk model for older adults with diverse care needs in home care using self-reportable information — the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT).

METHODS:

Using a derivation cohort that comprised adults living in Ontario, Canada, aged 50 years and older with at least 1 Resident Assessment Instrument for Home Care (RAI-HC) record between Jan. 1, 2007, and Dec. 31, 2012, we developed a mortality risk model. The primary outcome was mortality 6 months after a RAI-HC assessment. We used proportional hazards regression with robust standard errors to account for clustering by the individual. We validated this algorithm for a second cohort of users of home care who were assessed between Jan. 1 and Dec. 31, 2013. We used Kaplan–Meier survival curves to estimate the observed risk of death at 6 months for assessment of calibration and median survival. We constructed 61 risk groups based on incremental increases in the estimated median survival of about 3 weeks among adults at high risk and 3 months among adults at lower risk.

RESULTS:

The derivation and validation cohorts included 435 009 and 139 388 adults, respectively. We identified a total of 122 823 deaths within 6 months of a RAI-HC assessment in the derivation cohort. The mean predicted 6-month mortality risk was 10.8% (95% confidence interval [CI] 10.7%–10.8%) and ranged from 1.54% (95% CI 1.53%–1.54%) in the lowest to 98.1% (95% CI 98.1%–98.2%) in the highest risk group. Estimated median survival spanned from 28 days (11 to 84 d at the 25th and 75th percentiles) in the highest risk group to over 8 years (1925 to 3420 d) in the lowest risk group. The algorithm had a c-statistic of 0.753 (95% CI 0.750–0.756) in our validation cohort.

INTERPRETATION:

The RESPECT mortality risk prediction tool that makes use of readily available information can improve the identification of palliative and end-of-life care needs in a diverse older adult population receiving home care.

Fine particulate matter concentration and composition and the incidence of childhood asthma

BACKGROUND

Several studies have found positive associations between outdoor fine particulate air pollution (≤2.5 μm, PM_2.5) and childhood asthma incidence. However, the impact of PM_2.5 composition on children's respiratory health remains uncertain.

OBJECTIVE

We examined whether joint exposure to PM_2.5 mass concentrations and its major chemical components was associated with childhood asthma development.

METHODS

We conducted a population-based cohort study by identifying 1,130,855 singleton live births occurring between 2006 and 2014 in the province of Ontario, Canada. Concentrations of PM_2.5 and its seven major chemical components were assigned to participants based on their postal codes using chemical transport models and remote sensing. The joint impact of outdoor PM_2.5 concentrations and its major components and childhood asthma incidence (up to age 6) were estimated using Cox proportional hazards models, allowing for potential nonlinearity.

RESULTS

We identified 167,080 children who developed asthma before age 6. In adjusted models, outdoor PM_2.5 mass concentrations during childhood were associated with increased incidence of childhood asthma (Hazard Ratio (HR) for each 1 μg/m³ increase = 1.026, 95% CI: 1.021-1.031). We found that the joint effects of PM_2.5 and its components on childhood asthma incidence may be 24% higher than the conventional approach. Specific components/source markers such as black carbon, ammonium, and nitrate appeared to play an important role.

CONCLUSIONS

Early life exposure to PM_2.5 and its chemical components is associated with an increased risk of asthma development in children. The heterogeneous nature of PM_2.5 should be considered in future health risk assessments.

Case-Ascertainment Models to Identify Adults with Obstructive Sleep Apnea Using Health Administrative Data: Internal and External Validation

Background

There is limited evidence on whether obstructive sleep apnea (OSA) can be accurately identified using health administrative data.

Study Design and Methods

We derived and validated a case-ascertainment model to identify OSA using linked provincial health administrative and clinical data from all consecutive adults who underwent a diagnostic sleep study (index date) at two large academic centers (Ontario, Canada) from 2007 to 2017. The presence of moderate/severe OSA (an apnea–hypopnea index≥15) was defined using clinical data. Of 39 candidate health administrative variables considered, 32 were tested. We used classification and regression tree (CART) methods to identify the most parsimonious models via cost-complexity pruning. Identified variables were also used to create parsimonious logistic regression models. All individuals with an estimated probability of 0.5 or greater using the predictive models were classified as having OSA.

Results

The case-ascertainment models were derived and validated internally through bootstrapping on 5099 individuals from one center (33% moderate/severe OSA) and validated externally on 13,486 adults from the other (45% moderate/severe OSA). On the external cohort, parsimonious models demonstrated c-statistics of 0.75–0.81, sensitivities of 59–60%, specificities of 87–88%, positive predictive values of 79%, negative predictive values of 73%, positive likelihood ratios (+LRs) of 4.5–5.0 and –LRs of 0.5. Logistic models performed better than CART models (mean integrated calibration indices of 0.02–0.03 and 0.06–0.12, respectively). The best model included: sex, age, and hypertension at the index date, as well as an outpatient specialty physician visit for OSA, a repeated sleep study, and a positive airway pressure treatment claim within 1 year since the index date.

Interpretation

Among adults who underwent a sleep study, case-ascertainment models for identifying moderate/severe OSA using health administrative data had relatively low sensitivity but high specificity and good discriminative ability. These findings could help study trends and outcomes of OSA individuals using routinely collected health care data.

Short- and Long-term Health Care Resource Utilization and Costs Following Intracerebral Hemorrhage

OBJECTIVE

We sought to evaluate the short- and long-term resource use and costs associated with intracerebral hemorrhage (ICH) taken from an entire population. We in addition sought to evaluate the association of oral anticoagulation (OAC) and health care costs.

METHODS

This was a retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (2009-2017). We captured outcomes through linkage to health administrative databases. We used generalized linear models to identify factors associated with total cost. Analysis of OAC use was limited to patients ≥66 years of age. The primary outcome was total 1-year direct health care costs in 2020 US dollars.

RESULTS

Among 16,248 individuals with ICH (mean age 71.2 years, male 52.3%), 1-year mortality was 46.0%, and 24.2% required mechanical ventilation. The median total 1-year cost was $26,886 (interquartile range [IQR] $9,641-$62,907) with costs for those who died in hospital of $7,268 (IQR $4,031-$14,966) vs $44,969 (IQR $20,264-$82,414, p < 0.001) for survivors to discharge. OAC use (analysis limited to individuals ≥66 years old) was associated with higher total 1-year costs (cost ratio 1.06 [95% confidence interval 1.01-1.11]). Total 1-year costs for the entire cohort exceeded $120 million per year over the study period.

CONCLUSIONS

ICH is associated with significant health care costs, and the median cost of a patient with ICH is roughly 10 times the median inpatient cost in Ontario. Costs were higher among survivors than deceased patients. OAC use is independently associated with increased costs. To maximize cost-effectiveness, future therapies for ICH must aim to reduce disability, not only improve mortality.