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Objectives: Coordinated care plans (CCPs) for high-cost health care system users aim to improve system-level performance. We evaluated health care resource use and costs among CCP patients (enrollees) versus a control group that did not receive coordinated care (comparators) in Southeastern Ontario. Methods: A difference-in-differences analysis of a quasi-experimental, double propensity score-matched and adjusted cohort was conducted. Linked population-based administrative data were used to measure health care utilization and costs and to identify comparators for two enrollee groups who began CCPs between April 1, 2013, and March 31, 2019. Enrollees were recruited from hospitals in Quinte or community care centres in Rural Hastings/Thousand Islands, and were 1:1 propensity score matched to comparators. Difference-in-differences estimates were calculated using generalized estimating equations for hospitalization rates, homecare visits, primary care visits, other health care resources and total costs. Results: A total of 558 enrollees in Quinte and 538 in Rural Hastings/Thousand Islands were identified and matched to comparators. Difference-in-differences estimates were significant in both enrollee groups for number of homecare visits ([IRR 1.72; 95% CI (1.44, 2.06)] and [IRR 1.73; 95% CI (1.45, 2.06)], respectively). Number of primary care visits were 1.76 times greater for Rural Hastings/Thousand Islands enrollees versus comparators [IRR 1.76; 95% CI (1.32, 2.35)]; total costs increased by 23% ([IRR 1.23; 95% CI (1.09,1.39)]. Conclusions: Homecare use significantly increased for enrollees versus comparators, indicating specific priority areas of Ontario CCPs were met. However, no reductions were shown for other health system performance indicators. We also showed increased 7-day primary care follow-up visits for community care centre-recruited patients, but not for hospital-recruited patients. Decision-makers may wish to target patients who are less advanced in their chronic disease trajectory. [ABSTRACT FROM AUTHOR]

Objective: To explore variation in rates of acute care utilization for mental health conditions, including hospitalizations and emergency department (ED) visits, across high‐income countries before and during the COVID‐19 pandemic. Data Sources and Study Setting: Administrative patient‐level data between 2017 and 2020 of eight high‐income countries: Canada, England, Finland, France, New Zealand, Spain, Switzerland, and the United States (US). Study Design: Multi‐country retrospective observational study using a federated data approach that evaluated age‐sex standardized rates of hospitalizations and ED visits for mental health conditions. Principal Findings: There was significant variation in rates of acute mental health care utilization across countries. Among the subset of four countries with both hospitalization and ED data, the US had the highest pre‐COVID‐19 combined average annual acute care rate of 1613 episodes/100,000 people (95% CI: 1428, 1797). Finland had the lowest rate of 776 (686, 866). When examining hospitalization rates only, France had the highest rate of inpatient hospitalizations of 988/100,000 (95% CI 858, 1118) while Spain had the lowest at 87/100,000 (95% CI 76, 99). For ED rates for mental health conditions, the US had the highest rate of 958/100,000 (95% CI 861, 1055) while France had the lowest rate with 241/100,000 (95% CI 216, 265). Notable shifts coinciding with the onset of the COVID‐19 pandemic were observed including a substitution of care setting in the US from ED to inpatient care, and overall declines in acute care utilization in Canada and France. Conclusion: The study underscores the importance of understanding and addressing variation in acute care utilization for mental health conditions, including the differential effect of COVID‐19, across different health care systems. Further research is needed to elucidate the extent to which factors such as workforce capacity, access barriers, financial incentives, COVID‐19 preparedness, and community‐based care may contribute to these variations. What is known on this topic: Approximately one billion people globally live with a mental health condition, with significant consequences for individuals and societies.Rates of mental health diagnoses vary across high‐income countries, with substantial differences in access to effective care.The COVID‐19 pandemic has exacerbated mental health challenges globally, with varying impacts across countries. What this study adds: This study provides a comprehensive international comparison of hospitalization and emergency department visit rates for mental health conditions across eight high‐income countries.It highlights significant variations in acute care utilization patterns, particularly in countries that are more likely to care for people with mental health conditions in emergency departments rather than inpatient facilitiesThe study identifies temporal and cross‐country differences in acute care management of mental health conditions coinciding with the onset of the COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

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

Background: Individuals who experience a hip fracture have numerous care transitions. Improving the transition process is important for ensuring quality care; however, little is known about the priorities of different key interest groups. Our aim was to gather recommendations from these groups regarding care transitions for hip fracture. Methods: We conducted a concept mapping study, inviting persons with lived experience (PWLE) who had a hip fracture, care partners, healthcare providers, and decision-makers to share their thoughts about 'what is needed to improve care transitions for hip fracture'. Individuals were subsequently asked to sort the generated statements into conceptual piles, and then rate by importance and priority using a five-point scale. Participants decided on the final map, rearranged statements, and assigned a name to each conceptual cluster. Results: A total of 35 participants took part in this concept mapping study, with some individuals participating in multiple steps. Participants included 22 healthcare providers, 7 care partners, 4 decision-makers, and 2 PWLE. The final map selected by participants was an 8-cluster map, with the following cluster labels: (1) access to inpatient services and supports across the care continuum (13 statements); (2) informed and collaborative discharge planning (13 statements); (3) access to transitional and outpatient services (3 statements); (4) communication, education and knowledge acquisition (9 statements); (5) support for care partners (2 statements); (6) person-centred care (13 statements); (7) physical, social, and cognitive activities and supports (13 statements); and (8) provider knowledge, skills, roles and behaviours (8 statements). Conclusions: Our study findings highlight the importance of person-centred care, with active involvement of PWLE and their care partners throughout the care journey. Many participant statements included specific ideas related to continuity of care, and clinical knowledge and skills. This study provides insights for future interventions and quality improvement initiatives for enhancing transitions in care among hip fracture populations. [ABSTRACT FROM AUTHOR]

Rationale: A common strategy to reduce COPD readmissions is to encourage patient follow-up with a physician within 1 to 2 weeks of discharge, yet evidence confirming its benefit is lacking. We used a new study design called target randomized trial emulation to determine the impact of follow-up visit timing on patient outcomes. Methods: All Ontario residents aged 35 or older discharged from a COPD hospitalization were identified using health administrative data and randomly assigned to those who received and did not receive physician visit follow-up by within seven days. They were followed to all-cause emergency department visits, readmissions or death. Targeted randomized trial emulation was used to adjust for differences between the groups. COPD emergency department visits, readmissions or death was also considered. Results: There were 94,034 patients hospitalized with COPD, of whom 73.5% had a physician visit within 30 days of discharge. Adjusted hazard ratio for all-cause readmission, emergency department visits or death for people with a visit within seven days post discharge was 1.03 (95% Confidence Interval [CI]: 1.01–1.05) and remained around 1 for subsequent days; adjusted hazard ratio for the composite COPD events was 0.97 (95% CI 0.95–1.00) and remained significantly lower than 1 for subsequent days. Conclusion: While a physician visit after discharge was found to reduce COPD events, a specific time period when a physician visit was most beneficial was not found. This suggests that follow-up visits should not occur at a predetermined time but be based on factors such as anticipated medical need. [ABSTRACT FROM AUTHOR]

Among the challenges in delivering integrated health and social care services is the need to attend to the coordination of tasks, roles, activities, and operations, while considering how these efforts are experienced by patients, carers and communities. The literature has noted an important disconnect between how providers and leaders view their efforts to coordinate service delivery, and how patients perceive these efforts on the receiving end. Our team has provided guidance to integrated care efforts in Ontario, Canada by drawing on Goffman's theory of Dramaturgy to help classify the actions of integrated care delivery as linked to the roles individuals play in the delivery of care. Using this framing helps to uncover how "backstage" processes (such as team-functioning, funding models, and digital infrastructures) create a necessary foundation on which "frontstage" actions (or performances) can be effectively delivered. [ABSTRACT FROM AUTHOR]

Background: Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. Objectives: To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC. Methods: We conducted a population‐based cohort study in Ontario, Canada, of all 15–55‐year‐old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co‐occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit. Results: Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five‐class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus. Conclusions: MCC is common in pregnancy, with sub‐types dominated by co‐occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC. [ABSTRACT FROM AUTHOR]

Aims: Certain combinations of medications can be harmful and may lead to serious adverse drug events (ADEs). Identifying potentially problematic medication clusters could help guide prescribing and/or deprescribing decisions in hospital. The aim of this study is to characterize medication prescribing patterns at hospital discharge and determine which medication clusters were associated with an increased risk of ADEs in the 30‐day posthospital discharge. Methods: All residents of the province of Ontario in Canada aged 66 years or older admitted to hospital between March 2016 and February 2017 were included. Identification of medication clusters prescribed at hospital discharge was conducted using latent class analysis. Cluster identification and categorization were based on medications dispensed up to 30‐day posthospitalization. Multivariable logistic regression was used to assess the potential association between membership to a particular medication cluster and ADEs postdischarge, while also evaluating other patient characteristics. Results: In total, 188 354 patients were included in the study cohort. Median age (interquartile range) was 77 (71–84) years, and patients had a median (IQR) (interquartile range [IQR]) of 9 (6–13) medications dispensed prior to admission. Within the study population, 6 separate clusters of dispensing patterns were identified: cardiovascular (14%), respiratory (26%), complex care needs (12%), cardiovascular and metabolic (15%), infection (10%), and surgical (24%). Overall, 12 680 (7%) patients had an ADE in the 30 days following discharge. After considering other patient characteristics, those belonging to the respiratory cluster had the highest risk of ADEs (adjusted odds ratio: 1.12, 95% confidence interval: 1.08–1.17) compared with all the other clusters, while those in the complex care needs cluster had the lowest risk (adjusted odds ratio: 0.82, 95% confidence interval: 0.77–0.87). Conclusion: This study suggests that ADEs post hospital discharge can be linked with identifiable medication clusters. This information may help clinicians and researchers better understand patient populations that are more or less likely to benefit from peri‐hospital discharge interventions aimed at reducing ADEs. PLAIN LANGUAGE SUMMARY: Certain combinations of medications prescribed to patients when they are being discharged from hospital can increase the risk of adverse events after hospital discharge. [ABSTRACT FROM AUTHOR]

Background: Within the Learning Health System (LHS) model, learning routines, including evaluation, allow for continuous incremental change to take place. Within these learning routines, evaluation assists in problem identification, data collection, and data transformation into contextualized information, which is then re-applied to the LHS environment. Evaluation that catalyzes learning and improvement may also contribute to health innovation sustainability. However, there is little consensus as to why certain evaluations seem to support learning and sustainability, while others impede it. This realist synthesis seeks to understand the contextual factors and underlying mechanisms or drivers that best support health systems learning and sustainable innovation. Methods: This synthesis will be guided by Pawson and colleagues' 2005 and Emmel and colleagues' 2018 guidelines for conducting realist syntheses. The review process will encompass five steps: (1) scoping the review, (2) building theories, (3) identifying the evidence, (4) evidence selection and appraisal, and (5) data extraction and synthesis. An Expert Committee comprised of leaders in evaluation, innovation, sustainability, and realist methodology will guide this synthesis. Review findings will be reported using the RAMESES guidelines. Discussion: The use of a realist review will allow for exploration and theorizing about the contextual factors and underlying mechanisms that make evaluations 'work' (or 'not work') to support learning and sustainability. Depending on results, we will attempt to synthesize findings into a series of recommendations for evaluations with the intention to support health systems learning and sustainability. Finalized results will be presented at national and international conferences, as well as disseminated via a peer-reviewed publication. Systematic review registration: This realist synthesis protocol has been registered with PROSPERO (https://www.crd.york.ac.uk/prospero/ ID 382690). [ABSTRACT FROM AUTHOR]

Background: Many health systems struggle with delayed discharges (known as alternate level of care [ALC] in Canada). Our objectives were to describe and compare patient and hospitalization characteristics by ALC status, and to examine the impact of the initial period of the COVID-19 pandemic on ALC rates in Ontario, Canada. Methods: We conducted an interrupted time series using linked administrative data for acute care hospital discharges in Ontario between Feb. 28, 2018, and Nov. 30, 2020. We measured the monthly ALC rate among discharges before and after the onset of the COVID-19 pandemic (Mar. 1, 2020). We used interrupted time series regressions to examine the association between the onset of the pandemic and average ALC monthly rates. Results: We identified no meaningful differences in patient and admission characteristics, irrespective of time; however, differences were identified by ALC status. The overall average monthly rate of ALC discharges before the COVID-19 pandemic was 4.9% and after the onset of the pandemic was 5.0%. These discharges dropped to 4.3% (n = 3558) in March 2020 but then rebounded to their peak of 5.8% (n = 3915). There was no significant change in the average level of ALC rates per month after the onset of the pandemic (increase of 0.36% average per month, 95% confidence interval [CI] --0.11% to 0.83%) or monthly rate of change (slope) after the onset of the pandemic (-0.08%, 95% CI -0.15 to 0). Interpretation: We identified a continued high rate of hospital discharges with an ALC component despite the considerable efforts in hospital to reduce hospital occupancy during the COVID-19 pandemic. Future research should examine why ALC rates remain high despite hospital efforts. [ABSTRACT FROM AUTHOR]

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems. [ABSTRACT FROM AUTHOR]

Introduction: As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM). Objective: This study sought to explore case managers' perspectives and experiences with this new service delivery model. Methods: Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis. Results: Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention. Conclusion: The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria. [ABSTRACT FROM AUTHOR]

Background: Primary care surveys are a key source of evaluative data; understanding how survey respondents compare to the intended population is important to understand results in context. The objective of this study was to examine the physician and patient representativeness of two primary care surveys (TRANSFORMATION and QUALICOPC) that each used different sampling and recruitment techniques. Methods: We linked the physician and patient participants of the two surveys to health administrative databases. Patients were compared to other patients visiting the practice on the same day and other randomly selected dates using sociodemographic data, chronic disease diagnosis, and health system utilization. Physicians were compared to other physicians in the same practice, and other physicians in the intended geographic area using sociodemographic and practice characteristics. Results: Physician respondents of the TRANSFORMATION survey included more males compared to their practice groups, but not to other physicians in the area. TRANSFORMATION physicians cared for a larger roster of patients than other physicians in the area. Patient respondents of the QUALICOPC survey did not have meaningful differences from other patients who visit the practice. Patient respondents of the TRANSFORMATION survey resided in more rural areas, had less chronic disease, and had lower use of health services than other patients visiting the practice. Conclusion: Differences in survey recruitment methods at the physician and patient level may help to explain some of the differences in representativeness. When conducting primary care surveys, investigators should consider diverse methods of ensuring representativeness to limit the potential for nonresponse bias. [ABSTRACT FROM AUTHOR]

Background: There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18–64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets. Methods: Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546). Findings: There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions. Conclusions: Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas. [ABSTRACT FROM AUTHOR]

This study evaluated level of service need before and after a short-term community mental health case management intervention from the perspective of both clients and case managers. Ontario Common Assessment of Need data were used to describe client needs. McNemar's test was applied to assess differences in pre- and post- need scores. Psychological distress, company, daytime activities, and physical health were most commonly rated by clients as unmet needs at enrolment. At discharge, there was a significant change in psychological distress from the perspective of clients, and in psychological distress and daytime activities from the perspective of case managers. Statistically significant changes were observed for Total Need, Total Unmet Need and Met Need scores from the perspective of case managers. While both clients and case managers reported changes in total service needs between admission and discharge from short-term case management, clients were less likely to report a difference in needs. [ABSTRACT FROM AUTHOR]

Objectives: Globally, there has been a shift towards integrated care delivery and patient-centredness in the design of health services. Such a transformation is underway in Ontario, which is progressively using an interprofessional team-based approach known as Ontario Health Teams (OHTs) to deliver care. During their initial development, OHTs were required to integrate patient and families' preferences, experiences and opinions in the form of consultation and partnership with patient and family advisors (PFAs). This study aimed to understand how PFAs were involved in the early stages of planning for health system change and the perceived benefits of including PFAs in system reform. Methods: This study used a qualitative descriptive design. Semi-structured interviews were conducted with 126 participants at 12 OHTs, including PFA (n = 16) and non-PFA (n = 110) members (e.g. clinicians). Data were analysed thematically. Results: We identified four themes; mechanisms of engagement, motivations to engage, challenges to PFA engagement and PFAs' impact and added value. Overall, participants viewed PFA engagement positively and PFAs felt valued and empowered. There remain logistical challenges around PFA compensation, and the amount of time and training expected of PFAs. However, all participants believed that developing an understanding of the patient, caregiver and family experience will strengthen the engagement of PFAs in OHT planning, decisions and policies. Conclusions: Diverse approaches to and stages of PFA engagement fostered meaningful and highly valued contributions to OHT development. These were considered critical to successfully achieving the mandate of patient-centred care reform. [ABSTRACT FROM AUTHOR]

Background: Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched). Methods: Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data–derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls. Results: There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39–2.60) to 1.67 (95% CI 0.82–3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98–6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99–3.30]). Interpretation: Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods. Ontario ClinicalTrials.gov: 104191 [ABSTRACT FROM AUTHOR]

Background: The post-acute burden of health care use after SARS-CoV-2 infection is unknown. We sought to quantify the post-acute burden of health care use after SARS-CoV-2 infection among community-dwelling adults in Ontario by comparing those with positive and negative polymerase chain reaction (PCR) test results for SARS-CoV-2 infection.Methods: We conducted a retrospective cohort study involving community-dwelling adults in Ontario who had a PCR test between Jan. 1, 2020, and Mar. 31, 2021. Follow-up began 56 days after PCR testing. We matched people 1:1 on a comprehensive propensity score. We compared per-person-year rates for health care encounters at the mean and 99th percentiles, and compared counts using negative binomial models, stratified by sex.Results: Among 531 702 matched people, mean age was 44 (standard deviation [SD] 17) years and 51% were female. Females who tested positive for SARS-CoV-2 had a mean of 1.98 (95% CI 1.63 to 2.29) more health care encounters overall per-person-year than those who had a negative test result, with 0.31 (95% CI 0.05 to 0.56) more home care encounters to 0.81 (95% CI 0.69 to 0.93) more long-term care days. At the 99th percentile per-person-year, females who tested positive had 6.48 more days of hospital admission and 28.37 more home care encounters. Males who tested positive for SARS-CoV-2 had 0.66 (95% CI 0.34 to 0.99) more overall health care encounters per-person-year than those who tested negative, with 0.14 (95% CI 0.06 to 0.21) more outpatient encounters and 0.48 (95% CI 0.36 to 0.60) long-term care days, and 0.43 (95% CI -0.67 to -0.21) fewer home care encounters. At the 99th percentile, they had 8.69 more days in hospital per-person-year, with fewer home care (-27.31) and outpatient (-0.87) encounters.Interpretation: We found significantly higher rates of health care use after a positive SARS-CoV-2 PCR test in an analysis that matched test-positive with test-negative people. Stakeholders can use these findings to prepare for health care demand associated with post-COVID-19 condition (long COVID). [ABSTRACT FROM AUTHOR]

How does leadership emerge and function when multiple health care organizations come together to form a network? In this qualitative comparative case study, we draw on distributed leadership theory to examine the leadership practices that manifested during the implementation of three coordinated care networks. Thirty leaders and care providers participated in semistructured interviews. Interview data were inductively analyzed using thematic analysis. Although established in response to the same policy initiative, each case differed in its leadership approach and implementation strategy. We found that manifestation of distributed leadership was contingent on the presence of an individual leader who acted as a unifying force across their respective network. Our findings suggest that policies to encourage the development of interorganizational networks should include sufficient resources to support an individual leader who enables distributed leadership. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population. Objective: To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment. Methods: Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches. Results: Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants' needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment. Conclusions: More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors. [ABSTRACT FROM AUTHOR]

Background: Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke. Methods: We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function. Results: Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1–2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health. Conclusion: The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial. Trial registration: ClinicalTrials.gov, NCT03122626. Registered April 21, 2017 — retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: eHealth technologies for self-management can improve quality of life, but little is known about whether the benefits gained outweigh their costs. The electronic patient-reported outcome (ePRO) mobile app and portal system supports patients with multiple chronic conditions to collaborate with primary health care providers to set and monitor health-related goals. Objective: This study aims to estimate the cost of ePRO and the cost utility of the ePRO intervention compared with usual care provided to patients with multiple chronic conditions and complex needs living in the community, from the perspective of the publicly funded health care payer in Ontario, Canada. Methods: We developed a decision tree model to estimate the incremental cost per quality-adjusted life year (QALY) gained for the ePRO tool versus usual care over a time horizon of 15 months. Resource utilization and effectiveness of the ePRO tool were drawn from a randomized clinical trial with 6 family health teams involving 45 participants. Unit costs associated with health care utilization (adjusted to 2020 Canadian dollars) were drawn from literature and publicly available sources. A series of sensitivity analyses were conducted to assess the robustness of the findings. Results: The total cost of the ePRO tool was CAD $79,467 (~US $ 63,581; CAD $1733 [~US $1386] per person). Compared with standard care, the ePRO intervention was associated with higher costs (CAD $1710 [~US $1368]) and fewer QALYs (-0.03). The findings were consistent with the clinical evidence, suggesting no statistical difference in health-related quality of life between ePRO and usual care groups. However, the tool would be considered a cost-effective option if it could improve by at least 0.03 QALYs. The probability that the ePRO is cost-effective was 17.3% at a willingness-to-pay (WTP) threshold of CAD $50,000 (~US $40,000)/QALY. Conclusions: The ePRO tool is not a cost-effective technology at the commonly used WTP value of CAD $50,000 (~US $40,000)/QALY, but long-term and the societal impacts of ePRO were not included in this analysis. Further research is needed to better understand its impact on long-term outcomes and in real-world settings. The present findings add to the growing evidence about eHealth interventions' capacity to respond to complex aging populations within finite-resourced health systems. [ABSTRACT FROM AUTHOR]

Background: Multiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England. Methods and findings: A random sample of primary care patients from Clinical Practice Research Datalink (CPRD) was followed from 1st January 2015 until 31st December 2019. Ethnicity, usually self-ascribed, was obtained from primary care records if present or from hospital records. Long-term conditions were counted from a list of 32 that have previously been associated with greater primary care, hospital admissions, or mortality risk. Cox regression models were used to estimate mortality by count of conditions, ethnicity and their interaction, with adjustment for age and sex for 532,059 patients with complete data. During five years of follow-up, 5.9% of patients died. Each additional condition at baseline was associated with increased mortality. The direction of the interaction of number of conditions with ethnicity showed a statistically higher mortality rate associated with long-term conditions in Pakistani, Black African, Black Caribbean and Other Black ethnic groups. In ethnicity-stratified models, the mortality rate per additional condition at age 50 was 1.33 (95% CI 1.31,1.35) for White ethnicity, 1.43 (95% CI 1.26,1.61) for Black Caribbean ethnicity and 1.78 (95% CI 1.41,2.24) for Other Black ethnicity. Conclusions: The higher mortality rate associated with having multiple conditions is greater in minoritised compared with White ethnic groups. Research is now needed to identify factors that contribute to these inequalities. Within the health care setting, there may be opportunities to target clinical and self-management support for people with multiple conditions from minoritised ethnic groups. [ABSTRACT FROM AUTHOR]

Background: Patient engagement (PE) in hospital planning and improvement is widespread, yet we lack evidence of its impact. We aimed to identify benefits and harms that could be used to assess the impact of hospital PE. Methods: We interviewed hospital-affiliated persons involved in PE activities using a qualitative descriptive approach and inductive content analysis to derive themes. We interpreted themes by mapping to an existing framework of healthcare performance measures and reported themes with exemplar quotes. Results: Participants included 38 patient/family advisors, PE managers and clinicians from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Benefits of PE activities included 9 impacts on the capacity of hospitals. PE activities involved patient/family advisors and clinicians/staff in developing and spreading new PE processes across hospital units or departments, and those involved became more adept and engaged. PE had beneficial effects on hospital structures/resources, clinician staff functions and processes, patient experience and patient outcomes. A total of 14 beneficial impacts of PE were identified across these domains. Few unintended or harmful impacts were identified: overextended patient/family advisors, patient/family advisor turnover and clinician frustration if PE slowed the pace of planning and improvement. Conclusions: The 23 self reported impacts were captured in a Framework of Impacts of Patient/Family Engagement on Hospital Planning and Improvement, which can be used by decision-makers to assess and allocate resources to hospital PE, and as the basis for ongoing research on the impacts of hospital PE and how to measure it. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Despite growing emphasis on adopting team-based models of primary care to facilitate patient access to a diverse range of care providers, our understanding of team functioning within primary care teams remains limited. This study examined interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers – [CHC]) in Ontario and explored team-level and organizational factors associated with interprofessional teamwork. Interprofessional teamwork was measured using the Collaborative Practice Assessment Tool (CPAT), which was completed by providers in each participating team. The CPAT responses of 988 providers representing on average 12 professions (sd = 2.1) across 66 teams (44 FHTs and 22 CHCs) were included in the analysis. The average CPAT score was 46.6 (sd = 2.5). CHCs had significantly higher CPAT scores than FHTs (mdiff = 1.7, p =.02). Using diverse communication mechanisms to share information, increasing quality improvement capacities, and age of practice, had a statistically significant positive association with CPAT scores. Increasing team size, using centralized administrative processes, a high level of information exchange, and having a mixed governance board were significantly negatively associated with CPAT score. Findings illustrate factors associated with interprofessional teamwork and offer insight into the comparative performance of two team-based primary care models in Ontario. [ABSTRACT FROM AUTHOR]

Introduction: In 2019, Ontario's Ministry of Health (the Ministry) introduced Ontario Health Teams (OHTs) to provide population-based integrated healthcare. Primary care was foundational to this approach. We sought to identify factors that impacted primary care engagement during OHT formation from different perspectives. Methods: Interviews with 111 participants (administrators n = 80; primary care providers n = 17; patient family advisors = 14) from 11 OHTs were conducted following a semi-structured guide. Interviews were transcribed, coded, and thematically analyzed. Results: Participants felt that primary care engagement was an ongoing, continuous cycle. Four themes were identified: 1) 'A low rules environment': limited direction from the Ministry (system-level), 2) 'They're at different starting points': impact of local context (initiative-level); 3) 'We want primary care to be actively involved': engagement efforts made by OHTs (initiative-level); 4) 'Waiting to hear a little bit more': primary care concerns about the OHT approach (sector-level). Thirteen factors impacting primary care engagement were identified across the four themes. Discussion and Conclusion: The 13 factors influencing primary care engagement were interconnected and operated at health system, integrated care initiative, and sector levels. Future research should focus on integrated care initiatives as they mature, to address potential gaps in the involvement of primary care physicians. [ABSTRACT FROM AUTHOR]

Background: Digital health technologies can support primary care delivery, but clinical uptake in primary care is limited. This study explores enablers and barriers experienced by primary care providers when adopting new digital health technologies, using the example of the electronic Patient Reported Outcome (ePRO) tool; a mobile application and web portal designed to support goal-oriented care. To better understand implementation drivers and barriers primary care providers' usage behaviours are compared to their perspectives on ePRO utility and fit to support care for patients with complex care needs.Methods: This qualitative sub-analysis was part of a larger trial evaluating the use of the ePRO tool in primary care. Qualitative interviews were conducted with providers at the midpoint (i.e. 4.5-6 months after ePRO implementation) and end-point (i.e. 9-12 months after ePRO implementation) of the trial. Interviews explored providers' experiences and perceptions of integrating the tool within their clinical practice. Interview data were analyzed using a hybrid thematic analysis and guided by the Technology Acceptance Model. Data from thirteen providers from three distinct primary care sites were included in the presented study.Results: Three core themes were identified: (1) Perceived usefulness: perceptions of the tool's alignment with providers' typical approach to care, impact and value and fit with existing workflows influenced providers' intention to use the tool and usage behaviour; (2) Behavioural intention: providers had a high or low behavioural intention, and for some, it changed over time; and (3) Improving usage behaviour: enabling external factors and enhancing the tool's perceived ease of use may improve usage behaviour.Conclusions: Multiple refinements/iterations of the ePRO tool (e.g. enhancing the tool's alignment with provider workflows and functions) may be needed to enhance providers' usage behaviour, perceived usefulness and behavioural intention. Enabling external factors, such as organizational and IT support, are also necessary to increase providers' usage behaviour. Lessons from this study advance knowledge of technology implementation in primary care.Trial Registration: Clinicaltrials.gov Identified NCT02917954. Registered September 2016, https://www.clinicaltrials.gov/ct2/show/study/NCT02917954. [ABSTRACT FROM AUTHOR]

Objective: The objectives of this study are to compare the relative use of different postacute care settings in different countries and to compare three important outcomes as follows: total expenditure, total days of care in different care settings, and overall longevity over a 1‐year period following a hip fracture. Data Sources: We used administrative data from hospitals, institutional and home‐based long‐term care (LTC), physician visits, and medications compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) from five countries as follows: Canada, France, Germany, the Netherlands, and Sweden. Data Extraction Methods: Data were extracted from existing administrative data systems in each participating country. Study Design: This is a retrospective cohort study of all individuals admitted to acute care for hip fracture. Descriptive comparisons were used to examine aggregate institutional and home‐based postacute care. Care trajectories were created to track sequential care settings after acute‐care discharge through institutional and community‐based care in three countries where detailed information allowed. Comparisons in patient characteristics, utilization, and costs were made across these trajectories and countries. Principal Findings: Across five countries with complete LTC data, we found notable variations with Germany having the highest days of home‐based services with relatively low costs, while Sweden incurred the highest overall expenditures. Comparisons of trajectories found that France had the highest use of inpatient rehabilitation. Germany was most likely to discharge hip fracture patients to home. Over 365 days, France averaged the highest number of days in institution with 104, Canada followed at 94, and Germany had just 87 days of institutional care on average. Conclusion: In this comparison of LTC services following a hip fracture, we found international differences in total use of institutional and noninstitutional care, longevity, and total expenditures. There exist opportunities to organize postacute care differently to maximize independence and mitigate costs. [ABSTRACT FROM AUTHOR]

Objective: To identify and explore differences in spending and utilization of key health services at the end of life among hip fracture patients across seven developed countries. Data Sources: Individual‐level claims data from the inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC). Study Design: We retrospectively analyzed utilization and spending from acute hospital care, emergency department, outpatient primary care and specialty physician visits, and outpatient drugs. Patterns of spending and utilization were compared in the last 30, 90, and 180 days across Australia, Canada, England, Germany, New Zealand, Spain, and the United States. We employed linear regression models to measure age‐ and sex‐specific effects within and across countries. In addition, we analyzed hospital‐centricity, that is, the days spent in hospital and site of death. Data Collection/Extraction Methods: We identified patients who sustained a hip fracture in 2016 and died within 12 months from date of admission. Principal Findings: Resource use, costs, and the proportion of deaths in hospital showed large variability being high in England and Spain, while low in New Zealand. Days in hospital significantly decreased with increasing age in Canada, Germany, Spain, and the United States. Hospital spending near date of death was significantly lower for women in Canada, Germany, and the United States. The age gradient and the sex effect were less pronounced in utilization and spending of emergency care, outpatient care, and drugs. Conclusions: Across seven countries, we find important variations in end‐of‐life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems. [ABSTRACT FROM AUTHOR]

Background: Patient and family engagement (PE) in healthcare planning and improvement achieves beneficial outcomes and is widely advocated, but a lack of resources is a critical barrier. Little prior research studied how organizations support engagement specifically in hospitals.Objective: We explored what constitutes hospital capacity for engagement.Methods: We conducted descriptive qualitative interviews and complied with criteria for rigour and reporting in qualitative research. We interviewed patient/family advisors, engagement managers, clinicians and executives at hospitals with high engagement activity, asking them to describe essential resources or processes. We used content analysis and constant comparison to identify themes and corresponding quotes and interpreted findings by mapping themes to two existing frameworks of PE capacity not specific to hospitals.Results: We interviewed 40 patient/family advisors, patient engagement managers, clinicians and corporate executives from nine hospitals (two < 100 beds, four 100 + beds, three teaching). Four over-arching themes about capacity considered essential included resources, training, organizational commitment and staff support. Views were similar across participant and hospital groups. Resources included funding and people dedicated to PE and technology to enable communication and collaboration. Training encompassed initial orientation and project-specific training for patient/family advisors and orientation for new staff and training for existing staff on how to engage with patient/family advisors. Organizational commitment included endorsement from the CEO and Board, commitment from staff and continuous evaluation and improvement. Staff support included words and actions that conveyed value for the role and input of patient/family advisors. The blended, non-hospital-specific framework captured all themes. Hospitals of all types varied in the availability of funding dedicated to PE. In particular, reimbursement of expenses and compensation for time and contributions were not provided to patient/family advisors. In addition to skilled engagement managers, the role of clinician or staff champions was viewed as essential.Conclusion: The findings build on prior research that largely focused on PE in individual clinical care or research or in primary care planning and improvement. The findings closely aligned with existing frameworks of organizational capacity for PE not specific to hospital settings, which suggests that hospitals could use the blended framework to plan, evaluate and improve their PE programs. Further research is needed to yield greater insight into how to promote and enable compensation for patient/family advisors and the role of clinician or staff champions in supporting PE. [ABSTRACT FROM AUTHOR]

Objective: The objectives of this study are to compare the relative use of different postacute care settings in different countries and to compare three important outcomes as follows: total expenditure, total days of care in different care settings, and overall longevity over a 1‐year period following a hip fracture. Data Sources: We used administrative data from hospitals, institutional and home‐based long‐term care (LTC), physician visits, and medications compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) from five countries as follows: Canada, France, Germany, the Netherlands, and Sweden. Data Extraction Methods: Data were extracted from existing administrative data systems in each participating country. Study Design: This is a retrospective cohort study of all individuals admitted to acute care for hip fracture. Descriptive comparisons were used to examine aggregate institutional and home‐based postacute care. Care trajectories were created to track sequential care settings after acute‐care discharge through institutional and community‐based care in three countries where detailed information allowed. Comparisons in patient characteristics, utilization, and costs were made across these trajectories and countries. Principal Findings: Across five countries with complete LTC data, we found notable variations with Germany having the highest days of home‐based services with relatively low costs, while Sweden incurred the highest overall expenditures. Comparisons of trajectories found that France had the highest use of inpatient rehabilitation. Germany was most likely to discharge hip fracture patients to home. Over 365 days, France averaged the highest number of days in institution with 104, Canada followed at 94, and Germany had just 87 days of institutional care on average. Conclusion: In this comparison of LTC services following a hip fracture, we found international differences in total use of institutional and noninstitutional care, longevity, and total expenditures. There exist opportunities to organize postacute care differently to maximize independence and mitigate costs. [ABSTRACT FROM AUTHOR]

Objective: To identify and explore differences in spending and utilization of key health services at the end of life among hip fracture patients across seven developed countries. Data Sources: Individual‐level claims data from the inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC). Study Design: We retrospectively analyzed utilization and spending from acute hospital care, emergency department, outpatient primary care and specialty physician visits, and outpatient drugs. Patterns of spending and utilization were compared in the last 30, 90, and 180 days across Australia, Canada, England, Germany, New Zealand, Spain, and the United States. We employed linear regression models to measure age‐ and sex‐specific effects within and across countries. In addition, we analyzed hospital‐centricity, that is, the days spent in hospital and site of death. Data Collection/Extraction Methods: We identified patients who sustained a hip fracture in 2016 and died within 12 months from date of admission. Principal Findings: Resource use, costs, and the proportion of deaths in hospital showed large variability being high in England and Spain, while low in New Zealand. Days in hospital significantly decreased with increasing age in Canada, Germany, Spain, and the United States. Hospital spending near date of death was significantly lower for women in Canada, Germany, and the United States. The age gradient and the sex effect were less pronounced in utilization and spending of emergency care, outpatient care, and drugs. Conclusions: Across seven countries, we find important variations in end‐of‐life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems. [ABSTRACT FROM AUTHOR]

Background: Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings. Methods: We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome. Results: We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98–1.42; Q3 OR 1.34, 95% CI 1.10–1.63; Q4 OR 1.46, 95% CI 1.19–1.79; Q5 OR 1.87, 95% CI 1.50–2.33), after hours access (Q2 OR 1.26, 95% CI 1.09–1.47; Q3 OR 1.46, 95% CI 1.23–1.74; Q4 OR 1.77, 95% CI 1.46–2.15; Q5 OR 1.88, 95% CI 1.52–2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85–1.20; Q3 OR 1.17, 95% CI 0.97–1.41; Q4 OR 1.27, 95% CI 1.05–1.55; Q5 OR 1.63, 95% CI 1.32–2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98–1.69; Q3 OR 1.29, 95% CI 0.94–1.77; Q4 OR 1.58, 95% CI 1.16–2.13; Q5 OR 1.98, 95% CI 1.38–2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes. Interpretation: Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience. [ABSTRACT FROM AUTHOR]

Background: Many countries, including Canada, have introduced primary care reforms to improve health system functioning and value. The purpose of this study was to examine the association between receiving care from interprofessional primary care teams and after-hours access to care, patient-reported walk-in clinic visits and emergency department use.Methods: We conducted a retrospective cohort study linking population-based administrative databases to Ontario's Health Care Experience Survey (HCES) between 2012 and 2018. We adjusted for physician group characteristics as well as individual physician and patient characteristics while assessing the relationship between receiving care from interprofessional teams and the outcomes of interest.Results: As of March 31st, 2015, there were 465 physician groups with HCES respondents of which 177 (38.0%) were interprofessional teams and 288 (62.0%) were non-interprofessional teams in the same blended capitation reimbursement model. In this period, there were 4518 physicians with HCES respondents, of whom 2131 (47.2%) were in interprofessional teams and 2387 (52.8%) were in non-interprofessional teams. There were 10,102 HCES respondents included in this study, of whom 42.4% were in interprofessional teams and 42.3% were in non-interprofessional teams. After adjustment, we found that being in an interprofessional team was associated with an increase in the odds of patients reporting same/next day access to care by 12.0% (OR = 1.12 CI = 1.00 to 1.24 p-value 0.0436) and a decrease in the odds of patients reporting walk-in clinic use by 16% (OR = 0.84 CI = 0.75 to 0.94 p-value 0.0019). After adjustment, there were no significant differences in patient-reported after-hours access to care and emergency department use.Conclusions: Ontario has invested heavily in interprofessional primary care teams. As compared to patients in non-interprofessional teams, patients in interprofessional teams self-reported more timely access to care and less walk-in clinic use but no significant difference in self-reported access to after-hours care or in emergency department use. For jurisdictions aiming to expand physician voluntary participation in interprofessional teams, our study results inform expectations around access to care and health services utilization. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Patient engagement (PE) in health‐care planning and improvement is a growing practice. We lack evidence‐based guidance for PE, particularly in hospital settings. This study explored how to optimize PE in hospitals. Methods: This study was based on qualitative interviews with individuals in various roles at hospitals with high PE capacity. We asked how patients were engaged, rationale for approaches chosen and solutions for key challenges. We identified themes using content analysis. Results: Participants included 40 patient/family advisors, PE managers, clinicians and executives from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Hospitals most frequently employed collaboration (standing committees, project teams), followed by blended approaches (collaboration + consultation), and then consultation (surveys, interviews). Those using collaboration emphasized integrating perspectives into decisions; those using consultation emphasized capturing diverse perspectives. Strategies to support engagement included engaging diverse patients, prioritizing what benefits many, matching patients to projects, training patients and health‐care workers, involving a critical volume of patients, requiring at least one patient for quorum, asking involved patients to review outputs, linking PE with the Board of Directors and championing PE by managers, staff and committee/team chairs. Conclusion: This research generated insight on concrete approaches and strategies that hospitals can use to optimize PE for planning and improvement. On‐going research is needed to understand how to recruit diverse patients and best balance blended consultation/collaboration approaches. Patient or public contribution: Three patient research partners with hospital PE experience informed study objectives and interview questions. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is increasing among older adults, but the impact of these recent trends on the extent and complexity of polypharmacy and possible variation by sex remains unknown. We examined sex differences in multimorbidity, polypharmacy (5+ medications) and hyper-polypharmacy (10+ medications) in 2003 vs 2016, and the interactive associations between age, multimorbidity level, and time on polypharmacy measures. Methods and findings: We employed a repeated cross-sectional study design with linked health administrative databases for all persons aged ≥66 years eligible for health insurance in Ontario, Canada at the two index dates. Descriptive analyses and multivariable logistic regression models were conducted; models included interaction terms between age, multimorbidity level, and time period to estimate polypharmacy and hyper-polypharmacy probabilities, risk differences and risk ratios for 2016 vs 2003. Multimorbidity, polypharmacy and hyper-polypharmacy increased significantly over the 13 years. At both index dates prevalence estimates for all three were higher in women, but a greater absolute increase in polypharmacy over time was observed in men (6.6% [from 55.7% to 62.3%] vs 0.9% [64.2%-65.1%] for women) though absolute increases in multimorbidity were similar for men and women (6.9% [72.5%-79.4%] vs 6.2% [75.9%-82.1%], respectively). Model findings showed that polypharmacy decreased over time among women aged < 90 years (especially for younger ages and those with fewer conditions), whereas it increased among men at all ages and multimorbidity levels (with larger absolute increases typically at older ages and among those with 4 or fewer conditions). Conclusions: There are sex and age differences in the impact of increasing chronic disease burden on changes in measures of multiple medication use among older adults. Though the drivers and health consequences of these trends warrant further investigation, the findings support the heterogeneity and complexity in the evolving association between multimorbidity and polypharmacy measures in older populations. [ABSTRACT FROM AUTHOR]

Background: Continuity of care is a well-recognized principle of the primary care discipline owing to its medical, interpersonal, and cost-saving benefits. Relationship continuity or the ongoing therapeutic relationship between a patient and their physician is a particularly desirable goal, but its role in preventing the accumulation of chronic conditions diagnoses in individuals is unknown. The objective of this study was to investigate the effect of continuity of care with physicians on the rate of incident multimorbidity diagnoses in patients with existing conditions. Methods: This was a population-based, retrospective cohort study from 2001 to 2015 that focused on patients aged 18 to 105 years with at least one chronic condition (n = 166,665). Our primary exposure was relationship continuity of care with general practitioners and specialists measured using the Bice-Boxerman Continuity of Care Index (COCI). COCI was specified as a time-dependent exposure prior to the observation period. Our outcomes of interest were the time to diagnosis of a second, third, and fourth chronic condition estimated using cause-specific hazard regressions accounting for death as a competing risk. Findings: We observed that patients with a single chronic condition and high continuity of care (>0.50) were diagnosed with a second chronic condition or multimorbidity at an 8% lower rate compared to individuals with low continuity (cause-specific hazard ratio (HR) 0.92 (95% Confidence Interval 0.90–0.93; p<0.0001) after adjusting for age, sex, income, place of residence, primary care enrolment, and the annual number of physician visits. Continuity remained protective as the degree of multimorbidity increased. Among patients with two conditions, the risk of diagnosis of a third chronic condition was also 8% lower for individuals with high continuity (HR 0.92; CI 0.90–0.94; p<0.0001). Patients with three conditions and high continuity had a 9% lower risk of diagnosis with a fourth condition (HR 0.91; CI 0.89–0.93; p<0.0001). Conclusions: Continuity of care is a potentially modifiable health system factor that reduces the rate at which diagnoses of chronic conditions are made over time in patients with multimorbidity. Additional research is needed to explain the underlying mechanisms through which continuity is related to a protective effect and the clinical sequalae. [ABSTRACT FROM AUTHOR]

Background: Patient engagement (PE) in planning or improving hospital facilities or services is one approach for improving healthcare delivery and outcomes. To provide evidence on hospital capacity needed to support PE, we described the attributes of hospital PE capacity associated with clinical quality measures.Methods: We conducted a cross-sectional survey of general and specialty hospitals based on the Measuring Organizational Readiness for Patient Engagement framework. We derived a PE capacity index measure, and with Multiple Correspondence Analysis, assessed the association of PE capacity with hospital type, and rates of hand-washing, C. difficile infection rates and 30-day readmission.Results: Respondents (91, 66.4%) included general: < 100 beds (48.4%), 100+ beds (27.5%), teaching hospitals (11.0%) and specialty (13.2%) hospitals. Most featured PE in multiple clinical and corporate departments. Most employed PE in a range of Planning (design/improve facilities 94.5%, develop strategic plans 87.9%), Evaluation/Quality Improvement (accreditation 91.2%, develop QI plans 90.1%) and Service Delivery activities (develop information/communication aids 92.3%). Hospitals enabled PE with multiple supports (median 12, range 0 to 25), most often: 76.9% strategic plan recognizes PE, 74.7% patient/family advisory council, and 69.2% pool of patient volunteers; and least often: 30.0% PE staff, 26.4% PE funding and 16.5% patient reimbursement or 3.3% compensation. Hospitals employed a range of less (inform, consult) and more (involve, partner) active modes of engagement. Two variables accounted for 29.6% of variance in hospital PE capacity index measure data: number of departments featuring PE and greater use of active engagement modes. PE capacity was not associated with general hospital type or clinical quality measures.Conclusions: Hospitals with fewer resources can establish favourable PE conditions by deploying PE widely and actively engaging patients. Healthcare policy-makers, hospital executives and PE managers can use these findings to allocate PE resources. Future research should explore how PE modes and methods impact clinical outcomes. [ABSTRACT FROM AUTHOR]

Understanding the symptom burden trajectory for metastatic breast cancer patients can enable the provision of appropriate supportive care for symptom management. The aim of this study was to describe the longitudinal trajectories of symptom burden for metastatic breast cancer patients at the population-level. A cohort of 995 metastatic breast cancer patients with 16,146 Edmonton Symptom Assessment System (ESAS) assessments was constructed using linked population-level health administrative databases. The patient-reported ESAS total symptom distress score (TSDS) was studied over time using group-based trajectory modeling, and covariate influences on trajectory patterns were examined. Cohort patients experienced symptom burden that could be divided into six distinct trajectories. Patients experiencing a higher baseline TSDS were likely to be classified into trajectory groups with high, uncontrolled TSDS within the study follow-up period (2 (1, N = 995) = 136.25, p < 0.001). Compared to patients classified in the group trajectory with the highest relative TSDS (Group 6), patients classified in the lowest relative TSDS trajectory group (Group 1) were more likely to not have comorbidities (97.34% (for Groups 1-3) vs. 91.82% (for Group 6); p < 0.05), more likely to receive chemotherapy (86.52% vs. 80.50%; p < 0.05), and less likely to receive palliative care (52.81% vs. 79.25%; p < 0.0001). Receiving radiotherapy was a significant predictor of how symptom burden was experienced in all identified groups. Overall, metastatic breast cancer patients follow heterogeneous symptom burden trajectories over time, with some experiencing a higher, uncontrolled symptom burden. Understanding trajectories can assist in establishing risk-stratified care pathways for patients. [ABSTRACT FROM AUTHOR]

Background: Providing equitable care to patients in need across the life course is a priority for many healthcare systems. Aim: To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters). Design: Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap). Setting/Participants: A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016. Results: In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9–5.1%), which was 8.6% (6.2–10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8–7.8%) absolute gap, 26.3% (22.5–30.0%) relative gap) and for physician encounters (6.8% (5.7–7.9%) absolute gap, 13.2% (11.0–15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death). Conclusion: Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services. [ABSTRACT FROM AUTHOR]

Background: Improving health system value and efficiency are considered major policy priorities internationally. Ontario has undergone a primary care reform that included introduction of interprofessional teams. The purpose of this study was to investigate the relationship between receiving care from interprofessional versus non-interprofessional primary care teams and ambulatory care sensitive condition (ACSC) hospitalizations and hospital readmissions.Methods: Population-based administrative databases were linked to form data extractions of interest between the years of 2003-2005 and 2015-2017 in Ontario, Canada. The data sources were available through ICES. The study design was a retrospective longitudinal cohort. We used a "difference-in-differences" approach for evaluating changes in ACSC hospitalizations and hospital readmissions before and after the introduction of interprofessional team-based primary care while adjusting for physician group, physician and patient characteristics.Results: As of March 31st, 2017, there were a total of 778 physician groups, of which 465 were blended capitation Family Health Organization (FHOs); 177 FHOs (22.8%) were also interprofessional teams and 288 (37%) were more conventional group practices ("non-interprofessional teams"). In this period, there were a total of 13,480 primary care physicians in Ontario of whom 4848 (36%) were affiliated with FHOs-2311 (17.1%) practicing in interprofessional teams and 2537 (18.8%) practicing in non-interprofessional teams. During that same period, there were 475,611 and 618,363 multi-morbid patients in interprofessional teams and non-interprofessional teams respectively out of a total of 2,920,990 multi-morbid adult patients in Ontario. There was no difference in change over time in ACSC admissions between interprofessional and non-interprofessional teams between the pre- and post intervention periods. There were no statistically significant changes in all cause hospital readmission s between the post- and pre-intervention periods for interprofessional and non-interprofessional teams.Conclusions: Our study findings indicate that the introduction of interprofessional team-based primary care was not associated with changes in ACSC hospitalization or hospital readmissions. The findings point for the need to couple interprofessional team-based care with other enablers of a strong primary care system to improve health services utilization efficiency. [ABSTRACT FROM AUTHOR]

OBJECTIVES The main objective of the study was to investigate annual changes in the sociodemographic characteristics, morbidity, and functional status of new nursing home residents in Ontario, Canada, between 2000 and 2015. A secondary objective was to develop and assess the quality of an algorithm for ascertaining admissions into publicly funded nursing homes in Ontario using a combination of health administrative data sources that indirectly identifies the residential status of new nursing home residents. DESIGN Population‐based serial cross‐sectional study with an accompanying quality assessment study of algorithms. SETTING Publicly funded nursing care homes in Ontario, Canada. PARTICIPANTS The reference standard for the assessment of algorithm performance was 21 544 newly admitted nursing home residents identified from the Resident Assessment Instrument‐Minimum Data Set in 2012. The selected algorithm was then used to identify serial cross‐sectional cohorts of newly admitted residents between 2000 and 2015 that ranged in size between 14 651 and 23 630 residents. MEASUREMENTS Sociodemographic characteristics, morbidity, and functional status of new residents were determined upon admission to examine patterns in the cohorts' profiles. RESULTS: The proportion of residents aged 85 years and older increased from 45.1% to 53.8% over 16 years. The proportions of individuals with seven or more chronic conditions (from 14.1% to 22.1%) and with nine or more prescription medications (from 44.9% to 64.2%) have also increased in parallel over time. Hypertension, osteoarthritis, and dementia were the most prevalent conditions captured, with the proportion of incoming residents with dementia increasing from 42.3% to 54.1% between 2000 and 2015. Newly admitted residents were more likely to have extensive physical and cognitive impairments upon admission. CONCLUSION: Admission trends show that new residents were older and had greater multimorbidity and limitations in physical functioning over time. J Am Geriatr Soc 68:1293–1300, 2020. [ABSTRACT FROM AUTHOR]

Background: We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada.Methods: We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014.Results: For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes.Conclusions: Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to: (1) explore whether the quality of overall care for older people with diabetes is differentially affected by types and number of comorbid conditions and (2) examine the association between process of care measures and the likelihood of all-cause hospitalisations. Design A population-based, retrospective cohort study. Setting The province of Ontario, Canada. Participants We identified 673 197 Ontarians aged 65 years and older who had diabetes comorbid with hypertension, chronic ischaemic heart disease, osteoarthritis or depression on 1 April 2010. Main outcome measures The study outcome was the likelihood of having at least one hospital admission in each year, during the study period, from 1 April 2010 to 3 March 2014. Process of care measures specific to older adults with diabetes and these comorbidities, developed by means of a Delphi panel, were used to assess the quality of care. A generalised estimating equations approach was used to examine associations between the process of care measures and the likelihood of hospitalisations. Results The study findings suggest that patients are at risk of suboptimal care with each additional comorbid condition, while the incidence of hospitalisations and number of prescribed drugs markedly increased in patients with 2 versus 1 selected comorbid condition, especially in those with discordant comorbidities. The median continuity of care score was higher among patients with diabetes-concordant conditions compared with those with diabetes-discordant conditions, and it declined with additional comorbid conditions in both groups. Greater continuity of care was associated with lower hospital utilisation for older diabetes patients with both concordant and discordant conditions. Conclusions There is a need for focusing on improving continuity of care and prioritising treatment in older adults with diabetes with any multiple conditions but especially in those with diabetes-discordant conditions (eg, depression). [ABSTRACT FROM AUTHOR]

Background: This study examined the incidence of a person's first diagnosis of a selected chronic disease, and the relationships between modifiable lifestyle risk factors and age to first of six chronic diseases.Methods: Ontario respondents from 2001 to 2010 of the Canadian Community Health Survey were followed up with administrative data until 2014 for congestive heart failure, chronic obstructive respiratory disease, diabetes, lung cancer, myocardial infarction and stroke. By sex, the cumulative incidence function of age to first chronic disease was calculated for the six chronic diseases individually and compositely. The associations between modifiable lifestyle risk factors (alcohol, body mass index, smoking, diet, physical inactivity) and age to first chronic disease were estimated using cause-specific Cox proportional hazards models and Fine-Gray competing risk models.Results: Diabetes was the most common disease. By age 70.5 years (2015 world life expectancy), 50.9% of females and 58.1% of males had at least one disease and few had a death free of the selected diseases (3.4% females; 5.4% males). Of the lifestyle factors, heavy smoking had the strongest association with the risk of experiencing at least one chronic disease (cause-specific hazard ratio = 3.86; 95% confidence interval = 3.46, 4.31). The lifestyle factors were modelled for each disease separately, and the associations varied by chronic disease and sex.Conclusions: We found that most individuals will have at least one of the six chronic diseases before dying. This study provides a novel approach using competing risk methods to examine the incidence of chronic diseases relative to the life course and how their incidences are associated with lifestyle behaviours. [ABSTRACT FROM AUTHOR]