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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)., The public health effects of the COVID-19 pandemic are difficult to overstate. (1) More than 600 million SARS-CoV-2 infections and 6.5 million deaths have been reported worldwide as of September [...]

IMPORTANCE: Employment and personal income loss after traumatic brain injury is a major source of postinjury stress and a barrier to societal reintegration. The magnitude of labor market ramifications following traumatic brain injury remains largely unknown. OBJECTIVES: To quantify the 3-year postinjury labor market consequences following traumatic brain injury in Canada. To also estimate the incurred national labor market cost over the study period. DESIGN, SETTING, AND PARTICIPANTS: This retrospective quasi-experimental, pan-Canadian observational cohort study used linked administrative health and federal taxation data obtained between 2007 and 2017. Mixed-effects difference-in-difference regressions were constructed to estimate the annualized magnitude of the personal income and employment loss during each of the 3 years following injury, respectively, relative to preinjury baseline. Participants included tax-filing adult (19 to 61 years old) traumatic brain injury survivors. EXPOSURE: Traumatic brain injury. MAIN OUTCOME MEASURES: Coprimary outcomes were personal income loss and the proportion of newly unemployed individuals per annum. Secondary objectives were to quantify income and employment loss within mild, moderate, and severe traumatic brain injury subgroups. RESULTS: A total of 18 050 patients with traumatic brain injury between 2007 and 2017 were identified (mean age, 38.0 [SD, 12.4] years; 13 360 male [74.0%]), each of whom was followed up with for 3 consecutive fiscal years. Mean income was CAD $42 600 (US $31 083) in the fiscal year prior to injury and 82% were employed at time of injury. The adjusted mean loss of personal income was CAD $7635 (US $5650) in the first year after injury (Y+1) and CAD $5000 (US $3700) in the third year after injury (Y+3) relative to uninjured controls. In each of the 3 postinjury years, 7.8% individuals were newly unemployed compared with the preinjury baseline. The adjusted average personal income loss for mild, moderate, and severe traumatic brain injury subgroups were CAD $3354 (US $2482), CAD $6750 (US $4995), and CAD $17 375 (US $12 859), respectively, at Y+3; the proportion of unemployed individuals increased by 5.8%, 9.2%, and 20% across the same groups at Y+3 after injury relative to preinjury baseline. The estimated total reduction in personal income aggregated over the 3 postinjury years for the affected participants was CAD $588 million (US $435 million). CONCLUSIONS AND RELEVANCE: This work represents national cohort data quantifying the labor market implications of traumatic brain injury. These results may be used to inform economic evaluations and social service resource allocation.

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. KEYWORDS administrative data, age inequalities, end-of-life care, gender inequalities, health care spending, health care utilization, international comparison, What is known on this topic * Countries follow different approaches to providing end-of-life care. * Health care spending and utilization increases near death. * International studies of health systems [...]

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 homebased 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 communitybased 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. KEYWORDS care trajectories, hip fracture, international comparison, long-term care, What is known about this topic * International comparisons of long-term care mostly rely on global comparisons of national expenditure. * Little comparative work has examined variations in the care [...]

Objective: To establish a methodological approach to compare two high-need, highcost (HNHC) patient personas internationally. Data sources: Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. Study design: We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, homehealth care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries. Data collection/extraction methods: Data collected by ICCONIC partners. Principal findings: Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries. Conclusion: Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries. KEYWORDS international comparison, vignettes, What is known on this topic * International comparisons of health systems mostly rely on comparisons of the inpatient setting. * Little comparative work examines patterns of spending and utilization [...]

BACKGROUND: There is a lack of data in Canada on the longitudinal effects of adverse events that occur in hospital, specifically in the period after discharge. Our objective was to quantify the impact of adverse events on hospital length of stay, length of person-centred episodes of care (PCEs) and costs of PCEs, as well as their impact on the total health system. METHODS: We conducted a population-based, retrospective cohort study using linked health administrative databases. We included adults in Ontario who had an acute hospital admission between Apr. 1, 2015, and Mar. 31, 2016. We grouped hospital admissions into 1 of 9 episode types and used the Canadian Institute for Health Information methodology for hospital harm to measure adverse events. We specified generalized linear models to estimate the impact of hospital harm on the following: incremental length of index acute hospital admission, incremental length of the PCE, and incremental costs of the PCE. RESULTS: Out of 610979 hospital admissions, 36 004 (5.9%) involved an occurrence of harm. The impact of harm on the incremental length of hospital stay ranged from 0.4 to 24.2 days (p < 0.001); the incremental length of the PCE ranged from 0.3 to 30.2 days (p < 0.001); and the incremental costs of the PCE ranged from $800 to $51067 (p < 0.001). Total hospital days attributable to hospital harm amounted to 407 696, and the total attributable cost to the Ontario health system amounted to $1088330376. INTERPRETATION: We found that experiencing harm in hospital significantly affects both in-hospital and post-discharge use of health services and costs of care, and constitutes an enormous expense to Ontario's publicly funded health system., Patient safety is a key component of high-quality health care delivery as well as an expectation among patients and caregivers. Substantial interest in improving patient safety was prompted following the [...]

BACKGROUND: Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them. METHODS: Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models. RESULTS: Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery. INTERPRETATION: Exact wait times for urgent and emergent surgery can be measured using Canada's administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact., Hip fracture repair that is delayed more than 24 hours after hospital presentation is associated with increased medical complications (1) and health care costs. (2,3) Despite known consequences for delays, [...]

BACKGROUND: There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes. METHODS: We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach. RESULTS: We identified 26831 patients injured in motorcycle crashes and 281826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale > 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001). INTERPRETATION: Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety., Motor vehicle safety has improved substantially over the past 100 years. (1) Between 2000 and 2010, for example, deaths related to motor vehicle crashes decreased by 55.1% in 19 developed [...]

Background: Characterizing high-cost users of health care resources is essential for the development of appropriate interventions to improve the management of these patients. We sought to determine the concentration of health care spending, characterize demographic characteristics and clinical diagnoses of high-cost users and examine the consistency of their health care consumption over time. Methods: We conducted a retrospective analysis of all residents of Ontario, Canada, who were eligible for publicly funded health care between 2009 and 2011. We estimated the total attributable government health care spending for every individual in all health care sectors. Results: More than $30 billion in annual health expenditures, representing 75% of total government health care spending, was attributed to individual costs. One-third of high-cost users (individuals with the highest 5% of costs) in 2009 remained in this category in the subsequent 2 years. Most spending among high-cost users was for institutional care, in contrast to lower-cost users, among whom spending was predominantly for ambulatory care services. Costs were far more concentrated among children than among older adults. The most common reasons for hospital admissions among high-cost users were chronic diseases, infections, acute events and palliative care. Interpretation: Although high health care costs were concentrated in a small minority of the population, these related to a diverse set of patient health care needs and were incurred in a wide array of health care settings. Improving the sustainability of the health care system through better management of high-cost users will require different tactics for different high-cost populations., Health care spending per person in any given year is highly uneven. The concentration of health care utilization among small numbers of patients is well established. In the United States, [...]

Haemodialysis centres have conventionally provided maintenance haemodialysis using a standard dialysate temperature (eg, 36·5°C) for all patients. Many centres now use cooler dialysate (eg, 36·0°C or lower) for potential cardiovascular benefits. We aimed to assess whether personalised cooler dialysate, implemented as centre-wide policy, reduced the risk of cardiovascular-related death or hospital admission compared with standard temperature dialysate.

Objective. To examine the impact of diagnostic coding error on estimates of hospital costs attributable to adverse events. Data Sources. Original and reabstracted medical records of 9,670 complex medical and surgical admissions at 11 hospital corporations in Ontario from 2002 to 2004. Patient specific costs, not including physician payments, were retrieved from the Ontario Case Costing Initiative database. Study Design. Adverse events were identified among the original and reabstracted records using ICD 10-CA (Canadian adaptation of ICD 10) codes flagged as postadmission complications. Propensity score matching and multivariate regression analysis were used to estimate the cost of the adverse events and to determine the sensitivity of cost estimates to diagnostic coding error. Principal Findings. Estimates of the cost of the adverse events ranged from $16,008 (metabolic derangement) to $30,176 (upper gastrointestinal bleeding). Coding errors caused the total cost attributable to the adverse events to be underestimated by 16 percent. The impact of coding error on adverse event cost estimates was highly variable at the organizational level. Conclusions, Estimates of adverse event costs are highly sensitive to coding error. Adverse event costs may be significantly underestimated if the likelihood of error is ignored. Key Words. Medical errors, patient safety, hospital costs, propensity matching, A growing branch of research in the patient safety arena is the estimation of the economic cost of adverse events. Prior examinations have consistently reported alarmingly high estimates of the [...]

Objective. To examine the extent to which health plan quality measures capture physician practice patterns rather than plan characteristics. Data Source. We gathered and merged secondary data from the following four sources: a private firm that collected information on individual physicians and their health plan affiliations, The National Committee for Quality Assurance, InterStudy, and the Dartmouth Arias. Study Design. We constructed two measures of physician network overlap for all health plans in our sample and linked them to selected measures of plan performance. Two linear regression models were estimated to assess the relationship between the measures of physician network overlap and the plan performance measures. Principal Findings. The results indicate that in the presence of a higher degree of provider network overlap, plan performance measures tend to converge to a lower level of quality. Conclusions. Standard health plan performance measures reflect physician practice patterns rather than plans' effort to improve quality. This implies that more provider-oriented measurement, such as would be possible with accountable care organizations or medical homes, may facilitate patient decision making and provide further incentives to improve performance. Key Words. Physician network overlap, managed care, health plan, quality, accountable care organizations (ACO), HEDIS, CAHPS, One approach to reforming the health care system involves creating more competitive health care markets. Some proposals focus on competition among health plans, under the implicit assumption that well-informed purchasers [...]

There is considerable interest in examining how Medicaid payment affects nursing home care. This study examines the effect of Medicaid payment methods and reimbursement rates on the delivery of rehabilitation therapy to Medicaid nursing home residents in six States from 1992-1995. In States that changed payment from prospective facility-specific to prospective case-mix adjusted payment methods, Medicaid residents received more rehabilitation therapy after the change. While residents in States using case-mix adjusted payment rates for Medicaid payment were more likely to receive rehabilitation than residents in States using prospective facility-specific Medicaid payment, the differences were general and not specific to Medicaid residents. Retrospective payment for Medicaid resident care was associated with greater use of therapy for Medicaid residents., INTRODUCTION Through payment and regulation, governments play an important role in the nursing home market. Public payers have substantial influence, accounting for the majority of nursing home revenues, with State-funded [...]

Objective. To examine the effect of the Medicare prospective payment system (PPS) for skilled nursing facilities (SNF) on the delivery of rehabilitation therapy to residents. Data Sources. Resident-level data are based on the Resident Assessment Instrument Minimum Data Set for nursing facilities. All elderly residents admitted to SNFs in Michigan and Ohio in 1998 and 1999 form the study population (n = 99,952). Study Design. A differences-in-differences identification strategy is used to compare rehabilitation therapy for SNF residents before and after a change in Medicare SNF payment. Logistic and linear regression analyses are used to examine the effect of PPS on receipt of physical, occupational, or speech therapy and total therapy time. Data Extraction. Data for the present study were extracted from the University of Michigan Assessment Archive Project (UMAAP). One assessment was obtained for each resident admitted to nursing facilities during the study period. Principal Findings. The introduction of PPS for all U.S. Medicare residents in July of 1998 was associated with specific targeting of rehabilitation treatment time to the most profitable levels of therapy. The PPS was also associated with increased likelihood of therapy but less rehabilitation therapy time for Medicare residents. Conclusions. The present results indicate that rehabilitation therapy is sensitive to the specific payment incentives associated with PPS. Key Words. Prospective payment system, case-mix payment, nursing homes, rehabilitation, Payment for nursing home care is an important policy concern for federal and state governments. Total government expenditures for nursing home care in the United States amounted to $58.2 billion [...]

Objective: This study examines whether depression is associated with the development of physical illness and multimorbidity, after controlling for socioeconomic, behavioral, and other potential confounders.Methods: This is a retrospective cohort study in which adult respondents to three nationally representative population health surveys were linked to health administrative databases in Ontario, Canada, and followed for 10 years from survey index. Respondents with any of the study outcome conditions at baseline were excluded to create a final cohort of 29,838 participants. The main exposure of interest was depression, measured using the Composite International Diagnostic Interview–Short Form for Major Depression. We controlled for age, body mass index, marital status, immigrant status, annual household income, smoking, alcohol consumption, physical activity, health status, and having a regular doctor. The outcome measure was the development of physical illness over 10 years of follow-up, defined as 1 of 15 common chronic conditions using administrative data.Results: Among the 29,838 participants (15,259 [51%] female), 8% of females and 4% of males had depression at baseline. In this cohort with no comorbidities at baseline, even in the fully adjusted model, depression increased the risk of developing a first physical illness for females (hazard ratio [HR] 1.16; 95% CI, 1.07 to 1.26) and males (HR 1.20; 95% CI, 1.07 to 1.36) and increased the risk of developing a second physical illness for females (HR 1.16; 95% CI, 1.02 to 1.33) over 10 years of follow-up.Conclusions: For individuals with no prior comorbidities, depression is associated with a greater risk of developing subsequent physical illness and multimorbidity over time. Thus, depression identifies a population of people who may benefit from early identification, additional screening, and intervention. Further study needs to be done to determine whether interventions to manage and support people with depression can prevent or delay the increased risk of multimorbidity.

Objective: This study aimed to provide population-level data regarding trends in multimorbidity over 13 years. Methods: We linked provincial health administrative data in Ontario, Canada, to create 3 cross-sectional panels of residents of any age in 2003, 2009, and 2016 to describe: (i) 13-year trends in multimorbidity prevalence and constellations among residents and across age, sex, and income; and (ii) chronic condition clusters. Multimorbidity was defined as having at least any 2 of 18 selected conditions, and further grouped into levels of 2, 3, 4, or 5 or more conditions. Age-sex standardized multimorbidity prevalence was estimated using the 2009 population as the standard. Clustering was defined using the observed combinations of conditions within levels of multimorbidity. Results: Standardized prevalence of multimorbidity increased over time (26.5%, 28.8%, and 30.0% across sequential panels), across sex, age, and area-based income. Females, older adults and those living in lower income areas exhibited higher rates in all years. However, multimorbidity increased relatively more among males, younger adults, and those with 4 or 5 or more conditions. We observed numerous and increasing diversity in disease clusters, namely at higher levels of multimorbidity. Conclusion: Our study provides relevant and needed population-based information on the growing burden of multimorbidity, and related socio-demographic risk factors. Multimorbidity is markedly increasing among younger age cohorts. Also, there is an increasing complexity and lack of common clustering patterns at higher multimorbidity levels.

RÉSUMÉ:L’incapacité à prendre soin de soi est la difficulté ou la dépendance à l’égard d’autrui pour accomplir des activités de la vie quotidienne telles que se nourrir et se vêtir. L’invalidité aggrave l’incapacité à prendre soin de soi au fil du temps. Le Modèle du processus d’invalidité (MPD) est souvent utilisé pour conceptualiser la recherche en gérontologie traitant de l’invalidité et de l’incapacité à prendre soin de soi, mais il n’existe aucune synthèse des variables qui correspondent aux concepts de la MPD à l’échelle individuelle. Cette recension des écrits résume les résultats de 88 études visant à déterminer la nature et le rôle des variables associées à l’incapacité et à l’invalidité chez les personnes âgées en fonction des construits du MPD, à l’échelle individuelle (p. ex. caractéristiques démographiques, pathologies chroniques). Elle examine également les données probantes concernant les applications transversales du MPD et identifie les limites communes associées aux écrits existants, en vue de guider les recherches futures. Ces résultats pourront être utilisés par les chercheurs pour orienter les prochaines études qui reposent sur la théorie en matière d’incapacités et d’invalidités et sur les données liées à la santé qui sont recueillies en routine auprès de personnes âgées.ABSTRACT:Self-care disability is difficulty with or dependence on others to perform activities of daily living, such as eating and dressing. Disablement is worsening self-care disability measured over time. The disablement process model (DPM) is often used to conceptualize gerontology research on self-care disability and disablement; however, no summary of variables that align with person-level DPM constructs exists. This review summarizes the results of 88 studies to identify the nature and role of variables associated with disability and disablement in older adults according to the person-level constructs (e.g., demographic characteristics, chronic pathologies) in the DPM. It also examines the evidence for cross-sectional applications of the DPM and identifies common limitations in extant literature to address in future research. Researchers can apply these results to guide theory-driven disability and disablement research using routinely collected health data from older adults.

The administration of neuroleptic drug therapy for behavioral disorders, to older adults admitted to nursing homes is examined. Issues such as current levels of new exposure to neuroleptic drug therapies, assessment whether dosages are above recommended levels, and determination of the extent to which specialists are contacted before prescription decisions are highlighted.

Supplemental Digital Content is available in the text.

Objective:To determine the publicly funded health care system lifetime cost-of-illness of spinal cord injury (SCI) from the perspective of the Ontario Ministry of Health and Long-term Care.Methods:Individuals hospitalized for their first SCI between the years 2005 and 2011 were identified and their health care costs were calculated using Ontario administrative health care data. From this information, lifetime costs were estimated using phase-based costing methods. The spinal cord injured cohort was matched to a non-spinal cord injured using propensity score matching. Net costs were determined by calculating the difference in costs between the two matched groups. Net costs were also presented for subgroups stratified by demographic characteristics.Results:A total of 1,716 individuals with SCI were identified and matched in our study. The net lifetime cost of SCI was $336,000 per person. Much of the costs were observed in the first year post-SCI. The lifetime cost of SCI for individuals with a concurrent pressure ulcer at the initial hospitalization rises to $479,600. Costs were also higher for individuals with cervical or thoracic injury or requiring inpatient rehabilitation.Conclusions:Spinal cord injury is a substantial burden to the health care system. Our results are limited to the direct health care costs from the publicly funded health care payer perspective. Further analysis with a broader perspective is needed to understand the full economic impact of this catastrophic condition.

Information about the impact on the adult healthcare system is limited for complex rare paediatric diseases, despite their increasing collective prevalence that has paralleled advances in clinical care of children. Within a population-based healthcare context, we examined costs and multimorbidity in adults with an exemplar of contemporary genetic diagnostics.

Patients with advanced cancer can experience illness trajectories similar to other progressive chronic disease conditions where undertaking self-management (SM) and provision of self-management support (SMS) becomes important. The main objectives of this study were to map the literature of SM strategies and SMS needs of patients with advanced cancer and to describe SMS interventions tested in this patient population. A scoping review of all literature published between 2002 and 2016 was conducted. A total of 11 094 articles were generated for screening from MEDLINE, Embase, PsychINFO, CINAHL and Cochrane Library databases. A final 55 articles were extracted for inclusion in the review. Included studies identified a wide variety of SM behaviours used by patients with advanced cancer including controlling and coping with the physical components of the disease and facilitating emotional and psychosocial adjustments to a life-limiting illness. Studies also described a wide range of SMS needs, SMS interventions and their effectiveness in this patient population. Findings suggest that SMS interventions addressing SMS needs should be based on a sound understanding of the core skills required for effective SM and theoretical and conceptual frameworks. Future research should examine how a patient-oriented SMS approach can be incorporated into existing models of care delivery and the effects of SMS on quality of life and health system utilisation in this population.

A small proportion of the population accounts for the majority of healthcare costs. Mental health and addiction (MHA) patients are consistently high-cost. We aimed to delineate factors amenable to public health action that may reduce high-cost use among a cohort of MHA clients in Saskatoon, Saskatchewan. We conducted a population-based retrospective cohort study. Administrative health data from fiscal years (FY) 2009–2015, linked at the individual level, were analyzed (n= 129,932). The outcome of interest was ≥ 90th percentile of costs for each year under study (‘persistent high-cost use’). Descriptive analyses were followed by logistic regression modelling; the latter excluded long-term care residents. The average healthcare cost among study cohort members in FY 2009 was ~ $2300; for high-cost users it was ~ $19,000. Individuals with unstable housing and hospitalization(s) had increased risk of persistent high-cost use; both of these effects were more pronounced as comorbidities increased. Patients with schizophrenia, particularly those under 50 years old, had increased probability of persistent high-cost use. The probability of persistent high-cost use decreased with good connection to a primary care provider; this effect was more pronounced as the number of mental health conditions increased. Despite constituting only 5% of the study cohort, persistent high-cost MHA clients (n= 6455) accounted for ~ 35% of total costs. Efforts to reduce high-cost use should focus on reduction of multimorbidity, connection to a primary care provider (particularly for those with more than one MHA), young patients with schizophrenia, and adequately addressing housing stability. Une faible proportion de la population compte pour la majorité des coûts des soins de santé. Les patients en santé mentale et en toxicomanie (SMT) engendrent systématiquement des coûts élevés. Nous avons cherché à délimiter les facteurs qui se prêteraient à des mesures de santé publique susceptibles de réduire l’utilisation à coût élevé dans une cohorte d’usagers en SMT de Saskatoon (Saskatchewan). Nous avons mené une étude de cohorte populationnelle rétrospective. Les données administratives sur la santé des exercices 2009 à 2015, jumelées au niveau individuel, ont été analysées (n= 129 932). Le résultat qui nous intéressait était ≥ au 90ecentile des coûts pour chaque exercice à l’étude (« utilisation à coût élevé persistante »). Des analyses descriptives ont été suivies par des modèles de régression logistique; ces derniers ont exclu les résidents en soins de longue durée. Le coût moyen des soins de santé chez les membres de la cohorte étudiée était d’environ 2300 $ durant l’exercice 2009; pour les utilisateurs à coût élevé, il était d’environ 19 000 $. Les personnes vivant dans des conditions de logement précaires et ayant été hospitalisées une ou plusieurs fois présentaient un risque accru d’utilisation à coût élevé persistante; les deux effets s’accentuaient avec la présence de comorbidités. Les patients schizophrènes, surtout ceux de moins de 50 ans, présentaient une probabilité accrue d’utilisation à coût élevé persistante. La probabilité d’utilisation à coût élevé persistante diminuait avec la qualité du lien vers un dispensateur de soins primaires; cet effet s’accentuait avec l’augmentation du nombre de troubles de santé mentale. Bien qu’ils n’aient constitué que 5 % de la cohorte à l’étude, les usagers en SMT faisant une utilisation à coût élevé persistante des soins de santé (n= 6455) comptaient pour ~ 35 % des coûts totaux. Les efforts pour réduire l’utilisation à coût élevé devraient se concentrer sur la réduction des comorbidités, sur le lien vers un dispensateur de soins primaires (surtout pour les patients présentant plus d’un problème de SMT) et sur les jeunes patients schizophrènes, et ils devraient suffisamment tenir compte de la précarité du logement.

To determine the lifetime cost-of-illness of chronic ulcers from the perspective of the Ontario public health care payer.

BACKGROUND:Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them.METHODS:Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models.RESULTS:Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14 174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery.INTERPRETATION:Exact wait times for urgent and emergent surgery can be measured using Canada’s administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact.

To evaluate the impact of comorbidity on diabetes care quality and diabetes-related hospitalizations and to examine whether associations between the likelihood of diabetes-related hospitalizations and compliance with diabetes testing are modified by type of comorbidity.

RÉSUMÉCette étude a examiné comment les patients éprouvent des transitions à la communauté des hôpitaux, y compris les problèmes de la vie quotidienne et les préoccupations médicales. Grâce à l'analyse de données qualitatives à partir d'entretiens avec 36 personnes, y compris 17 adultes âgées à haut risque avec des problèmes multiples de santé chroniques, récemment sortis de l'hôpital, et 19 membres de la famille qui ont fourni les patients avec des soins continus, nous avons demandé (1) quels sont les défis que les patients éprouvent dans la transition de l'hôpital, et (2) quelles sont les solutions de systèmes et politiques qui peuvent répondre aux défis que ces patients éprouvent? Nos résultats révèlent des défis à court et a long terme associés aux transitions à la maison. Les défis à court terme comprennent la préparation de l'habitation pour le patient et la compréhension de l'organisation des soins à la maison. Les défis à long terme sont associés à des problèmes pratiques et émotionnels. Réfléchissant sur nos résultats, nous suggérons que les besoins sociaux des patients peuvent être d'une importance égale à leurs besoins médicaux lors de la récupération post-décharge, et nous discutons les implications pour la politique.

Short Term Case Management (STCM) was introduced in 2016 in Toronto, Ontario, as a brief intervention to address long wait-lists for case management services. STCM provides individuals with mental illness, living in the community, case management services on a weekly basis over 3 months to identify personal goals and work toward an improved state of health and well-being. Despite the small but growing body of evidence on short-term case management, there is limited research on clients’ reported experiences of these services. This study used a phenomenological approach to answer the question “What are the experiences with services of individuals who received short-term case management services?” Eight qualitative semistructured interviews were conducted between November 2019 and January 2020 to collect the perspectives and experiences of clients who had received STCM. Most participants valued engaging in a brief therapeutic relationship. Additionally, participants described that the intervention helped them connect with other agencies for ongoing support and begin achieving their own long-term goals. Some participants voiced concerns about the brief duration of the intervention. Future research should explore the role of briefcase management in the continuum of services and the typology of clients who may benefit from longer therapeutic relationship to achieve their goals.

RÉSUMÉCette étude visait à évaluer l’incidence de placement dans un établissement de soins de longue durée (SLD) et d’identifier les facteurs prédictifs de placement résidentiel et d’installation parmi résidents âgés dans établissements aidant à la vie autonome en Alberta, au Canada. 1,086 résidents de 59 installations en Alberta ont été inclus. Infirmières de recherche ont effectué des évaluations de résidents interRAI-AL et ont interrogé les aidants familiaux et les administrateurs. Les prédicteurs de placement ont été identifiés avec des modèles de risques proportionnels de Cox multivariés. L’incidence cumulative SLD de l’admission était de 18,3 pour cent en 12 mois. Le risque de placement a augmenté significativement pour les résidents âgés et ceux avec des relations sociales médiocres, peu d’implication dans les activités, la dépreciation cognitive et/ou fonctionnelle, l’instabilité de la santé,une histoire des chutes et des hospitalisations récentes/visites à l’urgence, et l’incontinence urinaire sévère. Une diminution du risque de placement a été montré pour les résidents de grandes établissements avec une infirmière autorisée et/ou une infirmière auxiliaire autorisée disponible 24 heures par jour et un médecin de premier recours affilié. Nos résultats font ressortir les domaines cliniques et politiques ou des interventions ciblées peuvent retarder les admissions SLD.

Administrative healthcare databases are increasingly used for health services and comparative effectiveness research. When comparing outcomes between different treatments, interventions, or exposures, the ability to adjust for differences in the risk of the outcome occurring between treatment groups is important. Similarly, when conducting healthcare provider profiling, adequate risk-adjustment is necessary for conclusions about provider performance to be valid. There are limited validated methods for risk adjustment in ambulatory populations using administrative healthcare databases.

Population-based diagnosis- and condition-specific health-related quality of life (HRQoL) scores are required for decision-making and research purposes. These HRQoL scores do not exist for hospital-based long-term care (LTC) residents.

Over 20 countries currently use the Minimum Data Set Resident Assessment Instrument (MDS) in long-term care settings for care planning, policy, and research purposes. A full assessment of the quality of the diagnostic information recorded on the MDS is lacking.

Total joint replacements (TJR) have emerged as a critical health policy issue. In particular, Canadian demand for these surgeries is forecast to grow annually by 8.7 in the next decade. Although the medical and surgical aspects of TJR have received considerable attention, very little research has explored the impact of increased TJR on the demand for rehabilitation services. In this study, we conducted seven focus group discussions across the province of Ontario (Canada) with multiple stakeholders (n50) ranging from clinicians and administrators, to policy makers and researchers. Our results indicate that demand for rehabilitation following TJR is rising sharply and that there are three primary factors affecting such demand (i) increase in the absolute number of TJR surgeries is increasing demand across the continuum of care; (ii) changing profile of clients whereby ‘younger and active’ groups are more willing to undergo surgery, and ‘older and complex’ groups are presenting with increased rates of medical complications and comorbidities; and (iii) widespread use of clinical pathways has increased requirements within the rehabilitation sector, but often without corresponding adjustments in levels of human resources. To align increasing demand with supply in the long term, participants offered strong support for health promotion and prevention programs, but they also highlighted the short-term benefits of implementing ‘prehabilitation’ programs for clients waiting for surgery. Overall, our results indicate that the demand for rehabilitation services after TJR is increasing and that innovative approaches to care delivery are required to align increasing demand with supply.

Although both quality and cost are important concerns for long term care (LTC) facility management and policy, the relationship between cost and quality is poorly understood. Such knowledge is necessary to guide facility management and policy action.

Wodchis WP, Teare GF, Naglie G, Bronskill SE, Gill SS, Hillmer MP, Anderson GM, Rochon PA, Fries BE. Skilled nursing facility rehabilitation and discharge to home after stroke.

In July 1998, the Centers for Medicare and Medicaid Services (CMS) changed the payment method for Medicare (Part A) skilled nursing facility (SNF) care from a cost-based system to a prospective payment system (PPS). Unlike the previous cost-based payment system, PPS restricts skilled nursing facility payment to pre-determined levels. CMS also reduced the total payments to SNFs coincident with PPS implementation. These changes might reduce quality of care at skilled nursing facilities and could be reflected in resident discharge patterns. The present study examines the effect of the 1998 policy change on resident discharge outcomes. The results indicate that PPS reduced the relative risk of discharge to home and to death for Medicare residents (compared to non-Medicare residents) and had no significant effect on hospitalizations or transfers.

Adductory spasmodic dysphonia is a focal dystonia of laryngeal muscles. Patients with this disorder typically have severe vocal difficulties, with significant functional, social, and emotional consequences. There is no widely accepted cure for this condition, however, botulinum toxin injections of the thyroarytenoid muscles are considered by most voice clinicians to be the state of the art treatment. Based on extensive experience treating patients for adductory spasmodic dysphonia, we feel that traditional means of voice assessment do not adequately measure either the disease severity or the treatment outcomes. That is, listening to or acoustically analyzing limited phonatory samples does not capture the functional, social, and emotional consequences of this disorder. These consequences will be reflected in a patient's voice-related quality of life (V-RQOL). Using a validated voice outcomes instrument, the V-RQOL Measure, the purpose of this study was to quantify longitudinal changes in the V-RQOL of patients with adductory spasmodic dysphonia who are undergoing botulinum toxin injections. Twenty-seven consecutive new patients presenting with dysphonia to our institution during an 18-month period were diagnosed with adductory spasmodic dysphonia, and treated patients were evaluated prospectively using the V-RQOL Measure. Results indicated that (1) V-RQOL was initially very low for these patients, (2) botulinum toxin injections improved it significantly for each injection cycle studied, and (3) the magnitude of the treatment effect appears to change across injections.

A Correction to this paper has been published: https://doi.org/10.17269/s41997-021-00533-4

As greater numbers of the elderly use health services, and as health care costs climb, effective financial tracking is essential. Cost management in health care can benefit if costs are linked to the care activities where they are incurred. Activity-based costing (ABC) provides a useful approach. The framework aligns costs (inputs), through activities (process), to outputs and outcomes. It allocates costs based on client care needs rather than management structure. The ABC framework was tested in a residential care facility and in supportive housing apartments. The results demonstrate the feasibility and advantages of ABC for long term care agencies, including community-based care.

Introduction: Previous research has shown that the socioeconomic status (SES)–health gradient also extends to high-cost patients; however, little work has examined high-cost patients with mental illness and/or addiction. The objective of this study was to examine associations between individual-, household- and area-level SES factors and future high-cost use among these patients.Methods: We linked survey data from adult participants (ages 18 and older) of 3 cycles of the Canadian Community Health Survey to administrative health care data from Ontario, Canada. Respondents with mental illness and/or addiction were identified based on prior mental health and addiction health care use and followed for 5 years for which we ascertained health care costs covered under the public health care system. We quantified associations between SES factors and becoming a high-cost patient (i.e., transitioning into the top 5%) using logistic regression models. For ordinal SES factors, such as income, education and marginalization variables, we measured absolute and relative inequalities using the slope and relative index of inequality.Results: Among our sample, lower personal income (odds ratio [OR] = 2.11, 95% confidence interval [CI], 1.54 to 2.88, for CAD$0 to CAD$14,999), lower household income (OR= 2.11, 95% CI, 1.49 to 2.99, for lowest income quintile), food insecurity (OR= 1.87, 95% CI, 1.38 to 2.55) and non-homeownership (OR= 1.34, 95% CI, 1.08 to 1.66), at the individual and household levels, respectively, and higher residential instability (OR = 1.72, 95% CI, 1.23 to 2.42, for most marginalized), at the area level, were associated with higher odds of becoming a high-cost patient within a 5-year period. Moreover, the inequality analysis suggested pro-high-SES gradients in high-cost transitions.Conclusions: Policies aimed at high-cost patients with mental illness and/or addiction, or those concerned with preventing individuals with these conditions from becoming high-cost patients in the health care system, should also consider non-clinical factors such as income as well as related dimensions including food security and homeownership.

OBJECTIVE: To compare the incidence of admissions to hospital for stroke among older adults with dementia receiving atypical or typical antipsychotics. Design Population based retrospective cohort study. Setting Ontario, Canada. Patients 32 710 older adults (≤ 65 years) with dementia (17 845 dispensed an atypical antipsychotic and 14 865 dispensed a typical antipsychotic). MAIN OUTCOME MEASURES: Admission to hospital with the most responsible diagnosis (single most important condition responsible for the patient's admission) of ischaemic stroke. Observation of patients until they were either admitted to hospital with ischaemic stroke, stopped taking antipsychotics, died, or the study ended. RESULTS: After adjustment for potential confounders, participants receiving atypical antipsychotics showed no significant increase in risk of ischaemic stroke compared with those receiving typical antipsychotics (adjusted hazard ratio 1.01, 95% confidence interval 0.81 to 1.26). This finding was consistent in a series of subgroup analyses, including ones of individual atypical antipsychotic drugs (risperidone, olanzapine, and quetiapine) and selected subpopulations of the main cohorts. CONCLUSION: Older adults with dementia who take atypical antipsychotics have a similar risk of ischaemic stroke to those taking typical antipsychotics.