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Introduction Anti-osteoclast treatment with denosumab or zoledronate is known to effectively reduce the need for radiotherapy to bone and other skeletal-related events (SREs) in patients with metastatic castration-resistant prostate cancer (mCRPC). In this study, we analyze primary versus secondary initiation of bone-targeting agents (BTAs) relative to first palliative bone radiotherapy in patients dying of mCRPC. Methods Provincial administrative databases from Ontario, Canada identified patients with prostate cancer (2007-2018, n  = 98 646) who received continuous androgen deprivation therapy (n  = 29 453), died of prostate cancer (2013-2018, n  = 3864), and received life-prolonging therapy for mCRPC (n  = 1850). Variables were collected looking back 3 years from death. Multivariable analysis explored the relationship between clinical variables and BTAs. Results Of the 58% (1066/1850) patients with mCRPC who received BTA, only 289 (25.4%) started BTA prior to first palliative bone radiotherapy as primary prevention. Eight hundred and forty-eight (74.6%) patients either never received BTA before death (n  = 447) or started BTA only after first bone radiotherapy (n  = 401). More patients received denosumab (n  = 825, 77%) than zoledronic acid (n  = 241, 23%). 51.2% (582/1137) of palliative bone radiotherapy was initiated in the last 12 months of life. Factors associated with the use of BTA included elevated alkaline phosphatase (OR = 1.0, P  = .023), de novo metastases (OR = 1.4, P  = .005), medical oncologist involvement (OR = 2.0, P  = .007), diagnosis 2012-2017 versus 2007-2011 (OR = 0.75, P  = .034), and academic center (OR = 0.061, P  = .007). Conclusion A majority of patients with mCRPC never receive BTAs prior to first SRE, despite universal access and availability of these agents in Ontario. These results highlight an opportunity to improve outcomes by emphasizing early introduction of BTA in patients with mCRPC being started on systemic therapy. [ABSTRACT FROM AUTHOR]

Introduction: Adherence to best practices for care of hip fracture patients is fundamental to decreasing morbidity and mortality in older adults. This includes timely transfer from the hospital to rehabilitation soon after their surgical care. Hospitals experience challenges in implementing several best practices. We examined the potential barriers associated with timely discharge for patients who underwent a hip fracture surgery in an academic hospital in Ontario, Canada. Methods: We conducted a retrospective cross-sectional review of a local database. We used descriptive statistics to characterize individuals according to the time of discharge after surgery. Multivariable binary logistic regression was used to evaluate factors associated with delayed discharge (>6 days post-surgery). Results: A total of 492 patients who underwent hip fracture surgery between September 2019 and August 2020 were included in the study. The odds of having a delayed discharge occurred when patients had a higher frailty score (odds ratios [OR] 1.19, 95% confidence interval [CI] 1.02;1.38), experienced an episode of delirium (OR 2.54, 95% CI 1.35;4.79), or were non-weightbearing (OR 3.00, 95% CI 1.07;8.43). Patients were less likely to have a delayed discharge when the surgery was on a weekend (OR.50, 95% CI.32;.79) compared to a weekday, patients had a total hip replacement (OR.28, 95% CI.10;.80) or dynamic hip screw fixation (OR.49, 95% CI.25;.98) compared to intramedullary nails, or patients who were discharged to long-term care (OR.05, 95% CI.02;.13), home (OR.26, 95% CI.15;.46), or transferred to another specialty in the hospital (OR.49, 95% CI.29;.84) compared to inpatient rehabilitation. Conclusions: Clinical and organizational factors can operate as potential barriers to timely discharge after hip fracture surgery. Further research is needed to understand how to overcome these barriers and implement strategies to improve best practice for post-surgery hip fracture care. [ABSTRACT FROM AUTHOR]

Background: The impact of delirium on cognition has not been well‐studied in long‐term care (LTC) residents. This study examined changes in cognition 1 year after a probable delirium episode among LTC residents, compared to LTC residents without probable delirium. We also evaluated whether the relationship between probable delirium and cognitive change differed according to a diagnosis of dementia. Methods: We conducted a population‐based retrospective cohort study using linked health administrative data. The study population included adults aged 65+ residing in LTC in Ontario, Canada and assessed via the Resident Assessment Instrument‐Minimum Dataset between January 1, 2016 and December 31, 2018. Probable delirium was ascertained via the delirium Clinical Assessment Protocol on the index assessment. Cognition was measured quarterly using the Cognitive Performance Scale (range 0–6, higher values indicate greater impairment). Cognitive decline up to 1 year after index was evaluated using multivariable proportional odds regression models. Results: Of 92,005 LTC residents, 2816 (3.1%) had probable delirium at index. Residents with probable delirium had an increased odds of cognitive decline compared to those without probable delirium, with adjusted odds ratios of 1.64 (95% confidence interval [CI] 1.35–1.99), 1.56 (95% CI 1.34–1.85), 1.57 (95% CI 1.32–1.86) and 1.50 (95% CI 1.25–1.80) after 1–3, 4–6, 7–9, and 10–12 months of follow‐up. Residents with probable delirium and a comorbid dementia diagnosis had the highest adjusted odds of cognitive decline (adjusted odds ratio 5.57, 95% CI 4.79–6.48) compared to those without probable delirium or dementia. Residents with probable delirium were also more likely to die within 1 year than those without probable delirium (52.5% vs. 23.4%). Conclusions: Probable delirium is associated with increased mortality and worsened cognition in LTC residents that is sustained months after the probable delirium episode. Efforts to prevent delirium in this population may help limit these adverse effects. See related editorial by Bellelli et al. in this issue. [ABSTRACT FROM AUTHOR]

Background and Methods: We conducted a population‐based, retrospective cohort study of first‐time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all‐cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. Results: A total of 71,776 AYA had a first‐time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First‐time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69–3.51). Mortality was associated with age 25–29 years (aHR 3.88, 95% CI 2.56–5.86), being male (aHR 1.98, 95% CI 1.49–2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64–6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96–4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27–3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. Conclusion: Incident ED visits due to alcohol in AYA are associated with a high risk of 1‐year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow‐up care in this population. [ABSTRACT FROM AUTHOR]

Background: Palliative medicine physicians may be at higher risk of burnout due to increased stressors and compromised resilience during the COVID-19 pandemic. Burnout prevalence and factors influencing this among UK and Irish palliative medicine physicians is unknown. Aim: To determine the prevalence of burnout and the degree of resilience among UK and Irish palliative medicine physicians during the COVID-19 pandemic, and associated factors. Design: Online survey using validated assessment scales assessed burnout and resilience: The Maslach Burnout Inventory Human Services Survey for Medical Personnel [MBI-HSS (MP)] and the Connor-Davidson Resilience Scale (CD-RISC). Additional tools assessed depressive symptoms, alcohol use, and quality of life. Setting/participants: Association of Palliative Medicine of UK and Ireland members actively practising in hospital, hospice or community settings. Results: There were 544 respondents from the 815 eligible participants (66.8%), 462 provided complete MBI-HSS (MP) data and were analysed. Of those 181/462 (39.2%) met burnout criteria, based on high emotional exhaustion or depersonalisation subscales of the MBI-HSS (MP). A reduced odds of burnout was observed among physicians who worked ⩽20 h/week (vs 31–40 h/week, adjusted odds ratio (aOR) 0.03, 95% confidence interval (CI) 0.002–0.56) and who had a greater perceived level of clinical support (aOR 0.70, 95% CI 0.62–0.80). Physicians with higher levels of depressive symptoms had higher odds of burnout (aOR 18.32, 95% CI 6.75–49.73). Resilience, mean (SD) CD-RISC score, was lower in physicians who met burnout criteria compared to those who did not (62.6 (11.1) vs 70.0 (11.3); p < 0.001). Conclusions: Over one-third of palliative medicine physicians meet burnout criteria. The provision of enhanced organisational and colleague support is paramount in both the current and future pandemics. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has increased the risk of psychological distress for older adults during a period of reduced access to mental health support. We identified predictors of persistent depressive and anxiety symptoms among older adults throughout the initial 9 months of the pandemic. Methods: This was a longitudinal study using web‐based surveys sent to a convenience sample of Canadians aged ≥55 years. A baseline survey was sent in May 2020, with eight surveys sent monthly between June 2020 and January 2021. Data were separated into three study periods, corresponding to coronavirus case rates. Respondents who met predetermined thresholds for elevated depressive or anxiety symptoms using standardized mental health scales during all three periods were defined as having persistent symptoms. Multivariable Poisson regression was used to compare the risk of persistent symptoms across respondent characteristics selected a priori. Results: There were 835 respondents who answered questions about depressive symptoms and 865 who answered questions about anxiety symptoms across all three study periods. Among those with complete follow‐up data, 19.2% (n = 159/827) reported persistent depressive symptoms and 16.4% (n = 140/856) reported persistent anxiety symptoms. Respondents with persistent depressive symptoms were more likely to be women (adjusted relative risk [aRR] 1.71; 95% CI 1.19–2.46), and report multimorbidity (aRR 1.45; 95% CI 1.07–1.97), pre‐existing depression (aRR 2.00; 95% CI 1.45–2.77) and pre‐existing anxiety (aRR 1.50; 95% CI 1.10–2.06). The same respondent characteristics were correlates of persistently elevated anxiety symptoms. Conclusions: Older women, older adults with pre‐existing depression and anxiety, and those with multimorbidity were more likely to report persistent mental health symptoms during the first 9 months of the COVID‐19 pandemic. These individuals were known to have elevated risk prior to the pandemic, and expanded interventions targeted to these groups are necessary to adequately address their mental health needs. [ABSTRACT FROM AUTHOR]

Background: Delirium is a distressing neurocognitive disorder that is common among terminally ill individuals, although few studies have described its occurrence in the acute care setting among this population. Aim: To describe the prevalence of delirium in patients admitted to acute care hospitals in Ontario, Canada, in their last year of life and identify factors associated with delirium. Design: Population-based retrospective cohort study using linked health administrative data. Delirium was identified through diagnosis codes on hospitalization records. Setting/participants: Ontario decedents (1 January 2014 to 31 December 2016) admitted to an acute care hospital in their last year of life, excluding individuals age of <18 years or >105 years at admission, those not eligible for the provincial health insurance plan between their hospitalization and death dates, and non-Ontario residents. Results: Delirium was recorded as a diagnosis in 8.2% of hospitalizations. The frequency of delirium-related hospitalizations increased as death approached. Delirium prevalence was higher in patients with dementia (prevalence ratio: 1.43; 95% confidence interval: 1.36–1.50), frailty (prevalence ratio: 1.67; 95% confidence interval: 1.56–1.80), or organ failure–related cause of death (prevalence ratio: 1.23; 95% confidence interval: 1.16–1.31) and an opioid prescription (prevalence ratio: 1.17; 95% confidence interval: 1.12–1.21). Prevalence also varied by age, sex, chronic conditions, antipsychotic use, receipt of long-term care or home care, and hospitalization characteristics. Conclusion: This study described the occurrence and timing of delirium in acute care hospitals in the last year of life and identified factors associated with delirium. These findings can be used to support delirium prevention and early detection in the hospital setting. [ABSTRACT FROM AUTHOR]

This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada. Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument–Minimum Dataset version 2.0 (RAI-MDS 2.0). LTC residents in Ontario between January 1, 2016, and December 31, 2019. We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models. The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non–CNS-related PIP criteria. This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium. [ABSTRACT FROM AUTHOR]

To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium. Population-based cross-sectional study using routinely collected administrative health data. All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument–Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217). Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported. Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability). There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition. [ABSTRACT FROM AUTHOR]

Background: Physicians experience high rates of burnout, which may negatively impact patient care. Palliative care is an emotionally demanding specialty with high burnout rates reported in previous studies from other countries. We aimed to estimate the prevalence of burnout and degree of resilience among Canadian palliative care physicians and examine their associations with demographic and workplace factors in a national survey. Methods: Physician members of the Canadian Society of Palliative Care Physicians and Société Québécoise des Médecins de Soins Palliatifs were invited to participate in an electronic survey about their demographic and practice arrangements and complete the Maslach Burnout Inventory for Medical Professionals (MBI-HSS (MP)), and Connor-Davidson Resilience Scale (CD-RISC). The association of categorical demographic and practice variables was examined in relation to burnout status, as defined by MBI-HSS (MP) score. In addition to bivariable analyses, a multivariable logistic regression analysis, reporting odds ratios (OR), was conducted. Mean CD-RISC score differences were examined in multivariable linear regression analysis. Results: One hundred sixty five members (29%) completed the survey. On the MBI-HSS (MP), 36.4% of respondents reported high emotional exhaustion (EE), 15.1% reported high depersonalization (DP), and 7.9% reported low personal accomplishment (PA). Overall, 38.2% of respondents reported a high degree of burnout, based on having high EE or high DP. Median CD-RISC resilience score was 74, which falls in the 25th percentile of normative population. Age over 60 (OR = 0.05; CI, 0.01–0.38), compared to age ≤ 40, was independently associated with lower burnout. Mean CD-RISC resilience scores were lower in association with the presence of high burnout than when burnout was low (67.5 ± 11.8 vs 77.4 ± 11.2, respectively, p < 0.0001). Increased mean CD-RISC score differences (higher resilience) of 7.77 (95% CI, 1.97–13.57), 5.54 (CI, 0.81–10.28), and 8.26 (CI, 1.96–14.57) occurred in association with age > 60 as compared to ≤40, a predominantly palliative care focussed practice, and > 60 h worked per week as compared to ≤40 h worked, respectively. Conclusions: One in three Canadian palliative care physicians demonstrate a high degree of burnout. Burnout prevention may benefit from increasing resilience skills on an individual level while also implementing systematic workplace interventions across organizational levels. [ABSTRACT FROM AUTHOR]

Background: Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval. Methods: This is a cross‐sectional study of CRC patients diagnosed in Ontario, Canada, in 2008–2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer‐related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile. Results: The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and −25 days, respectively). Conclusions: This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients. [ABSTRACT FROM AUTHOR]

To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. Nested case-control study. Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December 31, 2019. New residents of assisted living were matched on age, sex, and initiation date of home care (± 7 days) to community-dwelling home care recipients in a 1:4 ratio. Clinical and functional status, health service use, sociodemographic variables, and community-level characteristics were examined; conditional logistic regression was used to model associations with a transition to an assisted living facility. There were 2427 new residents of assisted living who were matched to 9708 home care recipients [mean (SD) age 85.5 (6.02) years, 72% female]. Most of the new residents were concentrated in urban communities and communities with higher income quintiles. New residents had an increased rate of physician-diagnosed dementia [adjusted hazard ratio (aHR), 1.28; 95% CI, 1.14–1.43], mood disorders (aHR, 1.17; 95% CI, 1.05–1.29), and cardiac arrhythmias (aHR, 1.19; 95% CI, 1.07–1.32). They also had higher rates of mild cognitive impairment (aHR, 1.43; 95% CI, 1.24–1.66), 2 or more falls (aHR, 1.29; 95% CI, 1.11–1.51), participation in activities of long-standing interest in the past 7 days (aHR, 1.29; 95% CI, 1.11–1.50), and a lower rate of a spouse or partner unpaid caregiver vs a child (aHR, 0.66; 95% CI, 0.56–0.79). New residents of assisted living were mostly women, were cognitively impaired, had clinical comorbidities that could increase their risk of injuries, and had caregivers who were their children. These findings stress the importance of upscaling memory and dementia care in assisted living to address the needs of this population. [ABSTRACT FROM AUTHOR]

End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions. Retrospective cohort study using administrative data. Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death. Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions. Of 110,776 decedents, 40.7% had organ failure, 37.5% had frailty, and 12.8% had a terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P <.001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04). Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes. [ABSTRACT FROM AUTHOR]