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Background: Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents., Methods: We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter., Results: Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference -2.65%, 95% confidence interval [CI]: -4.93 to -.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports., Conclusions: Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Competing Interests: Competing interests: Margaret MacGregor is a member of the board of the Vancouver Coastal Health Authority. Andrea Moser is the Associate Medical Director for The Apotex Centre, The Jewish Home for the Aged, Toronto, Ont. She is also the Chief Medical Information Officer for Baycrest Health Sciences, Toronto, Ont., and is the Chief Medical Consultant for Sienna Senior Living. No other competing interests were declared.

Background: After diagnosis of a health condition, information about survival and potential transition from community into institutional care can be helpful for patients and care providers. We sought to describe the association between a new diagnosis of dementia and risk of admission to a long-term care home and death at 5 years., Methods: We conducted a population-based retrospective cohort study using linked health administrative databases. We identified individuals aged 65 years or older, living in the community, with a first documented diagnosis of dementia between Jan. 1, 2010, and Dec. 31, 2012, in Ontario, Canada. Dementia diagnosis was captured using diagnostic codes from hospital discharges, physician billings, assessments conducted for home care and long-term care, and dispensed prescriptions for cholinesterase inhibitors. Our primary outcome measures were 5-year risk of death and placement in a long-term care home, adjusted for sociodemographic and clinical factors., Results: We identified 108 757 individuals in our study cohort. By the end of 5 years, 24.4% remained alive in the community and 20.5% were living in a long-term care home. Of the 55.1% who died, about half (27.9%) were admitted to a long-term care home before death. Three risk factors were associated with increased odds of death: older age (age ≥ 90 yr; odds ratio [OR] 9.5, 95% confidence interval [CI] 8.8-10.2 [reference: age 65-69 yr]), male sex (OR 1.7, 95% CI 1.6-1.7), and the presence of organ failure, including chronic obstructive pulmonary disease (OR 1.7, 95% CI 1.7-1.8), congestive heart failure (OR 2.0, 95% CI 1.9-2.0) and renal failure (OR 1.7, 95% CI 1.6-1.8). Groups formed by combinations of these 3 factors had an observed 5-year risk of death varying between 22% and 91%., Interpretation: Among community-dwelling older adults with newly identified dementia in Ontario, the majority died or were admitted to a long-term care home within 5 years. This information may be helpful for discussions on prognosis and need for admission to long-term care., Competing Interests: Competing interests: Sarah Spruin reports receiving a grant from the Canadian Institutes of Health Research, during the conduct of the study. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

Objectives: To determine whether decreased communication ability among long-term care residents is associated with increased antibiotic exposure., Design: Retrospective cohort study., Setting: All long-term care homes in Ontario, Canada., Participants: All adults aged 66 years or older residing in long-term care and undergoing a full assessment between January 1 and December 31, 2016 (N = 87,947)., Measurements: Data were obtained from linkable, population-wide administrative data sets. Residents were identified, and characteristics were abstracted from the Resident Assessment Instrument Minimum Dataset version 2.0. The primary predictors of interest were residents' ability to make themselves understood and ability to understand others. The primary outcome was antibiotic days of treatment per 1000 resident days in the 90 days following assessment (obtained from the Ontario Drug Benefits Database)., Results: Those who were sometimes/rarely/never able to make themselves understood received 50.7 antibiotic days per 1000 person-days of follow-up, compared to 62.1 received by those who were able to make themselves understood. Those who were sometimes/rarely/never able to understand others received 50.0 antibiotic days per 1000 person-days of follow-up, compared to 61.4 by those who were able to understand others. Multivariable Poisson regression, accounting for resident characteristics, confirmed that compared to those with highest levels of communication ability, those who could sometimes/rarely/never make themselves understood had significantly fewer days on antibiotics (rate ratio [RR] = 0.76; confidence interval [95% CI] = 0.73-0.79) as did those who could sometimes/rarely/never understand others (RR = 0.76; 95% CI = 0.74-0.79)., Conclusion: Poor resident communication ability is not a driver of antibiotic overuse in long-term care. In fact, lower ability to understand others and/or be understood by others is associated with less antibiotic exposure. Further work is needed to optimize antibiotic use in long-term care residents across the entire spectrum of communication skills., (© 2019 The American Geriatrics Society.)

Background: Guidance from randomized clinical trials about the ongoing benefits of statin therapies in residents of long-term care facilities is lacking. We sought to examine the effect of statin dose on 1-year survival and admission to hospital for cardiovascular events in this setting., Methods: We conducted a retrospective cohort study using population-based administrative data from Ontario, Canada. We identified 21 808 residents in long-term care facilities who were 76 years of age and older and were prevalent statin users on the date of a full clinical assessment between April 2013 and March 2014, and categorized residents as intensive- or moderate-dose users. Treatment groups were matched on age, sex, admission to hospital for atherosclerotic cardiovascular disease, resident frailty and propensity score. Differences in 1-year survival and admission to hospital for cardiovascular events were measured using Cox proportional and subdistribution hazard models, respectively., Results: Using propensity-score matching, we included 4577 well-balanced pairs of residents who were taking intensive- and moderate-dose statins. After 1 year, there were 1210 (26.4%) deaths and 524 (11.5%) admissions to hospital for cardiovascular events among residents using moderate-dose statins compared with 1173 (25.6%) deaths and 522 (11.4%) admissions to hospital for cardiovascular events among those taking intensive-dose statins. We found no significant association between prevalent use of intensive-dose statins and 1-year survival (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.90 to 1.05) or 1-year admission to hospital for cardiovascular events (HR 0.99, 95% CI 0.88 to 1.12) compared with use of moderate-dose statins., Interpretation: The rates of mortality and admission to hospital for cardiovascular events at 1 year were similar between residents in long-term care taking intensive-dose statins compared with those taking moderate-dose statins. This lack of benefit should be considered when prescribing statins to vulnerable residents of long-term care facilities who are at potentially increased risk of statin-related adverse events., Competing Interests: Competing interests: None declared., (© 2019 Joule Inc. or its licensors.)

Background: Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities., Methods: We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices., Results: Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice., Interpretation: Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities., Competing Interests: Competing interests: None declared., (© 2017 Canadian Medical Association or its licensors.)

Background: Evaluating different approaches to identifying frail home care clients at heightened risk for adverse health outcomes is an important but understudied area. Our objectives were to determine the prevalence and correlates of frailty (as operationally defined by three measures) in a home care cohort, the agreement between these measures, and their predictive validity for several outcomes assessed over one year., Methods: We conducted a retrospective cohort study with linked population-based administrative and clinical (Resident Assessment Instrument [RAI]) data for all long-stay home care clients (aged 66+) assessed between April 2010-2013 in Ontario, Canada (n = 234,552). We examined two versions of a frailty index (FI), a full and modified FI, and the CHESS scale, compared their baseline characteristics and their predictive accuracy (by calculating the area under the ROC curve [AUC]) for death, long-term care (LTC) admission, and hospitalization endpoints in models adjusted for age, sex and comorbidity., Results: Frailty prevalence varied by measure (19.5, 24.4 and 44.1 %, for full FI, modified FI and CHESS, respectively) and was similar among female and male clients. All three measures were associated with a significantly increased risk of death, LTC admission and hospitalization endpoints in adjusted analyses but their addition to base models resulted in modest improvement for most AUC estimates. There were significant differences between measures in predictive accuracy, with the full FI demonstrating a higher AUC for LTC admission and CHESS a higher AUC for hospitalization - although none of the measures performed well for the hospitalization endpoints., Conclusions: The different approaches to detecting vulnerability resulted in different estimates of frailty prevalence among home care clients in Ontario. Although all three measures were significant predictors of the health outcomes examined, the gains in predictive accuracy were often modest with the exception of the full FI in predicting LTC admission. Our findings provide some support for the clinical utility of a comprehensive FI measure and also illustrate that it is feasible to derive such a measure at the population level using routinely collected data. This may facilitate further research on frailty in this setting, including the development and evaluation of interventions for frailty.

Objectives: To establish if proprietary status (ie, for-profit or not-for-profit) is associated with mortality and hospitalizations among publicly funded long-term care (nursing) homes., Methods: We conducted a retrospective cohort study of new admissions in 640 publicly funded long-term care facilities in Ontario, Canada (384 for-profit, 256 not-for-profit). A population-based cohort of 53,739 incident admissions into long-term care facilities between January 1, 2010, and March 1, 2012, was observed. We measured adjusted rates of hospital admissions and mortality, per 1000 person-years (PY) of follow-up, among for-profit and not-for-profit facilities at 3, 6, and 12 months postadmission. Rates were measured postadmission and until discharge or death, whichever came first., Results: One year after admission and before discharge, 11.7% of residents died and 25.7% had at least one hospitalization. After 12 months of follow-up, residents in for-profit facilities had a hospitalization rate of 462 per 1000 PY versus 358 per 1000 PY in not-for-profit facilities. During this period, the crude mortality rate in for-profit facilities was 208 per 1000 PY versus 185 per 1000 PY in not-for-profit facilities. At 3, 6, and 1 year after admission, for-profit facilities had an adjusted hazard ratio of 1.36 (95% confidence interval [CI] 1.28-1.43), 1.33 (95% CI 1.27-1.39), and 1.25 (95% CI 1.21-1.30) for hospitalizations and hazards of 1.20 (95% CI 1.11-1.29), 1.16 (95% CI 1.09-1.24), and 1.10 (95% CI 1.05-1.16) for mortality, respectively., Conclusions: Publicly funded for-profit facilities have significantly higher rates of both mortality and hospital admissions., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Home care services play an integral role in promoting independence, reducing hospital admission and readmission rates, and preventing or delaying nursing home admission among older adults. Despite important sex differences in functional status and use of services by recipients of home care, differences in home care performance measures by sex have not been examined., Objective: To assess sex differences in the quality of publicly funded home care services in Ontario, Canada., Methods: Validated, publicly reported home care quality indicators derived from the Resident Assessment Instrument for Home Care using the 2009 and 2010 Home Care Reporting System database were assessed for 119,795 Ontario home care clients aged 65 years and older. Unadjusted and risk-adjusted sex differences in performance were examined provincially and by health region., Results: In unadjusted analyses, there were sex differences in health outcomes on all indicators examined (decline or failure to improve in activities of daily living, cognitive decline, depressive symptoms, and pain control). After risk adjustment, differences were minimal. For example, in unadjusted analyses, 23.1% of women and 18.7% of men reported poorly controlled pain. After risk adjustment, 21.2% of women and 21.6% of men reported poorly controlled pain, with a difference of -0.4% (95% CI, -0.4% to -0.3%). Across health regions risk adjustment eliminated sex differences. There was 1.3-fold to 2.6-fold variation in performance on indicators across health regions., Conclusions: After risk adjustment, no important sex differences in home care quality indicators were identified. Sizable regional variations observed indicate potential to improve home care outcomes for both women and men. Sex differences in unadjusted analyses demonstrate the value of examining both unadjusted and adjusted outcomes and suggest sex-specific strategies will likely be needed to improve home care quality., (Copyright © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies., Design: Cross-sectional study involving a 2005 province-wide census of LTC residents' charts linked to additional health care administrative databases., Setting: All LTC homes in Ontario., Participants: Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care., Main Outcome Measures: Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns., Results: The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents)., Conclusion: About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.

Background: Patient transitions, such as transfers between acute and long-term care (LTC), aposare times when the likelihood of communication failure between healthcare providers is increased. Employing appropriate health quality indicators helps support improvement efforts. To date, few quality indicators that evaluate the continuity of medication use between acute and LTC facilities have been described., Objective: The aim of the study was to develop quality indicators signalling the potential discontinuation of previously prescribed medications for chronic diseases when residents return to LTC following an acute-care hospitalization., Methods: A literature review for the selection of potential indicators was conducted, followed by a three-step process: (i) initial screening round that rated the indicators; (ii) a 1-day in-person consensus meeting in which the panel refined the parameters regarding the proposed quality indicators; and (iii) a final anonymous survey that assessed consensus among panel members. The study setting was a survey and consensus meeting with national representation, held in Toronto, ON, Canada. A ten-member expert panel with broad geographical and clinical representation participated and was made up of registered nurses, physicians, pharmacists, policy makers and academic researchers. A 75% agreement threshold was required for consensus, as measured on a 9-point Likert-type scale. The panel evaluated quality indicators for effectiveness, relevance and feasibility, using currently available healthcare administrative data., Results: The panel reached consensus on four quality indicators to assess the unintentional discontinuation of medications prescribed to LTC residents for chronic diseases upon return to LTC after an acute-care admission. The selected indicators were (i) HMG-CoA reductase inhibitors (statins) for all indications; (ii) anticoagulants (e.g. warfarin) for the indication of atrial fibrillation; (iii) proton-pump inhibitors for the indication of post-gastrointestinal haemorrhage; and (iv) thyroxine for all indications. The panel identified three additional treatment groups for future consideration as quality indicators: anti-Parkinson's disease, anti-diabetes and antidepressant medications., Conclusion: A novel set of quality indicators has been developed to evaluate medication continuity between acute and LTC facilities. The adoption and implementation of these indicators in clinical practice can help inform quality improvement efforts at various local and regional levels.

Objectives: Evaluation and optimization of antibiotic use (antibiotic stewardship) is being increasingly promoted as a means to reduce antibiotic resistance, adverse events, treatment complications and costs within institutions. Our goal was to examine the prevalence of antibiotic use among long-term care facility residents and the extent of variability across these institutions., Methods: We conducted a population-based, point-prevalence study of antibiotic use among elderly individuals (n = 37,371) residing in long-term care facilities (n = 363 institutions) in Ontario between April and June 2009, using linked healthcare databases from Canada's largest province. Facilities were grouped into quintiles according to their mean antibiotic dispensing rates and variation was compared across quintiles., Results: There were 2190 (5.9%) long-term care residents receiving antibiotic prescriptions on the study date. The three most prevalent antibiotics were agents most commonly used for the treatment of urinary tract infections, including nitrofurantoin (365, 15.4%), trimethoprim/sulfamethoxazole (338, 14.3%) and ciprofloxacin (304, 12.8%). The majority of treatment courses were at least 10 days in duration (1482, 62.6%), and many exceeded 90 days (495, 20.9%), suggesting chronic prophylaxis. There was substantial variability in antibiotic use across facilities, with a 5-fold variation from the highest-use quintile (10.8%) to the lowest-use quintile (2.2%). This variation persisted after adjustment for multiple facility-level and resident-level factors, including demographic characteristics, healthcare utilization statistics, co-morbidity prevalence, functional status and device dependence., Conclusions: Antibiotic use is common among long-term care residents, variable across institutions, and may benefit from focused antimicrobial stewardship interventions to standardize treatment indications and duration.

Background: There is growing interest in understanding the care needs of lonely people but studies are limited and examine healthcare settings separately. We estimated and compared healthcare trajectories in lonely and not lonely older female and male respondents to a national health survey. Methods: We conducted a retrospective cohort study of community‐dwelling, Ontario respondents (65+ years) to the 2008/2009 Canadian Community Health Survey—Healthy Aging. Respondents were classified at baseline as not lonely, moderately lonely, or severely lonely using the Three‐Item Loneliness Scale and then linked with health administrative data to assess healthcare transitions over a 12 ‐year observation period. Annual risks of moving from the community to inpatient, long‐stay home care, long‐term care settings—and death—were estimated across loneliness levels using sex‐stratified multistate models. Results: Of 2684 respondents (58.8% female sex; mean age 77 years [standard deviation: 8]), 635 (23.7%) experienced moderate loneliness and 420 (15.6%) severe loneliness. Fewer lonely respondents remained in the community with no transitions (not lonely, 20.3%; moderately lonely, 17.5%; and severely lonely, 12.6%). Annual transition risks from the community to home care and long‐term care were higher in female respondents and increased with loneliness severity for both sexes (e.g., 2‐year home care risk: 6.1% [95% CI 5.5–6.6], 8.4% [95% CI 7.4–9.5] and 9.4% [95% CI 8.2–10.9] in female respondents, and 3.5% [95% CI 3.1–3.9], 5.0% [95% CI 4.0–6.0], and 5.4% [95% CI 4.0–6.8] in male respondents; 5‐year long‐term care risk: 9.2% [95% CI 8.0–10.8], 11.1% [95% CI 9.3–13.6] and 12.2% [95% CI 9.9–15.3] [female], and 5.3% [95% CI 4.2–6.7], 9.1% [95% CI 6.8–12.5], and 10.9% [95% CI 7.9–16.3] [male]). Conclusions: Lonely older female and male respondents were more likely to need home care and long‐term care, with severely lonely female respondents having the highest probability of moving to these settings. [ABSTRACT FROM AUTHOR]

Background: A concern with long‐term opioid use is the increased risk arising when opioids are used concurrently with drugs that can potentiate their associated adverse effects. The drugs most often encountered are benzodiazepines (BZDs) and gabapentinoids. Our study objectives were to examine trends in the concurrent use of opioids and BZDs, or gabapentinoids, in a Canadian nursing home population over an 11‐year period, and current resident‐level correlates of this concurrent use. Methods: We conducted a population‐based, repeated cross‐sectional study among Ontario nursing home residents (>65 years) dispensed opioids between April 2009 and February 2020. For the last study year, we examined cross‐sectional associations between resident characteristics and concurrent use of opioids with BZDs or gabapentinoids. Linked data on nursing home residents from clinical and health administrative databases was used. The yearly proportions of residents who were dispensed an opioid concurrently with a BZD or gabapentinoid were plotted with percent change derived from log‐binomial regression models. Separate modified Poisson regression models estimated resident‐level correlates of concurrent use of opioids with BZDs or gabapentinoids. Results: Over the study period, among residents dispensed an opioid there was a 53.2% relative decrease (30.7% to 14.4%) in concurrent BZD and a 505.4% relative increase (4.4% to 26.6%) in concurrent gabapentinoid use. In adjusted models, increasing age and worsening cognition were inversely associated with the concurrent use of both classes, but most other significantly related covariates were unique to each drug class (e.g., sex and anxiety disorders for BZD, pain severity and presence of pain‐related conditions for gabapentinoids). Conclusions: Co‐administration of BZDs or gabapentinoids in Ontario nursing home residents dispensed opioids remains common, but the pattern of co‐use has changed over time. Observed covariates of concurrent use in 2019/20 suggest distinct but overlapping resident populations requiring consideration of the relative risks versus benefits of this co‐use and monitoring for potential harm. [ABSTRACT FROM AUTHOR]

Objectives: Cholinesterase inhibitors (ChEIs) and memantine are approved for Alzheimer disease in Canada. Regional drug reimbursement policies are associated with cross-provincial variation in ChEI use, but it is unclear how these policies influence predictors of use. Using standardized data from two provinces with differing policies, we compared resident-level characteristics associated with dementia pharmacotherapy at long-term care (LTC) admission.Methods: Using linked clinical and administrative databases, we examined characteristics associated with dementia pharmacotherapy use among residents with dementia and/or significant cognitive impairment admitted to LTC facilities in Saskatchewan (more restrictive reimbursement policies; n = 10,599) and Ontario (less restrictive; n = 93,331) between April 1, 2009, and March 31, 2015. Multivariable logistic regression models were utilized to assess resident demographic, functional, and clinical characteristics associated with dementia pharmacotherapy.Results: On admission, 8.1% of Saskatchewan residents were receiving dementia pharmacotherapy compared to 33.2% in Ontario. In both provinces, residents with severe cognitive impairment, aggressive behaviors, and recent antipsychotic use were more likely to receive dementia pharmacotherapy; while those who were unmarried, admitted in later years, had a greater degree of frailty, and recent hospitalizations were less likely. The direction of the association for older age, rural residency, medication number, and anticholinergic therapy differed between provinces.Conclusions: While more restrictive criteria for dementia pharmacotherapy coverage in Saskatchewan resulted in fewer residents entering LTC on dementia pharmacotherapy, there were relatively few differences in the factors associated with use across provinces. Longitudinal studies are needed to assess how differences in prevalence and characteristics associated with use impact patient outcomes. [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]

Objectives To examine the variability of statin use among nursing home residents and prescribing physicians, and to assess statin use by resident frailty. Design Population-based, cross-sectional analysis. Setting All nursing home facilities (N = 631) in Ontario, Canada between April 1, 2013 and March 31, 2014. Participants All adults aged 66 years and older who received a full clinical assessment while residing in a nursing home facility and their assigned, most responsible, physician. Measurements Statin use on date of clinical assessment. Resident- and physician-level characteristics ascertained through clinical assessment and health administrative data. Resident frailty was derived using a previously validated index. Results Among 76,226 nursing home residents assigned to 1,919 physicians, 25,648 (33.6%) were statin users. There were 13,331 (30.1%) statin users among the 44,290 residents categorized as frail. In an adjusted mixed-effects logistic regression model, frail residents (adjusted odds ratio = 0.62, 95% confidence interval 0.58-0.65) were significantly less likely to be statin users compared with non-frail residents. After adjustment for resident characteristics, the intraclass correlation coefficient indicated that between-physician variability accounted for 9.1% of the residual unexplained variation in statin use ( P < .001). Among the 894 physicians assigned 20 or more residents, funnel plots confirmed there were more low-outlying (17.4%) and high-outlying (12.0%) prescribers of statins than expected by chance. Physicians who were high-outlying prescribers had higher historical rates of statin prescribing. Conclusions and Relevance Statin prescribing was substantial within nursing homes, even among frail residents. After controlling for resident characteristics, the likelihood of statin prescribing varied significantly across physicians. Further studies are required to evaluate the risks and benefits of statin use, and discontinuation, among nursing home residents to better inform clinical practice in this setting. [ABSTRACT FROM AUTHOR]

Objective: To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE. Data sources: Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11. Study design: This study is a retrospective cohort study. Data collection/extraction methods: A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year. Principal findings: Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year. Conclusions: Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring. [ABSTRACT FROM AUTHOR]

• Mortality rates were consistent for Ontario nursing home residents in 2010–2019. • Hospitalization and emergency department (ED) visits were also consistent. • During 2020, increases in mortality and decreases in hospitalization/ED visits were seen. • This provides context for assessment of COVID-19 vaccine safety in this population. Nursing home (NH) residents are prioritized for COVID-19 vaccination. We report monthly mortality, hospitalizations, and emergency department (ED) visit incidence rates (IRs) during 2010–2020 to provide context for COVID-19 vaccine safety assessments. We observed outcomes among all NH residents in Ontario using administrative databases. IRs were calculated by month, sex, and age group. Comparisons between months were assessed using one-sample t-tests; comparisons by age and sex were assessed using chi-squared tests. From 2010 to 2019, there were 83,453 (SD: 652.4) NH residents per month, with an average of 2.3 (SD: 0.28) deaths, 3.1 (SD: 0.16) hospitalizations, and 3.6 (SD: 0.17) ED visits per 100 residents per month. From March to December 2020, mortality IRs were increased, but hospitalization and ED visit IRs were reduced (p < 0.05). We identified consistent monthly mortality, hospitalization, and ED visit IRs during 2010–2019. Marked differences in these rates were observed during 2020, coinciding with the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

We investigate whether older adults who were newly diagnosed with dementia (severity unspecified) and resided in an assisted living facility that offered a dementia care program had a lower rate of transition to a nursing home, compared to those who resided in an assisted living facility without such a program. Population-based retrospective cohort study. Linked, person-level health system administrative data on older adults who were newly diagnosed with dementia and resided in an assisted living facility in Ontario, Canada, from 2014 to 2019 (n = 977). Access to a dementia care program in an assisted living facility (n = 57) was examined. Multivariable Cox proportional hazards regression with robust standard errors clustered on the assisted living facility was used to model the time to transition to a nursing home from the new dementia diagnosis. There were 11.8 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility with a dementia care program, compared with 20.5 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility without a dementia care program. After adjustment for relevant characteristics at baseline, older adults who resided in an assisted living facility with a dementia care program had a 40% lower rate of transition to a nursing home (hazard ratio 0.60, 95% confidence interval 0.44, 0.81), compared with those in an assisted living facility without such a program at any point during the follow-up period. The rate of transition to a nursing home was significantly lower among older adults who resided in an assisted living facility that offered a dementia care program. These findings support the expansion of dementia care programs in assisted living facilities. [ABSTRACT FROM AUTHOR]