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Aim: In patients with incurable metastatic colorectal cancer (mCRC), resection of the primary tumour is debated; however, patients with intact primaries may be at a higher risk of complications requiring surgery when receiving treatment with bevacizumab. Our aim was to estimate the risk of nonelective colorectal surgery in patients undergoing bevacizumab therapy for mCRC and evaluate the association between intact primary tumours and risk of nonelective surgery. Method: We designed a population‐based, retrospective cohort study using administrative and cancer registry data in Ontario, Canada. We included patients with mCRC who received bevacizumab from 1 January 2008 to 31 December 2014. The primary outcome was nonelective colorectal surgery after initiation of bevacizumab. We determined the cumulative incidence of nonelective colorectal surgery among patients with previously resected and unresected primaries, accounting for the competing risk of death. We explored the relationship between previous resection of the primary and need for nonelective surgery using a cause‐specific hazards model, controlling for patient, tumour and treatment factors. Results: We identified 1840 (32.7%) patients with intact primaries and 3784 (67.3%) patients with prior resection. The cumulative incidence of nonelective surgery 1 year after initiating bevacizumab for all patients was 3.9% (95% CI 3.4–4.5%). One‐year cumulative incidence was higher in those with intact primaries than in those with resected primaries (6.1% vs 2.9%, P < 0.0001). After adjustment, an intact primary remained strongly associated with nonelective colorectal surgery (hazard ratio = 2.89, 95% CI 2.32–3.61; P < 0.0001). Conclusion: Bevacizumab is associated with a low but meaningful risk for serious gastrointestinal complications, necessitating vigilance, particularly among patients with an intact primary tumour. [ABSTRACT FROM AUTHOR]

Purpose: Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures.Methods: We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates.Results: We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26).Conclusion: Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs. [ABSTRACT FROM AUTHOR]

Importance: Respiratory syncytial virus (RSV) transmission was disrupted worldwide following the COVID-19 pandemic, and further study is required to better understand these changes., Objective: To compare observed and expected RSV hospital and intensive care unit (ICU) admission rates and characteristics of admitted children during the 2021-2022 and 2022-2023 seasons., Design, Setting, and Participants: A population-based cohort study of all children aged younger than 5 years in Ontario, Canada, July 1, 2017, through March 31, 2023, was conducted., Exposures: Individual and neighborhood-level sociodemographic and clinical characteristics were identified from administrative data, including age, palivizumab eligibility, complex medical conditions, rurality, and living in a marginalized neighborhood., Main Outcomes and Measures: The main outcome was RSV-associated hospitalization. Secondary outcomes included ICU admissions, mechanical ventilation, extracorporeal membrane oxygenation, and in-hospital death. Poisson generalized estimating equations were used to model weekly age- and sex-specific hospitalization rates and estimate expected rates in the postpandemic era; adjusted rate ratios (RRs) and 95% CIs are reported., Results: This cohort study included approximately 700 000 children per study year. Compared with prepandemic years (2017-2018, 2018-2019, and 2019-2020), the 2021-2022 RSV season peaked slightly earlier, but overall admission rates were comparable (289.1 vs 281.4-334.6 per 100 000, or approximately 2000 admissions). The 2022-2023 season peaked a month earlier and resulted in more than twice as many hospitalizations (770.0 per 100 000; n = 4977 admissions). The proportion of children admitted to an ICU in 2022-2023 (13.9%) was slightly higher than prepandemic (9.6%-11.4%); however, the population-based rate was triple the prepandemic levels (106.9 vs 27.6-36.6 per 100 000 children in Ontario). With the exception of palivizumab-eligible children, all sociodemographic and health status characteristics were associated with lower-than-expected RSV hospitalization rates in 2021-2022. In contrast, older age of patients was associated with higher-than-expected rates in 2022-2023 (ie, 24-59 months: RR, 1.90; 95% CI, 1.35-2.66)., Conclusions and Relevance: There were notable differences in RSV epidemiologic characteristics in Ontario following the COVID-19 pandemic. It is not yet clear whether and how long atypical RSV epidemics may persist. Clinicians and program planners should consider the potential for ongoing impacts to health care capacity and RSV immunization programs.

Importance: Unintentional injury, suicide, and homicide are leading causes of death among young females. Teen pregnancy may be a marker of adverse life experiences., Objective: To evaluate the risk of premature mortality from 12 years of age onward in association with number of teen pregnancies and age at pregnancy., Design, Setting, and Participants: This population-based cohort study was conducted among all females alive at 12 years of age from April 1, 1991, to March 31, 2021, in Ontario, Canada (the most populous province, which has universal health care and data collection). The study period ended March 31, 2022., Exposures: The main exposure was number of teen pregnancies between 12 and 19 years of age (0, 1, or ≥2). Secondary exposures included how the teen pregnancy ended (birth or miscarriage vs induced abortion) and age at first teen pregnancy., Main Outcomes and Measures: The main outcome was all-cause mortality starting at 12 years of age. Hazard ratios (HRs) were adjusted for year of birth, comorbidities at 9 to 11 years of age, and area-level education, income level, and rurality., Results: Of 2 242 929 teenagers, 163 124 (7.3%) experienced a pregnancy at a median age of 18 years (IQR, 17-19 years). Of those with a teen pregnancy, 60 037 (36.8%) ended in a birth (of which 59 485 [99.1%] were live births), and 106 135 (65.1%) ended in induced abortion. The median age at the end of follow-up was 25 years (IQR, 18-32 years) for those without a teen pregnancy and 31 years (IQR, 25-36 years) for those with a teen pregnancy. There were 6030 deaths (1.9 per 10 000 person-years [95% CI, 1.9-2.0 per 10 000 person-years]) among those without a teen pregnancy, 701 deaths (4.1 per 10 000 person-years [95% CI, 3.8-4.5 per 10 000 person-years]) among those with 1 teen pregnancy, and 345 deaths (6.1 per 10 000 person-years [95% CI, 5.5-6.8 per 10 000 person-years]) among those with 2 or more teen pregnancies; adjusted HRs (AHRs) were 1.51 (95% CI, 1.39-1.63) for those with 1 pregnancy and 2.14 (95% CI, 1.92-2.39) for those with 2 or more pregnancies. Comparing those with vs without a teen pregnancy, the AHR for premature death was 1.25 (95% CI, 1.12-1.40) from noninjury, 2.06 (95% CI, 1.75-2.43) from unintentional injury, and 2.02 (95% CI, 1.54-2.65) from intentional injury., Conclusions and Relevance: In this population-based cohort study of 2.2 million female teenagers, teen pregnancy was associated with future premature mortality. It should be assessed whether supports for female teenagers who experience a pregnancy can enhance the prevention of subsequent premature mortality in young and middle adulthood.

Background and Objectives: Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics., Methods: This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region., Results: During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic., Conclusions: Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic., Methods: This population-based repeated cross-sectional study of children and adolescents (3-17 years; N  = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017-2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status., Results: Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata., Conclusion: During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning., Competing Interests: Declaration of Conflicts of InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: N. Saunders reported receiving personal fees from the Archives of Diseases in Childhood, grants from the Canadian Institutes for Health Research and the Ontario Ministry of Health, grants from the Centre for Addiction and Mental Health, and grants from The Hospital for Sick Children outside the submitted work. S. Vigod reported receiving royalties from UpToDate Inc. for authorship of materials related to depression and pregnancy unrelated to the submitted work. No other disclosures were reported.

Background: Increased rates of pediatric eating disorders have been observed during the COVID-19 pandemic, but little is known about trends among adults. We aimed to evaluate rates of emergency department visits and hospital admissions for eating disorders among adolescents and adults during the pandemic., Methods: We conducted a population-based, repeated cross-sectional study using linked health administrative data for Ontario residents aged 10-105 years during the prepandemic (Jan. 1, 2017, to Feb. 29, 2020) and pandemic (Mar. 1, 2020, to Aug. 31, 2022) periods. We evaluated monthly rates of emergency department visits and hospital admissions for eating disorders, stratified by age., Results: Compared with expected rates derived from the prepandemic period, emergency department visits for eating disorders increased during the pandemic among adolescents aged 10-17 years (7.38 v. 3.33 per 100 000; incidence rate ratio [IRR] 2.21, 95% confidence interval [CI] 2.17-2.26), young adults aged 18-26 years (2.79 v. 2.46 per 100 000; IRR 1.13, 95% CI 1.10-1.16) and older adults aged 41-105 years (0.14 v. 0.11 per 100 000; IRR 1.15, 95% CI 1.07-1.24). Hospital admissions for eating disorders increased during the pandemic for adolescents (8.82 v. 5.74 per 100 000; IRR 1.54, 95% CI 1.54-1.54) but decreased for all adult age groups, especially older adults aged 41-105 years (0.21 v. 0.30 per 100 000; IRR 0.72, 95% CI 0.64-0.80)., Interpretation: Emergency department visits for eating disorders increased among adolescents, young adults and older adults during the pandemic, but hospital admissions increased only for adolescents and decreased for all adult groups. Differential rates of acute care use for eating disorders by age have important implications for allocation of inpatient mental health resources., Competing Interests: Competing interests: Natasha Saunders reports receiving personal fees from The BMJ Group’s Archives of Diseases in Childhood and grants from the Canadian Institutes of Health Research (CIHR), the Ontario Ministry of Health, the Centre for Addiction and Mental Health and The Hospital for Sick Children. Astrid Guttmann reports funding from CIHR. No other competing interests were reported., (© 2023 CMA Impact Inc. or its licensors.)

Background: Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use., Methods: We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10-17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10-13 yr and 14-17 yr), sex and mental health service use (new and continuing)., Results: In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19-1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46-2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10-13 years and those aged 14-17 years, as well as for both those new to the mental health system and those already engaged in care., Interpretation: Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population., Competing Interests: Competing interests: Rachel Mitchell reports receiving grants from the American Foundation for Suicide Prevention, the TD Pooler Fund and the Sunnybrook Foundation, as well as an Academic Scholar Award from the Department of Psychiatry at Sunnybrook Health Sciences Centre and the University of Toronto and an honourarium from Medscape. Eyal Cohen is a member of the Committee to Evaluate Drugs. Rachel Strauss reports consulting fees from Canadian Doctors for Prevention from Guns. Simone Vigod reports receiving authorship royalties from UpToDate. Kimberly Moran receives salary support from the Ontario College of Family Physicians. Astrid Guttmann reports receiving grants from the Canadian Institutes for Health Research. Paul Kurdyak is Vice President, Clinical at the Mental Health and Addictions Centre of Excellence at Ontario Health. Natasha Saunders reports receiving grants from the Canadian Institutes for Health Research, the Ontario Ministry of Health, the Centre for Addiction and Mental Health and The Hospital for Sick Children, as well as personal fees from the BMJ Group for her role as associate editor for the Archives of Diseases in Childhood. She is a member of the Canadian Paediatric Society Mental Health and Developmental Disabilities committee. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Scarce evidence is available on the impact of real-world smoking cessation treatment on subsequent health outcomes, such as incidence of chronic disease. This study compared two cohorts of people that smoke-those that enrolled in a smoking cessation program, and a matched control that had not accessed the program-to assess the incidence of cancer, chronic obstructive pulmonary disease, diabetes, hypertension, and major cardiovascular events over a 5-year follow-up period. We selected five sub-cohorts with matched treatment-control pairs in which both individuals were at risk of the five chronic diseases. Incident chronic disease from index date until December 31, 2017, was determined through linkage with routinely collected healthcare data. The cumulative incidence of each chronic disease was estimated using the cumulative incidence function with death as a competing risk. Gray's test was used to test for a difference between matched treatment and control groups in the chronic disease-specific cumulative incidence function over follow-up. Analyses were stratified by sex. Among females, cumulative incidence of diabetes was higher over follow-up for the treatment group (5-year cumulative incidence 5.8% vs 4.2%, p = 0.004), but did not differ for the four other chronic diseases. Among males, cumulative incidence of chronic obstructive pulmonary disease (12.2% vs 9.1%, p < 0.001) and diabetes (6.7% vs 4.8%, p < 0.001) both had higher 5-year cumulative incidence for the treated versus control groups but did not differ for the other three chronic diseases. We conclude that accessing primary-care based smoking cessation treatment is associated with increased incidence of diabetes for both sexes, and chronic obstructive pulmonary disease for males (possibly due to under diagnosis prior to treatment), within 5 years of treatment. The associations detected require further research to understand causal relationships., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: DB has received investigator-initiated grant support from Pfizer Canada, Ontario Ministry of Health and Long-Term Care, and the Canadian Institutes of Health Research (CIHR). CdO reports receiving grant funding from CIHR, University of Toronto, Medical Research Council, National Institutes of Health, Centre for Addiction and Mental Health (CAMH), Ontario Ministry of Health and Long-Term Care, Canadian Centre for Applied Research in Cancer Control and Ontario Mental Health Foundation. PS reports receiving funding from CCSRI, CIHR, Canadian Partnership Against Cancer, Centre for Addiction and Mental Health (CAMH), Health Canada, Medical Psychiatry Alliance, Ontario Ministry of Health and Long-Term Care, Ontario Neurotrauma Foundation and the Public Health Agency of Canada. PS also reports funding from the following commercial organizations: Patient-Centred Outcome Research Institute and Pfizer. PS has received honoraria in the past 3 years from University of Ottawa Heart Institute, Royal College of Physicians and Surgeons of Canada, Royal Victoria Regional Health Centre, Department of Family and Community Medicine at the University of Toronto, Northern Ontario School of Medicine, Canadian Partnership Against Cancer, Battle River Treaty 6 Healthcare, Lung Association of Nova Scotia, Exchange Summit, Toronto Public Health, Ontario Association of Public Health Dentistry and ECHO. PS has been retained as an expert witness by the Ontario and New Brunswick provincial governments in litigation against the tobacco industry. PS was a member and co-chaired the Ministry of Health’s Ontario Smoke Free Strategy cessation subcommittee. Through an open tender process, Johnson & Johnson, Novartis and Pfizer are vendors of record for providing free/discounted smoking cessation pharmacotherapy for research studies in which PS and LZ are principal or co-investigator. PK reports receiving grant funding from CIHR and the Ontario Ministry of Health and Long-Term Care. LR reports receiving grant funding from CIHR, SSHRC, New Frontiers in Research Fund, Canada Research Chairs and the Connaught Foundation. LZ reports receiving grant funding from Pfizer, Ontario Ministry of Health and Long-Term Care, Health Canada, CIHR and CCSRI. LZ also received honoraria and travel funds from Pfizer and University of Ottawa Heart Institute. RS reports receiving funding from CIHR, Terry Fox Research Institute, Garron Family Cancer Centre and Sick Kids Foundation, Canadian Society of Colon and Rectal Surgeons, Sunnybrook Foundation, Pediatric Oncology Group of Ontario, Ontario Institute for Cancer Research, PSI Foundation, C17 Research Network, Cancer Care Ontario, Canadian Centre for Applied Research in Cancer Control, Canadian Breast Cancer Foundation, Sunnybrook AFP Innovation Fund, CCSRI, Ministry of Health and Long-Term Care and the Ontario Medical Association. No other disclosures were reported. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Baliunas et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To examine physician factors associated with practice-level uptake of virtual mental healthcare for children and adolescents., Design, Setting and Participants: A population-based data linkage study of a cohort of all physicians (n=12 054) providing outpatient mental healthcare to children and adolescents (aged 3-17 years, n=303 185) in a single-payer provincial health system in Ontario, Canada from 1 July 2020 to 31 July 2021., Exposures: Physician characteristics including gender, age, specialty, location of training, practice region, practice size and overall and mental health practice size., Main Outcomes: Practice-level proportion of outpatient virtual care provided: (1) mostly in-person (<25% virtual care), (2) hybrid (25%-99% virtual care) or (3) exclusively virtual (100% virtual care). Multinomial logistic regression models tested the association between practice-level virtual care provided and physician characteristics., Results: Among physicians, 1589 (13.2%) provided mostly in-person mental healthcare with 8714 (67.8%) providing hybrid care, and 2291 (19.0%) providing exclusively virtual care. The provision of exclusive virtual care (vs mostly in-person) was associated with female sex (adjusted OR (aOR) 1.97, 95% CI 1.70 to 2.27 (ref: male)), foreign training (aOR 1.27, 95% CI 1.07 to 1.50 (ref: Canadian-trained)), family physicians (aOR 2.05, 95% CI 1.56 to 2.69 (ref: psychiatrist)) and reversely associated with large practice size (aOR 0.32, 95% CI 0.25 to 0.40 (ref smallest quintile)). Mostly in-person care was associated with older age physicians (71+ years) and practice outside the Toronto region., Conclusions and Relevance: In a single-payer universal healthcare system that remunerates physicians using the same fee structure for in-person and virtual outpatient care, there is heterogeneity in utilisation of virtual care that is associated with provider factors. This practice variation, with limited evidence on effectiveness and appropriate contexts for virtual care use, suggests there may be opportunity for further outcomes research and guidance on appropriate context for paediatric virtual mental healthcare delivery., Competing Interests: Competing interests: NRS reported receiving personal fees from the Archives of Diseases in Childhood, grants from the Canadian Institutes for Health Research and the Ontario Ministry of Health, grants from the Centre for Addiction and Mental Health and grants from The Hospital for Sick Children outside the submitted work. SV reported receiving royalties from UpToDate for authorship of materials related to depression and pregnancy outside the submitted work. No other disclosures were reported., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe changes in service delivery and access to rheumatologists before and during the coronavirus disease 2019 (COVID-19) pandemic periods., Methods: We conducted a population-based study in Ontario, Canada. Patient visits with rheumatologists were ascertained using billing claims data. Contact with rheumatologists was defined separately by the type of patient encounter (including office visits, telemedicine visits, and new patient consultations). Changes in the total weekly volume of encounters and monthly rates after COVID-19 public health measures were imposed were compared to expected baseline rates determined before pandemic onset (March 17, 2020)., Results: In the year prior to the pandemic, there were 289,202 patients (of which 96,955 were new consults) seen by 239 rheumatologists. In the 1 year following the pandemic onset, there were 276,686 patients (of which 86,553 were new consults) seen by 247 rheumatologists. In March 2020, there was an immediate 75.9% decrease in outpatient office visits and a rapid rise in telemedicine visits. By September 2021, 49.7% of patient encounters remained telemedicine visits. For new patient consultations, there was an immediate 50% decrease in visits at the pandemic onset, with 54.8% diverted to telemedicine visits in the first year of the pandemic versus 37.4% by September 2021. New rheumatology consultation rates continued decreasing over the study period., Conclusion: Rheumatology care delivery has shifted due to the pandemic, with telemedicine increasing sharply early in the pandemic and persisting over time. The pandemic also negatively affected access to rheumatologists, resulting in fewer new consultations and raising concerns for potential delays to diagnosis., (Copyright © 2023 by the Journal of Rheumatology.)

Background: ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization., Research Question: For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt?, Study Design and Methods: This population-based cohort study included ICU survivors aged ≥ 66 years who had not filled sedative prescriptions within ≤ 6 months before hospitalization (sedative-naive) in Ontario, Canada (2003-2019). Using multilevel logistic regression, demographic, clinical, and hospital characteristics and their association with new sedative prescription within ≤ 7 days of discharge are described. Variation between hospitals was quantified by using the adjusted median OR. Factors associated with persistent prescriptions (≤ 6 months) were examined with a multivariable proportional hazards model., Results: A total of 250,428 patients were included (mean age, 76 years; 61% male). A total of 15,277 (6.1%) filled a new sedative prescription, with variation noted across hospitals (2% [95% CI, 1-3] to 44% [95% CI, 3-57]); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (adjusted OR [aOR], 4.00; 95% CI, 3.72-4.31), receipt of inpatient geriatric (aOR, 1.95; 95% CI, 1.80-2.10) or psychiatry (aOR, 2.76; 95% CI, 2.62-2.91) consultation, invasive ventilation (aOR, 1.59; 95% CI, 1.53-1.66), and ICU length of stay ≥ 7 days (aOR, 1.50; 95% CI, 1.42-1.58). The residual heterogeneity between hospitals (adjusted median OR, 1.43; 95% CI, 1.35-1.49) had a stronger association with new sedative prescriptions than the Charlson Comorbidity Index score or sepsis. Factors associated with persistent sedative use were similar with the addition of female subjects (subdistribution hazard ratio, 1.07; 95% CI, 1.02-1.13) and pre-existing polypharmacy (subdistribution hazard ratio, 0.88; 95% CI, 0.80-0.93)., Interpretation: One in 15 sedative-naive, older adult ICU survivors filled a new sedative within ≤ 7 days of discharge; more than one-half of these survivors filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care., Objective: To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care., Design, Setting, and Participants: This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months., Intervention: Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care., Main Outcomes and Measures: Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost., Results: Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01)., Conclusions and Relevance: The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions., Trial Registration: ClinicalTrials.gov Identifier: NCT02928757.

Introduction: There has been little investigation of whether the clinical effectiveness of smoking cessation treatments translates into differences in healthcare costs, using real-world cost data, to determine whether anticipated benefits of smoking cessation treatment are being realized., Aims and Methods: We sought to determine the association between smoking cessation treatment and healthcare costs using linked administrative healthcare data. In total, 4752 patients who accessed a smoking cessation program in Ontario, Canada between July 2011 and December 2012 (treatment cohort) were each matched to a smoker who did not access these services (control cohort). The primary outcome was total healthcare costs in Canadian dollars, and secondary outcomes were sector-specific costs, from one year prior to the index date until December 31, 2017, or death. Costs were partitioned into four phases: pretreatment, treatment, posttreatment, and end-of-life for those who died., Results: Among females, total healthcare costs were similar between cohorts in pretreatment and posttreatment phases, but higher for the treatment cohort during the treatment phase ($4,554 vs. $3,237, p < .001). Among males, total healthcare costs were higher in the treatment cohort during pretreatment ($3,911 vs. $2,784, p < .001), treatment ($4,533 vs. $3,105, p < .001) and posttreatment ($5,065 vs. $3,922, p = .001) phases. End-of-life costs did not differ. Healthcare sector-specific costs followed a similar pattern., Conclusions: Five-year healthcare costs were similar between females who participated in a treatment program versus those that did not, with a transient increase during the treatment phase only. Among males, treatment was associated with persistently higher healthcare costs. Further study is needed to address the implications with respect to long-term costs., Implications: The clinical effectiveness of pharmacological and behavioral smoking cessation treatments is well established, but whether such treatments are associated with healthcare costs, using real-world data, has received limited attention. Our findings suggest that the use of a smoking cessation treatment offered by their health system is associated with persistent higher healthcare costs among males but a transient increase among females. Given increasing access to evidence-based smoking cessation treatments is an important component in national tobacco control strategies, these data highlight the need for further exploration of the relations between smoking cessation treatment engagement and healthcare costs., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: No research has assessed the individual-level impact of smoking cessation treatment delivered within a general primary care patient population on multiple forms of subsequent healthcare service use., Objective: We aimed to compare the rate of outpatient visits, emergency department (ED) visits and hospitalisations during a 5-year follow-up period among smokers who had and had not accessed a smoking cessation treatment programme., Methods: The study was a retrospective matched cohort study using linked demographic and administrative healthcare databases in Ontario, Canada. 9951 patients who accessed smoking cessation services between July 2011 and December 2012 were matched to a smoker who did not access services, obtained from the Canadian Community Health Survey, using a combination of hard matching and propensity score matching. Outcomes were rates of healthcare service use from index date (programme enrolment or survey response) to March 2017., Results: After controlling for potential confounders, patients in the overall treatment cohort had modestly greater rates of the outcomes: outpatient visits (rate ratio (RR) 1.10, 95% CI: 1.06 to 1.14), ED visits (RR 1.08, 95% CI: 1.03 to 1.13) and hospitalisations (RR 1.09, 95% CI: 1.02 to 1.18). Effect modification of the association between smoking cessation treatment and healthcare service use by prevalent comorbidity was found for outpatient visits (p=0.006), and hospitalisations (p=0.050), but not ED visits., Conclusions: Patients who enrolled in smoking cessation treatment offered through primary care clinics in Ontario displayed a modest but significantly greater rate of outpatient visits, ED visits and hospitalisations over a 5-year follow-up period., Competing Interests: Competing interests: DB reports receiving grant funding in the past 5 years from Pfizer, Ontario Ministry of Health and Long-Term Care, Canadian Institutes of Health Research (CIHR) and the Canadian Cancer Society Research Institute (CCSRI). PS reports receiving funding in the past 3 years from CCSRI, CIHR, Canadian Partnership Against Cancer, Centre for Addiction and Mental Health (CAMH), Health Canada, Medical Psychiatry Alliance, Ontario Ministry of Health and Long-Term Care, Ontario Neurotrauma Foundation and the Public Health Agency of Canada. PS also reports funding from the following commercial organisations: Patient-Centred Outcome Research Institute and Pfizer. PS has received honoraria in the past 3 years from University of Ottawa Heart Institute, Royal College of Physicians and Surgeons of Canada, Royal Victoria Regional Health Centre, Department of Family and Community Medicine at the University of Toronto, Northern Ontario School of Medicine, Canadian Partnership Against Cancer, Battle River Treaty 6 Healthcare, Lung Association of Nova Scotia, Exchange Summit, Toronto Public Health, Ontario Association of Public Health Dentistry and ECHO. PS has been retained as an expert witness by the Ontario and New Brunswick provincial governments in litigation against the tobacco industry. PS was a member and co-chaired the Ministry of Health’s Ontario Smoke Free Strategy cessation subcommittee. Through an open tender process, Johnson & Johnson, Novartis and Pfizer are vendors of record for providing free/discounted smoking cessation pharmacotherapy for research studies in which PS and/or LZ are principal or co-investigator. CdO reports receiving grant funding in the past 5 years from CIHR, University of Toronto, Medical Research Council, National Institutes of Health, CAMH, Alberta Innovates, Ontario Ministry of Health and Long-Term Care, Canadian Centre for Applied Research in Cancer Control and Ontario Mental Health Foundation. PK reports receiving grant funding in the past 5 years from CIHR and the Ontario Ministry of Health and Long-Term Care. LR reports receiving grant funding in the past 5 years from CIHR, New Frontiers in Research Fund, Canada Research Chairs and the Connaught Foundation. LZ reports receiving grant funding in the past 5 years from Pfizer, Ontario Ministry of Health and Long-Term Care, Health Canada, CIHR and CCSRI. LZ also received honoraria and travel funds from Pfizer and University of Ottawa Heart Institute. RS reports receiving funding in the past 5 years from CIHR, Terry Fox Research Institute, Garron Family Cancer Centre and Sick Kids Foundation, Canadian Society of Colon and Rectal Surgeons, Sunnybrook Foundation, Pediatric Oncology Group of Ontario, Ontario Institute for Cancer Research, PSI Foundation, C17 Research Network, Cancer Care Ontario, Canadian Centre for Applied Research in Cancer Control, Canadian Breast Cancer Foundation, Sunnybrook AFP Innovation Fund, CCSRI, Ministry of Health and Long-Term Care and the Ontario Medical Association. PS, LZ, PK, DB and CdO have been employed by CAMH in the past 36 months; results of this study may impact whether CAMH continues to receive funding from the Ministry of Health to administer the STOP programme. No other author has competing interests to declare., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Accruing evidence suggests that gestational hypertensive disorders (GHTD) and gestational diabetes (GD) are each associated with an increased risk of cardiovascular disease (CVD). However, the extent to which the co-occurrence of GHTD and GD is associated with the risk of CVD remains largely unknown., Objective: To estimate the individual and joint associations of GHTD and GD with incident CVD., Design, Setting, and Participants: This population-based cohort study used the Ministry of Health and Long-Term Care of Ontario (Canada) health care administrative databases. All women in Ontario with a GHTD and/or GD diagnosis, and a live-birth singleton delivery between July 1, 2007, and March 31, 2018, were considered for inclusion. Women with pregravid diabetes, hypertension, or cardiovascular disease were excluded. Statistical analysis was performed from November 2021 to September 2022., Exposures: GD and/or GHTD, defined using diagnosis coding., Main Outcomes and Measures: Individual and joint associations of GHTD and GD with incident CVD (including a composite of myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy), estimated using Cox regression models, adjusting for relevant cardiometabolic risk factors. The follow-up extended from the index pregnancy until March 31, 2020., Results: Among 886 295 eligible women (mean [SD] age, 30 [5.6] years; 43 861 [4.9%] with isolated GHTD, 54 061 [6.1%] with isolated GD, and 4975 [0.6%] with GHTD and GD), there were 1999 CVD events over 12 years of follow-up. In the early postpartum phase (first 5 years post partum), there was no association of co-occurrence of GTHD and GD (adjusted hazard ratio [aHR], 1.42, 95% CI, 0.78-2.58) or GD alone (aHR, 0.80; 95% CI, 0.60-1.06) with CVD; there was an association between isolated GTHD and incident CVD compared with no GTHD and no GD (aHR, 1.90; 95% CI, 1.51-2.35). In the late postpartum period (after the initial 5 years post partum), compared with no GD and no GHTD, isolated GHTD (aHR, 1.41, 95% CI, 1.12-1.76) and co-occurrence of GHTD and GD (aHR, 2.43, 95% CI, 1.60-3.67) were each associated with a higher risk of incident CVD. There was no association between isolated GD and incident CVD., Conclusions and Relevance: In this cohort study, GHTD was associated with a high risk of CVD post partum, and the co-occurrence of GD and GHTD was associated with a much greater postpartum CVD risk. These findings suggest that CVD preventive care is particularly needed in the aftermath of combined GD and GHTD.

Purpose: Unplanned rehospitalization at a hospital other than the initial hospital may contribute to poor outcomes. We examined the location of rehospitalizations and assessed outcomes following critical illness in a single-payer healthcare system., Materials and Methods: Population-based retrospective cohort study using linked datasets (2012-2017) from Ontario, Canada including adults (≥18 years) with an unplanned rehospitalization within 30-days after an index hospitalization that included an ICU stay with mechanical ventilation. Outcomes were the percentage of 30-day rehospitalizations at non-index hospitals, mortality and costs. We employed logistic regression and generalized linear models to assess associations., Results: There were 14,997 (16.4%) 30-day rehospitalizations. Of these 2765 (18.4%) occurred in a non-index hospital. Distance of home residence from the index hospital was the strongest predictor of a non-index rehospitalization (adjusted odds ratio (aOR) 8.40, 95%CI 7.05-10.01, highest vs. lowest distance quintile). Within 30-days of rehospitalization, deaths (aOR 0.91, 95%CI (0.80-1.04)) and total healthcare costs (adjusted relative risk 1.03 (1.00-1.06)), were similar for patients readmitted to the index or a non-index hospital., Conclusion: Non-index rehospitalization within 30-days of initial discharge is common following critical illness. These rehospitalizations were not significantly associated with an increased risk of harm or higher costs in a single-payer healthcare system., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization., Method: Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization., Results: In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P  < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P  < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P  < 0.001)]. In the second cohort ( n  = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up., Conclusions: Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Importance: Public health measures to reduce the spread of COVID-19 have heightened distress among children and adolescents and contributed to a shift in delivery of mental health care services., Objectives: To measure and compare physician-based outpatient mental health care utilization before and during the COVID-19 pandemic and quantify the extent of uptake of virtual care delivery., Design, Setting, and Participants: Population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada. All individuals aged 3 to 17 years residing in Ontario from January 1, 2017, to February 28, 2021., Exposures: Pre-COVID-19 period from January 1, 2017, to February 29, 2020, and post-COVID-19 onset from March 1, 2020, to February 28, 2021., Main Outcomes and Measures: Physician-based outpatient weekly visit rates per 1000 population for mental health diagnoses overall and stratified by age group, sex, and mental health diagnostic grouping and proportion of virtual visits. Poisson generalized estimating equations were used to model 3-year pre-COVID-19 trends and forecast expected trends post-COVID-19 onset and estimate the change in visit rates before and after the onset of COVID-19. The weekly proportions of virtual visits were calculated., Results: In a population of almost 2.5 million children and adolescents (48.7% female; mean [SD] age, 10.1 [4.3] years), the weekly rate of mental health outpatient visits was 6.9 per 1000 population. Following the pandemic onset, visit rates declined rapidly to below expected (adjusted relative rate [aRR], 0.81; 95% CI, 0.79-0.82) in April 2020 followed by a growth to above expected (aRR, 1.07; 95% CI, 1.04-1.09) by July 2020 and sustained at 10% to 15% above expected as of February 2021. Adolescent female individuals had the greatest increase in visit rates relative to expected by the end of the study (aRR, 1.26; 95% CI, 1.25-1.28). Virtual care accounted for 5.0 visits per 1000 population (72.5%) of mental health visits over the study period, with a peak of 5.3 visits per 1000 population (90.1%) (April 2020) and leveling off to approximately 70% in the latter months., Conclusions and Relevance: Physician-based outpatient mental health care in Ontario increased during the pandemic, accompanied by a large, rapid shift to virtual care. There was a disproportionate increase in use of mental health care services among adolescent female individuals. System-level planning to address the increasing capacity needs and to monitor quality of care with such large shifts is warranted.

Purpose: Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic., Methods: Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3-17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates., Results: In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41-1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25-1.50) increase in risk for emergency department visit and hospitalization, respectively., Conclusions: Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: There were large disruptions to health care services after the onset of the COVID-19 pandemic. We sought to describe the extent to which pandemic-related changes in service delivery and access affected use of primary care for children overall and by equity strata in the 9 months after pandemic onset in Manitoba and Ontario., Methods: We performed a population-based study of children aged 17 years or less with provincial health insurance in Ontario or Manitoba before and during the COVID-19 pandemic (Jan. 1, 2017-Nov. 28, 2020). We calculated the weekly rates of in-person and virtual primary care well-child and sick visits, overall and by age group, neighbourhood material deprivation level, rurality and immigrant status, and assessed changes in visit rates after COVID-19 restrictions were imposed compared to expected baseline rates calculated for the 3 years before pandemic onset., Results: Among almost 3 million children in Ontario and more than 300 000 children in Manitoba, primary care visit rates declined to 0.80 (95% confidence interval [CI] 0.77-0.82) of expected in Ontario and 0.82 (95% CI 0.79-0.84) of expected in Manitoba in the 9 months after the onset of the pandemic. Virtual visits accounted for 53% and 29% of visits in Ontario and Manitoba, respectively. The largest monthly decreases in visits occurred in April 2020. Although visit rates increased slowly after April 2020, they had not returned to prerestriction levels by November 2020 in either province. Children aged more than 1 year to 12 years experienced the greatest decrease in visits, especially for well-child care. Compared to prepandemic levels, visit rates were lowest among rural Manitobans, urban Ontarians and Ontarians in low-income neighbourhoods., Interpretation: During the study period, the pandemic contributed to rapid, immediate and inequitable decreases in primary care use, with some recovery and a substantial shift to virtual care. Postpandemic planning must consider the need for catch-up visits, and the long-term impacts warrant further study., Competing Interests: Competing interests: None declared., (© 2021 CMA Joule Inc. or its licensors.)

Introduction/aims: Amyotrophic lateral sclerosis (ALS) symptoms mimic those of other conditions and often require multiple physician and healthcare contacts for investigation and accurate diagnosis. We examined the type and frequency of healthcare service utilization prior to ALS diagnosis and tracheostomy-free survival by sex and rurality among individuals treated with riluzole in Ontario, Canada., Methods: This population-based cohort study used administrative databases to identify patients aged 18+ y diagnosed with ALS and started on riluzole between April 2002-March 2018. Using Poisson regression, rate ratios of healthcare utilization and atypical diagnostic tests and unnecessary therapeutic interventions 5 y prior to ALS diagnosis were compared by sex and rurality. Tracheostomy-free survival after diagnosis was compared between groups using Kaplan-Meier estimators and proportional hazards models., Results: A total of 1071 patients with ALS were identified with a mean age of 70 y; 563 (52.6%) were men and 134 (12.5%) were rural residents. The number of physician visits increased in the 18 mo prior to ALS diagnosis. We observed modest sex differences in healthcare utilization. Rural patients had lower neurologist visit rates (rate ratio [RR], 0.78; 95% confidence interval [CI], 0.70-0.87) and were significantly more likely to receive an atypical diagnostic test or unnecessary therapeutic intervention (RR, 1.80; 95% CI, 1.04-3.10). Tracheostomy-free survival did not differ by sex (log-rank P-value = .78) or rurality (log-rank P-value = .84)., Discussion: Given disparities observed in healthcare of rural ALS patients, policy strategies are needed to ensure all patients have timely access to care along the pathway from symptom onset to ALS diagnosis, to enable access to new therapeutics and clinical trials., (© 2021 Wiley Periodicals LLC.)

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.)

Background: Granular data related to the likelihood of individuals of different ages accessing acute and critical care services over time is lacking., Methods: We used population-based, administrative data from Ontario to identify residents of specific ages (20, 30, 40, etc. to 100) on January 1st every year from 1995-2019. We assessed rates of emergency department (ED) visits (2003-19), hospitalizations, intensive care unit (ICU) admissions (2003-19), and mechanical ventilation., Findings: Overall the 25-year study period, ED were the most common acute healthcare encounter with 100-year-olds having the lowest rate (138.7/1,000) and 90-year-olds the highest (378.5/1,000). Rates of hospitalization ranged from 24.2/1,000 for those age 20 up to 224.9/1,000 for those age 90. Rates of ICU admission and mechanical ventilation were lowest for those age 20 (1.0 and 0.4/1,000), more than tripled by age 50 (3.3 and 1.7/1,000) and peaked at age 80 (20.3 and 10.1/1,000). Over time rates of ED visits increased (164.3 /1,000 in 2003 vs 199.1 /1,000 in 2019) as did rates of invasive mechanical ventilation (2.0/1,000 in 1995 vs 2.9/1,000 in 2019), whereas rates of ICU admission remained stable (4.8/1,000 in 2003 vs 4.9/1,000 in 2019) and hospitalization declined (66.8/1,000 in 1995 vs 51.5/1,000 in 2019). Age stratified analysis demonstrated that rates of ED presentation increased for those age 70 and younger while hospitalization decreased for all age groups; ICU admission and mechanical ventilation rates changed variably by age, with increasing rates demonstrated primarily among people under the age of 50., Interpretation: Rates of hospitalizations have decreased over time across all age groups, whereas rates of ED presentation, ICU admissions, and mechanical ventilation have increased, primarily driven by younger adults. These findings suggest that although the delivery of healthcare may be moving away from inpatient medicine, there is a growing population of young adults requiring significant healthcare resources., Competing Interests: The authors have declared that no competing interests exist.

Population-level identification of children and youth with ASD is essential for surveillance and planning for required services. The objective of this study was to develop and validate an algorithm for the identification of children and youth with ASD using administrative health data. In this retrospective validation study, we linked an electronic medical record (EMR)-based reference standard, consisting 10,000 individuals aged 1-24 years, including 112 confirmed ASD cases to Ontario administrative health data, for the testing of multiple case-finding algorithms. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and corresponding 95% confidence intervals (CI) were calculated for each algorithm. The optimal algorithm was validated in three external cohorts representing family practice, education, and specialized clinical settings. The optimal algorithm included an ASD diagnostic code for a single hospital discharge or emergency department visit or outpatient surgery, or three ASD physician billing codes in 3 years. This algorithm's sensitivity was 50.0% (95%CI 40.7-88.7%), specificity 99.6% (99.4-99.7), PPV 56.6% (46.8-66.3), and NPV 99.4% (99.3-99.6). The results of this study illustrate limitations and need for cautious interpretation when using administrative health data alone for the identification of children and youth with ASD. LAY SUMMARY: We tested algorithms (set of rules) to identify young people with ASD using routinely collected administrative health data. Even the best algorithm misses more than half of those in Ontario with ASD. To understand this better, we tested how well the algorithm worked in different settings (family practice, education, and specialized clinics). The identification of individuals with ASD at a population level is essential for planning for support services and the allocation of resources. Autism Res 2021, 14: 1037-1045. © 2021 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC., (© 2021 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC.)

Autism spectrum disorder (ASD) is a neurodevelopmental disorder requiring significant health and educational resources for affected individuals. A reference standard for ASD was generated from an existing population-based cohort of 10,000 children and youth aged 1-24 years who were randomly selected for chart abstraction from 29,256 patients from 119 family physicians. We developed and validated an algorithm to identify children and youth with ASD within an electronic medical record system (N = 80,237, aged 1-24 years) in order to examine the prevalence of comorbidities and quantify health system utilization within the cohort. We identified 1,062 children and youth with ASD representing a prevalence of 1.32%. Compared to individuals without ASD, those with ASD had a higher prevalence of asthma, were more likely to visit a specialist, undergo surgery, and be hospitalized for psychiatric reasons. Children and youth with ASD in Ontario have complex health system needs, illustrated through a significant burden of comorbidities and increased health system utilization. LAY SUMMARY: Our paper generates population-based estimates of health system use by children and youth with ASD, who have a higher burden of comorbidities than the general population. We developed a case-finding algorithm and applied it in electronic medical records to create a cohort of children and youth with ASD, thereby generating an important resource to further study the health care needs of individuals with ASD., (© 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC.)

Background: Since 2005, the Smoking Treatment for Ontario Patients (STOP) program has provided smoking cessation treatment of varying form and intensity to smokers through 11 distinct treatment models, either in-person at partnering healthcare organizations or remotely via web or telephone. We aimed to characterize the patient populations reached by different treatment models., Methods: We linked self-report data to health administrative databases to describe sociodemographics, physical and mental health comorbidity, healthcare utilization and costs. Our sample consisted of 107,302 patients who enrolled between 18Oct2005 and 31Mar2016, across 11 models operational during different time periods., Results: Patient populations varied on sociodemographics, comorbidity burden, and healthcare usage. Enrollees in the Web-based model were youngest (median age: 39; IQR: 29-49), and enrollees in primary care-based Family Health Teams were oldest (median: 51; IQR: 40-60). Chronic Obstructive Pulmonary Disease and hypertension were the most common physical health comorbidities, twice as prevalent in Family Health Teams (32.3% and 30.8%) than in the direct-to-smoker (Web and Telephone) and Pharmacy models (13.5%-16.7% and 14.7%-17.7%). Depression, the most prevalent mental health diagnosis, was twice as prevalent in the Addiction Agency (52.1%) versus the Telephone model (25.3%). Median healthcare costs in the two years up to enrollment ranged from $1,787 in the Telephone model to $9,393 in the Addiction Agency model., Discussion: While practitioner-mediated models in specialized and primary care settings reached smokers with more complex healthcare needs, alternative settings appear better suited to reach younger smokers before such comorbidities develop. Although Web and Telephone models were expected to have fewer barriers to access, they reached a lower proportion of patients in rural areas and of lower socioeconomic status. Findings suggest that in addition to population-based strategies, embedding smoking cessation treatment into existing healthcare settings that reach patient populations with varying disparities may enhance equitable access to treatment., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: DB reports grants from the Canadian Cancer Society Research Institute during the conduct of the study; she also reports grants from a Pfizer GRAND award, outside the submitted work. LZ reports grants from the Canadian Cancer Society Research Institute during the conduct of the study; she also reports grants from Pfizer GRAND Awards, outside the submitted work. PLS reports receiving grants from the Centre for Addiction and Mental Health, Ontario Ministry of Health and Long-Term Care, Health Canada, Canadian Institutes of Health Research, Canadian Cancer Society Research Institute, Canadian Partnership Against Cancer, Medical Psychiatry Alliance, Ontario Neurotrauma Foundation, the Patient-Centered Outcomes Research Institute, Bhasin Consulting Fund Inc and Pfizer Inc./Canada. PLS also reports serving on advisory boards and receiving consulting fees and honoraria from Pfizer Canada Inc., Johnson & Johnson Group of Companies, Evidera Inc., Miller Medical Communications, NVision Insight Group, Myelin & Associates, University of Ottawa Heart Institute, Royal College of Physicians and Surgeons of Canada, Royal Victoria Regional Health Centre, the University of Toronto Department of Family and Community Medicine, Northern Ontario School of Medicine, Canadian Partnership Against Cancer, Battle River Treaty 6 Healthcare, Lung Association of Nova Scotia, Exchange Summit, Toronto Public Health, Ontario Association of Public Health Dentistry and ECHO. PLS also reports that MedPlan Communications assisted in organizing Pfizer Canada Inc. Advisory Board events for which he was a consultant and that Pfizer Inc., Novartis, and Johnson & Johnson are vendors of record for providing free/discounted smoking cessation pharmacotherapy for research studies on which he is principal or co-investigator. No other author has competing interests to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Ethnicity may be associated with important aspects of end-of-life care, such as what treatments are received, access to palliative care and where people die. However, most studies have focused on end-of-life care of white, Hispanic and black patients. We sought to compare end-of-life care delivered to people of Chinese and South Asian ethnicity with that delivered to others from the general population, in Ontario, Canada., Methods: In this population-based cohort study, we included all people who died in Ontario, Canada, between Apr. 1, 2004, and Mar. 31, 2015. People were identified as having Chinese or South Asian ethnicity on the basis of a validated surname algorithm. We used modified Poisson regression analyses to assess location of death and care received in the last 6 months of life., Results: We analyzed 967 339 decedents, including 18 959 (2.0%) of Chinese and 11 406 (1.2%) of South Asian ethnicity. Chinese (13.6%) and South Asian (18.5%) decedents were more likely than decedents from the general population (10.1%) to die in the intensive care unit (ICU). The adjusted relative risk of dying in intensive care was 1.21 (95% confidence interval [CI] 1.15 to 1.27) for Chinese and 1.25 (95% CI 1.20 to 1.30) for South Asian decedents. In their last 6 months of life, decedents of Chinese and South Asian ethnicity experienced significantly more ICU admission, hospital admission, mechanical ventilation, dialysis, percutaneous feeding tube placement, tracheostomy and cardiopulmonary resuscitation than the general population., Interpretation: Decedents of Chinese and South Asian ethnicity in Ontario were more likely than decedents from the general population to receive aggressive care and to die in an ICU. These findings may be due to communication difficulties between patients and clinicians, differences in preferences about end-of-life care or differences in access to palliative care services., Competing Interests: Competing interests: None declared., (© 2020 Joule Inc. or its licensors.)

Background: Transition to adult diabetes care is a high-risk period for acute complications, yet the optimal transition care model is unknown. To gain insight into the impact on health outcomes of system-level transition processes that reflect resourcing differences, we examined acute complications in youth with diabetes across transition in 2 Canadian provinces with different transition care models., Methods: We used linked provincial health administrative data for Ontario and Newfoundland and Labrador to create 2 parallel cohorts of youth with diabetes diagnosed before age 15 years who turned 17 between 2006 and 2011. Participants were followed until 2015 (maximum age 21 yr). We described rates of and proportion of participants with at least 1 diabetes-related hospital admission at age 15-17 years and 18-20 years, standardized according to material deprivation based on the 2006 Canadian Marginalization Index. We compared diabetes-related admissions at age 15-17 years and 18-20 years in the Ontario cohort., Results: The cohorts consisted of 2525 youth in Ontario and 93 in Newfoundland and Labrador. In Newfoundland and Labrador, 39 participants (42.0%) were in the lowest socioeconomic quintile, versus 326 (12.9%) in Ontario. The standardized rate of diabetes-related hospital admissions per 100 person-years was 13.5 (95% confidence interval [CI] 12.6-14.4) at age 15-17 years and 14.4 (95% CI 13.5-15.3) at age 18-20 years in Ontario, and 11.4 (95% CI 7.0-15.8) at age 15-17 years and 10.5 (95% CI 6.4-14.6) at age 18-20 years in Newfoundland and Labrador. In Ontario, there was no association between the rate (adjusted rate ratio 1.10, 95% CI 0.94-1.28) or occurrence (adjusted odds ratio 1.03, 95% CI 0.91-1.17) of diabetes-related admissions across transition., Interpretation: Although posttransition care is delivered differently in the 2 provinces, rates of adverse events across transition were stable in both. Coordinated support during transition is needed to help mitigate adverse events for young adults in both provinces. Delivery of other health care and social services, including primary care, may be influencing the risk of adverse events after transition to adult care., Competing Interests: Competing interests: None declared., (Copyright 2020, Joule Inc. or its licensors.)

Importance: Adolescents with severe mental illness often age out of pediatric care without a clear transfer of care to adult services. The extent to which primary care provides stability during this vulnerable transition period is not known., Objective: To analyze the association between primary care continuity during the transition from pediatric to adult care and need for acute mental health services in young adulthood., Design, Setting, and Participants: This population-based cohort study used linked health and demographic administrative data for all adolescents aged 12 to 16 years with severe mental illness ascertained by hospitalization for schizophrenia, eating disorder, or mood disorder between April 1, 2002, and April 1, 2014, in Ontario, Canada. Participants were followed up through March 31, 2017. Data were analyzed from July 2018 to January 2019., Exposures: Continuous primary care (same physician as baseline [age 12-16 years] always or sometimes), discontinuous primary care (visits to a primary care physician during the transition period who was not the patient's usual physician), and no primary care during the transition period (age 17-18 years)., Main Outcomes and Measures: Mental health-related hospitalizations and emergency department visits in young adulthood (age 19-26 years) adjusted for sex, rurality, neighborhood income, mental illness type, and health service use before transition., Results: Among 8409 adolescents with severe mental illness (5720 [68.0%] female; mean [SD] age, 14.8 [1.2] years), 5478 (65.1%) had continuous primary care, 2391 (28.4%) had discontinuous primary care, and 540 (6.4%) had no primary care during the transition period. Youths with no primary care during transition were more likely to be male (57.2%), have lower socioeconomic status (31.5%), and have no usual primary care practitioner at baseline (25.6%). Compared with continuous care, patients with discontinuous and no primary care had an increased rate of mental health-related hospitalization in young adulthood (adjusted relative rate, 1.20; 95% CI, 1.10-1.30; and adjusted relative rate, 1.30; 95% CI, 1.08-1.56, respectively)., Conclusions and Relevance: In the context of decreasing outpatient specialist mental health visit rates following transition to adult care, ensuring adequate access to primary care during this vulnerable period may improve mental health outcomes in young adulthood.

Importance: The idea that physicians as patients choose less-aggressive care at the end of life for themselves is an often-cited rationale to advocate for less technology-laden end-of-life care., Objective: To assess end-of-life care received by physicians compared with nonphysicians in a system with universal health care., Design, Setting, and Participants: In this population-level decedent cohort study of data from April 1, 2004, through March 31, 2015 (fiscal years 2004-2014), in Ontario, Canada, 2507 physicians were matched approximately 1:3 to 7513 nonphysicians (ie, individuals who never were registered as a physician with the College of Physicians and Surgeons of Ontario) according to age, sex, income quintile, and location of residence., Main Outcomes and Measures: The primary outcome was location of death. Other outcomes included measures of health care use in the last 6 months of life. Differences were assessed using Poisson regression with robust error variances, adjusting for the Charlson Comorbidity Index., Results: In total, 2516 physicians and 954 836 nonphysicians died between April 1, 2004, and March 31, 2015, in Ontario; 2247 physicians (89.3%) and 474 182 nonphysicians (49.7%) were men. The median (interquartile range) age at death was 82 (74-87) years for the physicians and 80 (68-87) years for the nonphysicians. After matching, data for 2507 physicians and 7513 nonphysicians were analyzed. For physicians, the risk of death at home was no different from that for nonphysicians (42.8% vs 39.0%; adjusted relative risk [aRR], 1.04; 95% CI, 0.99-1.09), but the risk of death in an intensive care unit was increased (11.9% vs 10.0%; aRR, 1.22; 95% CI, 1.08-1.39). In the prior 6 months, physicians had a decreased risk of an emergency department visit (73.0% vs 78.4%; aRR, 0.96; 95% CI, 0.94-0.98) but increased risks of an intensive care unit admission (20.8% vs 19.1%; aRR, 1.14; 95% CI, 1.05-1.24) and of receipt of palliative care services (52.9% vs 47.4%; aRR, 1.18; 95% CI, 1.13-1.23). Among a subgroup of 457 physicians and 1347 nonphysicians with cancer, the risk of death at home or intensive care unit was increased (37.6% vs 28.6%; aRR, 1.30; 95% CI, 1.13-1.50), as was the risk of receiving chemotherapy in the last 6 months of life., Conclusions and Relevance: There was no difference overall for physicians compared with nonphysicians in terms of the likelihood of dying at home; physicians were more likely to die in an intensive care unit and to receive chemotherapy, but also to receive palliative care services. These findings suggest that physicians do not consistently opt for less-aggressive care but instead receive end-of-life care that includes both intensive and palliative care. These findings inform a more nuanced perspective of what physicians may perceive to be optimal care at the end of life.

Background: The general health check, which includes the periodic health visit and annual physical exam, is not recommended to maintain the health of asymptomatic adults with no risk factors. Different funding mechanisms for primary care may be associated with the provision of service delivery according to recommended guidelines. We sought to determine how use of the periodic health visit for healthy individuals without comorbidities, despite evidence against its use, differed by primary care model., Methods: Population-based cross-sectional study using linked health and administrative datasets in Ontario, Canada, where most residents are insured for physician services through Ontario's single payer, provincially funded Ontario Health Insurance Plan. Participants included all living adults (> 19 years) in Ontario on January 1st, 2014, eligible for the Ontario Health Insurance Plan. Primary care enrollment model was the main exposure and included traditional fee-for-service, enhanced fee-for-service, capitation, team-based care, other (including salaried), and unenrolled. The main outcome measure was receipt of a periodic health visit during 2014. Age-sex standardized rates of periodic health visits performed during the one-year study period were analyzed by number of comorbid conditions., Results: Of 10,712,804 adults in Ontario, 2,350,386 (21.9%) had a periodic health visit in 2014. The age-sex standardized rate was 6.1% (95% confidence interval [CI] 6.0, 6.1%) for healthy individuals. In the traditional fee-for-service model, the periodic health visit was performed for 55.3% (95% CI 54.4, 56.3%) of healthy individuals versus 10.2% (95% CI 10.0, 10.3%) in team-based care. Periodic health visit rates varied by primary care provider models. Traditional and enhanced fee-for-service models had higher rates across all comorbidity groups., Conclusions: Patients whose primary care physicians are funded exclusively through fee-for-service had the highest rates of periodic health visits in healthy individuals. Primary care reform initiatives must consider the influence of remuneration on providing evidence-based primary care.

Life satisfaction is increasingly recognized as an important determinant of health; however, prospective population-based studies on this topic are limited. We estimated the risk of chronic disease and death according to life satisfaction among a population-based cohort in Ontario, Canada (n = 73,904). The cohort included 3 pooled cycles of the Canadian Community Health Survey (2003-2008) linked to 6 years of follow-up (to 2015), using population-based health databases and validated disease-specific registries. The databases capture incident and prevalent cases of diabetes, cancer, chronic obstructive pulmonary disease, heart disease, and death. Multivariable Cox proportional hazard models were used to estimate hazards of incident chronic disease and death, and were adjusted for sociodemographic, behavioral, and clinical confounders, including age, sex, comorbidity, mood disorder, smoking, alcohol consumption, physical activity, body mass index, immigrant status, education, and income. In the fully adjusted models, risk of both death and incident chronic disease was highest for those most dissatisfied with life (for mortality, hazard ratio = 1.59, 95% confidence interval: 1.15, 2.19; for chronic disease, hazard ratio = 1.70, 95% confidence interval: 1.16, 2.51). In this population-based cohort, poor life satisfaction was an independent risk factor for incident chronic disease and death, supporting the idea that interventions and programs that improve life satisfaction will affect population health.

Aims: To describe patterns of primary and diabetes care during transition age (17 to < 19 years) into early adulthood (age 19 to 26 years), and to evaluate the association of primary and diabetes care patterns during transition age with the risk of adverse events in early adulthood., Methods: We conducted a population-based cohort study of individuals in Ontario, Canada who were diagnosed with diabetes aged < 15 years and who turned 17 between November 2006 and March 2011, followed until March 2015 (n = 2525). Using linked administrative databases, we examined healthcare use during: 'pre-transition-age' (15 to < 17 years), 'transition-age' (17 to < 19 years), and 'early adulthood' (19 to 26 years). The main outcomes were time to death or ketoacidosis and rate of diabetes-related admissions. The main exposures were the gap in diabetes care and primary care visits during transition age., Results: There were < 6 deaths and 446 individuals (17.7%) had at least one admission for ketoacidosis during early adulthood. In all, 1188 individuals (47.0%) had a > 12-month gap in diabetes care and 241 (9.5%) had no primary care visits during transition age. A gap in diabetes care of > 12 months and no primary care visits during transition age were associated with an increased risk of ketoacidosis or death (adjusted hazard ratio 1.31, 95% CI 1.04-1.66 and adjusted hazard ratio 1.42, 95% CI 1.02-1.97, respectively)., Conclusions: In Ontario, Canada, where physician and hospital-based services are universally covered, a high proportion of young adults with diabetes have insufficient care during transition age and this is associated with a higher risk of important adverse outcomes in early adulthood. Ensuring primary care involvement during transition may be a strategy to reduce morbidity., (© 2018 Diabetes UK.)

Introduction: Studies have highlighted the importance of life satisfaction or, more generally, happiness, on health. However, there are few studies that have prospectively assessed the relationship between life satisfaction and healthcare utilization and costs., Methods: Participants were from three national survey cycles conducted between 2005 and 2010 to future healthcare utilization up to 2015. Analysis was conducted in 2016-2017. Annual per person costs were calculated and individuals ranked. Adjusted multinomial logistic regression models were used to quantify the association between life satisfaction and being in the top 5% or top 6%-50%, compared to the bottom 50%, during follow-up., Results: After exclusions, the study population included 85,225 adults. Increasing life dissatisfaction was associated with higher healthcare utilization and costs. In the fully adjusted model, the odds for those with the lowest level of life satisfaction being in the top 5% of healthcare costs relative to the lowest 50% is 3.05 (95% CI=1.61, 5.80). Those with the lowest life satisfaction were also at increased odds of being in the middle utilization category (6%-50%) with a significant OR=2.24 (95% CI=1.60, 3.14). All trends for increasing dissatisfaction were significant (p<0.001)., Conclusions: Life dissatisfaction was significantly associated with being a high-cost user in the future. This relationship persisted after adjustment for demographic factors, comorbidity, socioeconomic factors, and health behaviors. This study points to the importance of considering broader correlates of well-being with respect to future healthcare utilization and costs., (Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to examine the short-term and long-term impacts of psychiatric hospitalisations among patients of Chinese and South Asian origin., Design: Retrospective population-based cohort study using linked health administrative data., Setting: We examined all adult psychiatric inpatients discharged between 1 April 2006 and 31 March 2014 in Ontario, Canada, who were classified as Chinese, South Asian and all other ethnicities (ie, 'general population') using a validated algorithm. We identified 2552 Chinese, 2439 South Asian and 127 142 general population patients., Primary and Secondary Outcome Measures: We examined psychiatric severity measures at admission and discharge and performed multivariable logistic regression analyses to examine 30-day, 180-day and 365-day postdischarge service utilisation and outcomes, comparing each of the ethnic groups with the reference population, after adjustment for age, sex, income, education, marital status, immigration status, community size and discharge diagnosis., Results: Despite presenting to hospital with greater illness severity, Asian psychiatric inpatients had shorter lengths of hospital stay and greater absolute improvements in mental health and functional status at discharge compared with other inpatients. After hospitalisation, Chinese patients were more likely to visit psychiatrists and South Asian patients were more likely to seek mental healthcare from general practitioners. They were also less likely to have a psychiatric readmission or die 1 year following hospitalisation (adjusted OR Chinese =0.87; 95% CI 0.79 to 0.97; adjusted OR South Asian =0.82, 95% CI 0.73 to 0.91). Findings were consistent across genders, psychiatric diagnoses and immigrant groups., Conclusion: Once hospitalised, patients of Chinese and South Asian origin fared as well as or better than general population patients at discharge and following discharge, and had a positive trajectory of psychiatric service utilisation., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Women with diabetes have higher breast cancer incidence and mortality. The purpose of this study was to examine the impact of diabetes on stage at breast cancer diagnosis, as a possible reason for their higher mortality. Using population-based health databases from Ontario, Canada, this retrospective cohort study examined stage at diagnosis (II, III, or IV vs I) among women aged 20-105 years who were newly diagnosed with invasive breast cancer between 2007 and 2012. We compared those with diabetes to those without diabetes. Diabetes was defined based on medical records using a validated algorithm. Among 38,407 women with breast cancer, 6115 (15.9 %) women had diabetes. Breast cancer patients with diabetes were significantly more likely to present with advanced-stage breast cancer than those without diabetes. After adjustment for mammograms and other covariates, diabetes was associated with a significantly increased risk of Stage II [adjusted odds ratio (aOR) 1.14, 95 % confidence interval (CI) 1.07, 1.22], Stage III (aOR 1.21, 95 % CI 1.11, 1.33), and Stage IV (aOR 1.16, 95 % CI 1.01, 1.33) versus Stage I breast cancer. Women with diabetes had a higher risk of lymph node metastases (aOR 1.16, 95 % CI 1.06, 1.27) and tumors with size over 2 cm (aOR 1.16, 95 % CI 1.06, 1.28). Diabetes was associated with more advanced-stage breast cancer, even after accounting for differences in screening mammogram use and other factors. Our findings suggest that diabetes may predispose to more aggressive breast cancer, which may be a contributor to their higher cancer mortality.

Objectives: To understand how drug therapy differently affects older women and men., Design: Population-based, retrospective cohort study., Setting: Ontario, Canada., Participants: Twenty-one thousand five hundred twenty-six older adults (13,760 women, 7,766 men) with dementia newly started on oral atypical antipsychotic therapy between April 1, 2007, and March 1, 2010., Measurements: Numbers and rates of serious events. Serious events were defined as a hospital admission or death within 30 days of treatment initiation. Unadjusted and adjusted odds ratios of women and men were compared in the full cohort and in strata based on setting of care, age, Charlson Comorbidity Index (CCI), and antipsychotic dose., Results: Of 21,526 older adults with a median age of 84, 1,889 (8.8%) had a serious event (1,044 women, 7.6%; 845 men, 10.9%). Of these, 363 women (2.6%) and 355 men (4.6%) died. Men were more likely than women to be hospitalized or die during the 30-day follow-up period (adjusted odds ratio = 1.47, 95% confidence interval = 1.33-1.62) and consistently more likely to experience a serious event in each stratum. A gradient of risk according to drug dose was found for the development of a serious event in women and men., Conclusion: The risk of developing a serious event shortly after the initiation of antipsychotic therapy was high in women and men with dementia but was consistently higher in older men. This pattern remained the same in strata based on setting of care, age, CCI, and antipsychotic dose., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

This research presents a disaggregated modeling approach for investigating the link between winter road collision occurrence, weather, road surface conditions, traffic exposure, temporal trends and site-specific effects. This approach is unique as it allows for quantification of the safety effects of different winter road maintenance activities at an operational level. Different collision frequency models are calibrated using hourly data collected from 31 different highway routes across Ontario, Canada. It is found that factors such as visibility, precipitation intensity, air temperature, wind speed, exposure, month of the winter season, and storm hour have statistically significant effects on winter road safety. Most importantly, road surface conditions are identified as one of the major contributing factors, representing the first contribution showing the empirical relationship between safety and road surface conditions at such a disaggregate level. The applicability of the modeling framework is demonstrated using several examples, such as quantification of the benefits of alternative maintenance operations and evaluation of the effects of different service standards using safety as a performance measure., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Cholinesterase inhibitors (ChEIs) are a mainstay treatment for individuals with dementia. ChEIs may worsen airflow obstruction because of their pro-cholinergic properties., Objective: The objective of this study was to evaluate the risk of serious pulmonary complications in the elderly with concomitant chronic obstructive pulmonary disease (COPD) and dementia who were receiving ChEIs., Methods: This was a population-based, cohort study conducted between 2003 and 2010 in residents of Ontario, Canada. Subjects were over the age of 66 years and had concomitant dementia and COPD, identified using linked administrative databases. Exposure to ChEIs was determined using a drug benefits database. The primary outcome was an emergency room (ER) visit or hospitalization for COPD. The risk difference at 60 days and the relative risk (RR) for study outcomes were estimated in the propensity score-matched sample., Results: Of 266,840 individuals with COPD, 45,503 had a concomitant diagnosis of dementia. A total of 7166 unexposed subjects were matched to subjects newly exposed to ChEIs. New users of ChEIs were not at significantly higher risk of ER visits or hospitalizations for COPD (RR 0.90; 95% CI 0.76, 1.07) or COPD exacerbations (RR 1.02; 95% CI 0.91, 1.15). Furthermore, ER visits for any respiratory diagnoses were not increased among new users of ChEIs (RR 1.02; 95% CI 0.87, 1.19) when compared with non-users. Sub-group analyses were consistent with the main analysis., Conclusions: In a large cohort of elderly individuals with COPD and dementia, new users of ChEIs had a similar risk for adverse pulmonary outcomes as those who were not receiving ChEIs.

This research presents a modeling approach to investigate the association of the accident frequency during a snow storm event with road surface conditions, visibility and other influencing factors controlling for traffic exposure. The results have the premise to be applied for evaluating different maintenance strategies using safety as a performance measure. As part of this approach, this research introduces a road surface condition index as a surrogate measure of the commonly used friction measure to capture different road surface conditions. Data from various data sources, such as weather, road condition observations, traffic counts and accidents, are integrated and used to test three event-based models including the Negative Binomial model, the generalized NB model and the zero inflated NB model. These models are compared for their capability to explain differences in accident frequencies between individual snow storms. It was found that the generalized NB model best fits the data, and is most capable of capturing heterogeneity other than excess zeros. Among the main results, it was found that the road surface condition index was statistically significant influencing the accident occurrence. This research is the first showing the empirical relationship between safety and road surface conditions at a disaggregate level (event-based), making it feasible to quantify the safety benefits of alternative maintenance goals and methods., (2010 Elsevier Ltd. All rights reserved.)