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BACKGROUND: Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability. METHODS: We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1, 2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤ 64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity. RESULTS: Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [CI] 1.19-1.56) and greater risk of readmission (relative risk 1.77, 95% CI 1.14-2.75). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability. INTERPRETATION: Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.

BACKGROUND: Patient characteristics, clinical care, resource use and outcomes associated with admission to hospital for coronavirus disease 2019 (COVID-19) in Canada are not well described. METHODS: We described all adults with COVID-19 or influenza discharged from inpatient medical services and medical-surgical intensive care units (ICUs) between Nov. 1, 2019, and June 30, 2020, at 7 hospitals in Toronto and Mississauga, Ontario. We compared patient outcomes using multivariable regression models, controlling for patient sociodemographic factors and comorbidity level. We validated the accuracy of 7 externally developed risk scores to predict mortality among patients with COVID-19. RESULTS: There were 1027 hospital admissions with COVID-19 (median age 65 yr, 59.1% male) and 783 with influenza (median age 68 yr, 50.8% male). Patients younger than 50 years accounted for 21.2% of all admissions for COVID-19 and 24.0% of ICU admissions. Compared with influenza, patients with COVID-19 had significantly greater in-hospital mortality (unadjusted 19.9% v. 6.1%, adjusted relative risk [RR] 3.46, 95% confidence interval [CI] 2.56-4.68), ICU use (unadjusted 26.4% v. 18.0%, adjusted RR 1.50, 95% CI 1.25-1.80) and hospital length of stay (unadjusted median 8.7 d v. 4.8 d, adjusted rate ratio 1.45, 95% CI 1.25-1.69). Thirty-day readmission was not significantly different (unadjusted 9.3% v. 9.6%, adjusted RR 0.98, 95% CI 0.70-1.39). Three points-based risk scores for predicting in-hospital mortality showed good discrimination (area under the receiver operating characteristic curve [AUC] ranging from 0.72 to 0.81) and calibration. INTERPRETATION: During the first wave of the pandemic, admission to hospital for COVID-19 was associated with significantly greater mortality, ICU use and hospital length of stay than influenza. Simple risk scores can predict in-hospital mortality in patients with COVID-19 with good accuracy.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. METHODS: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. RESULTS: There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. INTERPRETATION: The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Background It is unclear if human immunodeficiency virus (HIV) affects the prognosis for community-acquired pneumonia (CAP) in the current era of effective antiretroviral therapy. In this multicenter retrospective cohort study of patients admitted for CAP, we compared the in-hospital mortality rate between people with HIV (PWH) and those without. Methods The study included consecutive patients admitted with a diagnosis of CAP across 31 hospitals in Ontario, Canada, from 2015 to 2022. HIV infection was based on discharge diagnoses and antiretroviral prescription. The primary outcome was in-hospital mortality. Competing risk models were used to describe time to death in hospital or discharge. Potential confounders were balanced using overlap weighting of propensity scores. Results Of 82 822 patients admitted with CAP, 1518 (1.8%) had a diagnosis of HIV. PWH were more likely to be younger, male, and have fewer comorbidities. In the hospital, 67 (4.4%) PWH and 6873 (8.5%) people without HIV died. HIV status had an adjusted subdistribution hazard ratio of 1.02 (95% confidence interval,.80–1.31; P =.8440) for dying in the hospital. Of 1518 PWH, 440 (29.0%) patients had a diagnosis of AIDS. AIDS diagnosis had an adjusted subdistribution hazard ratio of 3.04 (95% CI, 1.69–5.45; P =.0002) for dying in the hospital compared to HIV without AIDS. Conclusions People with and without HIV admitted for CAP had a similar in-hospital mortality rate. For PWH, AIDS significantly increased the mortality risk. HIV infection by itself without AIDS should not be considered a poor prognostic factor for CAP. [ABSTRACT FROM AUTHOR]

Background: We aimed to describe the association between insertion of a new long‐term enteral feeding tube during admission for aspiration and in‐hospital mortality. Methods: This retrospective cohort study across 28 Canadian hospitals from 2015 to 2022 included consecutive patients who were admitted for aspiration. Patients were categorized based on new long‐term enteral feeding tube insertion during hospital stay or not. The primary outcome was the time to death in hospital. Secondary outcomes included time to discharge alive and hospital readmission for aspiration within 90 days. We used propensity score weighting to balance covariates, and a competing risk model to describe in‐hospital death and discharge. Results: Of 12,850 patients admitted for aspiration, 852 (6.6%) patients received a long‐term enteral feeding tube. In the hospital, 184 (21.6%) and 2489 (20.8%) patients in the enteral feeding tube group and no enteral feeding tube group died, respectively. Within 90 days of discharge, 127 (14.9%) and 1148 (9.6%) patients in the enteral feeding tube and no enteral feeding tube group were readmitted for aspiration, respectively. After balancing covariates, an enteral feeding tube was associated with a similar in‐hospital mortality risk (subdistribution hazard ratio [sHR] = 1.05, 95% CI = 0.89–1.23; P = 0.5800), longer time to discharge alive (sHR = 0.58, 95% CI = 0.54–0.63; P < 0.0001), and a higher risk of readmission (risk difference = 5.0%, 95% CI = 2.4%–7.6%; P = 0.0001). Conclusion: Initiation of long‐term enteral tube feeding was not uncommon after admission for aspiration and was not associated with an improvement in the probability of being discharged alive from the hospital or readmitted for aspiration. [ABSTRACT FROM AUTHOR]

BackgroundAs originally proposed by Fries, conceptualizing morbidity solely through associated functional limitation/disability (FL/D) remains the most widely accepted metric to assess whether increases in longevity have been accompanied by a compression of morbidity.ObjectiveTo propose a departure from a highly restrictive FL/D-based definition of "morbidity" to a broader view that considers the burden of chronic diseases even when no overt FL/D occur.DesignWe outline three reasons why the current framework of compression of morbidity should be broadened to also consider morbidity to be present even when there are no overtly measurable FL/D. We discuss various scenarios of morbidity compression and morbidity expansion under this broader rubric of morbidity.ConclusionThe rationale to go beyond a purely FL/D-based definition of morbidity includes: (1) substantial damage from chronic disease that can develop prior to overt FL/D symptoms occurring; (2) multiple costs to the individual and society that extend beyond FL/D, including medication costs, health care visits, and opportunity costs of lifelong treatment; and (3) psychosocial and stress burden of being labeled as diseased and the consequence for overall well-being. Adopting this broader definition of morbidity suggests that increases in longevity have been possibly accompanied by an expansion of morbidity, in contrast to Fries' original hypothesis that morbidity onset (based on only FL/D) would be delayed to a greater extent than increases in survival. There is an urgent need for better data and more research to document morbidity onset and its link with increases in longevity and assess the important question on whether populations while living longer are also healthier.

Background: In Canada, one in seven adults has diabetes (i.e., 2.3 million) and the lifetime risk of developing diabetes is approximately 30% by age 65. Although 30% of patients admitted to the hospital have diabetes, data from inpatient hospitalizations for patients with diabetes are lacking, both in Canada and globally. Objective: To validate International Classification of Diseases 10th edition Canadian version (ICD-10-CA) codes for the identification of patients with diabetes, to create a multicenter database of patients with diabetes hospitalized under internal medicine in Ontario, and to determine their baseline characteristics, medication use, and admission characteristics. Study design: We created a database of people who had diabetes and were hospitalized between 2010 and 2020 at 8 hospitals in Ontario that were part of the General Medicine Inpatient Initiative (GEMINI) hospital data-sharing network. Patients who had diabetes were identified using chart review, based upon either (i) a previous physician diagnosis of diabetes, (ii) a recorded hemoglobin A1c ≥ 6.5% or (iii) outpatient prescription of a diabetes medication preceding the hospitalization. The test characteristics of ICD-10-CA codes for diabetes were evaluated. We compared baseline demographics, medication use and hospitalization details among patients with and without diabetes. For hospitalization details, we collected information on the admission diagnosis, comorbidity index, length of stay, receipt of ICU-level care, and inpatient mortality. Results: There were 384,588 admissions within the total study cohort, of which 118,987 (30.9%) had an ICD-10-CA diagnosis code of diabetes (E10.x, E11.x, E13.x, E14.x). The sensitivity and specificity of ICD-10-CA diagnostic codes was 95.9% and 98.8%, respectively. Most patients with an ICD-10-CA code for diabetes had a code for type 2 diabetes (93.9%) and a code for type 1 diabetes was rare (6.1%). The mean age was 66.4 years for patients without diabetes and 71.3 years for those with an ICD-10-CA diagnosis code for diabetes. Patients with diabetes had a higher prevalence of hypertension (64% vs. 37.9%), coronary artery disease (28.7% vs. 15.3%), heart failure (24.5% vs. 12.1%) and renal failure (33.8% vs. 17.3%) in comparison to those without diabetes. The most prevalent diabetes medications received in hospital were metformin (43%), DPP4 inhibitors (22.7%) and sulfonylureas (18.8%). The most common reason for admission among patients with diabetes was heart failure (9.0%), and among patients without diabetes was pneumonia (7.8%). Median length of stay was longer for patients with diabetes (5.5 vs. 4.5 days) and in-hospital mortality was similar between groups (6.8% with diabetes vs. 6.5% without diabetes). Importance: Diabetes is one of the most prevalent chronic medical conditions, affecting roughly one third of all patients hospitalized on an internal medicine ward and is associated with other comorbidities and longer hospital stays. ICD-10-CA codes were highly accurate in identifying patients with diabetes. The development of an inpatient cohort will allow for further study of in-hospital practices and outcomes among patients with diabetes. [ABSTRACT FROM AUTHOR]