Patterns of publicly funded naltrexone use among patients diagnosed with alcohol use disorder in Ontario.

AIMS: Naltrexone is recommended first-line to manage alcohol use disorder (AUD). With previous studies indicating poor retention on naltrexone, we determined duration of naltrexone use and assessed the association between prescription setting and time to discontinuation in Ontario. METHODS: We conducted a retrospective population-based cohort study among Ontario public drug beneficiaries diagnosed with AUD who initiated publicly funded naltrexone from June 2018 to September 2019. The primary outcome was time to naltrexone discontinuation, with a secondary analysis assessing receipt of at least one prescription refill. We used Cox proportional hazards models and logistic regression to test the association between prescription setting and each medication persistence outcome. RESULTS: Among 2531 new naltrexone patients with AUD, the median duration of naltrexone use was 31 days and 394 (15.6%) continued naltrexone for 6 months or longer. There was no association between setting of initiation and duration of naltrexone use; however, those initiating naltrexone following an acute inpatient hospital stay were more likely to fill a second prescription (aOR 1.43, 95% CI 0.96-2.14), while those initiating after an ED visit were less likely to be dispensed a second prescription (aOR = 0.69, 95% CI 0.52-0.90) compared to those starting in a physician's office. CONCLUSION: Persistence on naltrexone to treat an AUD is low, regardless of the setting of initiation. Further research is needed to elucidate the barriers encountered by patients with AUD that lead to poor treatment persistence in order to develop interventions that facilitate patient-centered access to evidence-based treatment for AUD in the province.

Impact of COVID-19 pandemic on prescription stimulant use among children and youth: a population-based study.

COVID-19 associated public health measures and school closures exacerbated symptoms in some children and youth with attention-deficit hyperactivity disorder (ADHD). Less well understood is how the pandemic influenced patterns of prescription stimulant use. We conducted a population-based study of stimulant dispensing to children and youth ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of stimulants occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected stimulant use. Our main outcome was the change in the monthly rate of stimulant use per 100,000 children and youth. Following an initial immediate decline of 60.1 individuals per 100,000 (95% confidence interval [CI] - 99.0 to - 21.2), the monthly rate of stimulant dispensing increased by 11.8 individuals per 100,000 (95% CI 10.0-13.6), with the greatest increases in trend observed among females, individuals in the highest income neighbourhoods, and those aged 20 to 24. Observed rates were between 3.9% (95% CI 1.7-6.2%) and 36.9% (95% CI 34.3-39.5%) higher than predicted among females from June 2020 onward and between 7.1% (95% CI 4.2-10.0%) and 50.7% (95% CI 47.0-54.4%) higher than expected among individuals aged 20-24 from May 2020 onward. Additional research is needed to ascertain the appropriateness of stimulant use and to develop strategies supporting children and youth with ADHD during future periods of long-term stressors.

Brief Report: A population-based study of the impact of the COVID-19 pandemic on benzodiazepine use among children and young adults.

The COVID-19 pandemic was associated with increases in the prevalence of depression and anxiety among children and young adults. We studied whether the pandemic was associated with changes in prescription benzodiazepine use. We conducted a population-based study of benzodiazepine dispensing to children and young adults ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in prescription benzodiazepine dispensing occurred, and interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected benzodiazepine use. A structural break occurs where there is a sudden change in the trend of a time series. We observed an immediate decline in benzodiazepine dispensing of 23.6 per 100,000 (95% confidence interval [CI]: -33.6 to -21.2) associated with a structural break in April 2020, followed by a monthly decrease in the trend of 0.3 per 100,000 (95% CI: -0.74 to 0.14). Lower than expected benzodiazepine dispensing rates were observed each month of the pandemic from April 2020 onward, with relative percent differences ranging from - 7.4% (95% CI: -10.1% to - 4.7%) to -20.9% (95% CI: -23.2% to -18.6%). Results were generally similar in analyses stratified by sex, age, neighbourhood income quintile, and urban versus rural residence. Further research is required to understand the clinical implications of these findings and whether these trends were sustained with further follow-up.

Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario.

BACKGROUND: Emergency department visits and hospital admissions for opioid toxicity are opportunities to initiate opioid agonist therapy (OAT), which reduces morbidity and mortality in patients with opioid use disorder (OUD). The study objectives were to evaluate OAT initiation rates after a hospital encounter for opioid toxicity in Ontario, Canada, and determine whether publication of a 2018 Canadian OUD management guideline was associated with increased initiation. METHODS: We conducted a retrospective, population-based serial cross-sectional study of hospital encounters for opioid toxicity among patients with OUD between Jan. 1, 2013, and Mar. 31, 2020, in Ontario, Canada. The primary outcome was OAT initiation (methadone, buprenorphine-naloxone, or slow-release oral morphine) within 7 days of discharge, measured quarterly. We examined the impact of the release of the OUD management guideline on OAT initiation rates using Autoregressive Integrated Moving Average models. RESULTS: Among 20 702 hospital visits for opioid toxicity among patients with OUD, the median age was 35 years, and 65.1% were male. Over the study period, the percentage of visits leading to OAT initiation within 7 days rose from 1.7% or less (Q1 2013) to 5.6% (Q1 2020); however, the publication of the Canadian OUD management guideline was not associated with a significant increase in these rates (0.14% slope change, 95% confidence interval -0.11% to 0.38%; p = 0.3). INTERPRETATION: Among hospital encounters for opioid toxicity, despite rising prevalence over time, only 1 in 18 patients were dispensed OAT within a week of discharge in early 2020. These findings highlight missed opportunities to initiate therapies proven to reduce mortality in patients with OUD.

Impact of national recommendations for routine pertussis vaccination during pregnancy on infant pertussis in Ontario, Canada: a population-based time-series study.

BACKGROUND: In February 2018, Canada's National Advisory Committee on Immunization (NACI) recommended antenatal tetanus-diphtheria-acellular pertussis (Tdap) immunization in every pregnancy regardless of previous Tdap immunization history. We examined the impact of the NACI recommendation on rates of infant pertussis in Ontario, Canada. METHODS: We conducted a population-based time-series study of all live births in Ontario between August 1, 2011 and February 28, 2020. We used interventional autoregressive integrated moving average models to examine the impact of the NACI recommendation on monthly rates of pertussis among infants ≤ 3 months of age. RESULTS: We observed 675 incident cases of pertussis among 1,368,024 infants 3 months of age or less between August 2011 and February 2020. The average monthly percent change in infant pertussis during the period up to and including publication of the NACI guidance and the period following publication were 0.0% (95% CI: -0.4-0.3%) and - 0.8% (95% CI -2.3% to -0.1%), respectively. Following interventional ARIMA modelling, publication of the NACI guidance was not associated with a statistically significant decrease in the monthly pertussis incidence trend (-0.67 cases per 100,000 infants; p = 0.73). CONCLUSION: Publication of national recommendations for antenatal Tdap immunization in every pregnancy did not significantly reduce infant pertussis rates. This may reflect the persistently low rate of antenatal vaccination following publication of the recommendations. Expanding the scope of practice of allied health care providers to include antenatal Tdap immunization and patient education regarding antenatal pertussis immunization should be considered to further optimize uptake of vaccination.

Impact of a Publicly-Funded Pharmacare Program on Prescription Stimulant use Among Children and Youth: A Population-Based Observational Natural Experiment.

OBJECTIVE: Stimulants are first-line pharmacotherapy for individuals with attention-deficit hyperactivity disorder. However, disparities in drug coverage may contribute to inequitable treatment access. In January 2018, the government of Ontario, Canada, implemented a publicly-funded program (OHIP+) providing universal access to medications at no cost to children and youth between the ages of 0 and 24. In April 2019, the program was amended to cover only children and youth without private insurance. We studied whether these policy changes were associated with changes in prescription stimulant dispensing to Ontario children and youth. METHODS: We conducted a population-based observational natural experiment study of stimulant dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the association between OHIP+ and its subsequent modification with stimulant dispensing trends. RESULTS: The implementation of OHIP+ was associated with a significant immediate increase in the monthly rate of stimulant dispensing of 53.6 individuals per 100,000 population (95% confidence interval [CI], 36.8 to 70.5 per 100,000) and a 14.2% (95% CI, 12.8% to 15.6%) relative percent increase in stimulant dispensing rates between December 2017 and March 2019 (1198.6 vs. 1368.7 per 100,000 population). The April 2019 OHIP+ program amendment was associated with an increase in monthly stimulant dispensing trends of 10.2 individuals per 100,000 population (95% CI, 5.0 to 15.5), with rates increasing 7.5% (95% CI, 6.2% to 8.7%) between March 2019 and March 2020 (1368.7 vs. 1470.8 per 100,000 population). These associations were most pronounced among males, children and youth living in the highest income neighbourhoods and individuals aged 20 to 24. CONCLUSION: A publicly-funded pharmacare program was associated with more children and youth being dispensed stimulants.

Geographic variation and sociodemographic correlates of prescription psychotropic drug use among children and youth in Ontario, Canada: a population-based study.

BACKGROUND: Population-based research examining geographic variability in psychotropic medication dispensing to children and youth and the sociodemographic correlates of such variation is lacking. Variation in psychotropic use could reflect disparities in access to non-pharmacologic interventions and identify potentially concerning use patterns. METHODS: We conducted a population-based study of all Ontario residents aged 0 to 24 years who were dispensed a benzodiazepine, stimulant, antipsychotic or antidepressant between January 1, 2018, and December 31, 2018. We conducted small-area variation analyses and identified determinants of dispensing using negative binomial generalized estimating equation models. RESULTS: The age- and sex-standardized rate of psychotropic dispensing to children and youth was 76.8 (range 41.7 to 144.4) prescriptions per 1000 population, with large variation in psychotropic dispensing across Ontario's census divisions. Males had higher antipsychotic [rate ratio (RR) 1.40; 95% confidence interval (CI) 1.36 to 1.44) and stimulant (RR 1.75; 95% CI 1.70 to 1.80) dispensing rates relative to females, with less use of benzodiazepines (RR 0.85; 95% CI 0.83 to 0.88) and antidepressants (RR 0.81; 95% CI 0.80 to 0.82). Lower antipsychotic dispensing was observed in the highest income neighbourhoods (RR 0.72; 95% CI 0.70 to 0.75) relative to the lowest. Benzodiazepine (RR 1.12; 95% CI 1.01 to 1.24) and stimulant (RR 1.11; 95% CI 1.01 to 1.23) dispensing increased with the density of mental health services in census divisions, whereas antipsychotic use decreased (RR 0.82; 95% CI 0.73 to 0.91). The regional density of child and adolescent psychiatrists and developmental pediatricians (RR 1.00; 95% CI 0.99 to 1.01) was not associated with psychotropic dispensing. CONCLUSION: We found significant variation in psychotropic dispensing among young Ontarians. Targeted investment in regions with long wait times for publicly-funded non-pharmacological interventions and novel collaborative service models may minimize variability and promote best practices in using psychotropics among children and youth.

Impact of a publicly-funded pharmacare program policy on benzodiazepine dispensing among children and youth: a population-based natural experiment.

BACKGROUND: In January 2018, the Government of Ontario, Canada, initiated a universal pharmacare program (OHIP+) for all individuals aged 24 years and younger. In April 2019, the program was amended to cover only children and youth without private insurance. Because benzodiazepines are commonly prescribed to children and youth despite their potential hazards, we examined whether changes in publicly-funded drug coverage influenced benzodiazepine dispensing trends in this demographic. METHODS: We conducted a population-based natural experiment study of benzodiazepine dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the impact of OHIP + and its subsequent modification on these trends. RESULTS: The implementation of OHIP + was associated with an immediate increase in the monthly rate of benzodiazepine dispensing of 12.9 individuals per 100,000 population (95% confidence interval [CI]; 7.5 to 18.3 per 100,000). Benzodiazepine dispensing rates rose from 214.2 to 241.5 per 100,000 from December 2017 to March 2019, a 12.8% (95% CI 9.6-16.0%) increase. In stratified analyses, increases were most pronounced among females, children and youth living in the lowest income neighbourhoods and individuals aged 20 to 24. The April 2019 modification to OHIP + was not associated with changes in monthly benzodiazepine dispensing trends (0.39 individuals per 100,000; 95% CI -1.3 to 2.1 per 100,000). However, rates remained elevated relative to the period preceding OHIP + implementation. CONCLUSIONS: Implementation of a publicly-funded pharmacare program resulted in more children and youth being prescribed benzodiazepines.

Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario.

BACKGROUND: London InterCommunity Health Centre (LIHC) launched a safer opioid supply (SOS) program in 2016, where clients are prescribed pharmaceutical opioids and provided with comprehensive health and social supports. We sought to evaluate the impact of this program on health services utilization and health care costs. METHODS: We conducted an interrupted time series analysis of London, Ontario, residents who received a diagnosis of opioid use disorder (OUD) and who entered the SOS program between January 2016 and March 2019, and a comparison group of individuals matched on demographic and clinical characteristics who were not exposed to the program. Primary outcomes were emergency department (ED) visits, hospital admissions, admissions for infections and health care costs. We used autoregressive integrated moving average (ARIMA) models to evaluate the impact of SOS initiation and compared outcome rates in the year before and after cohort entry. RESULTS: In the time series analysis, rates of ED visits (-14 visits/100, 95% confidence interval [CI] -26 to -2; p = 0.02), hospital admissions (-5 admissions/100, 95% CI -9 to -2; p = 0.005) and health care costs not related to primary care or outpatient medications (-$922/person, 95% CI -$1577 to -$268; p = 0.008) declined significantly after entry into the SOS program (n = 82), with no significant change in rates of infections (-1.6 infections/100, 95% CI -4.0 to 0.8; p = 0.2). In the year after cohort entry, the rate of ED visits (rate ratio [RR] 0.69, 95% CI 0.53 to 0.90), hospital admissions (RR 0.46, 95% CI 0.29 to 0.74), admissions for incident infections (RR 0.51, 95% CI 0.27 to 0.96) and total health care costs not related to primary care or outpatient medications ($15 635 v. $7310/person-year; p = 0.002) declined significantly among SOS clients compared with the year before. We observed no significant change in any of the primary outcomes among unexposed individuals (n = 303). INTERPRETATION: Although additional research is needed, this preliminary evidence indicates that SOS programs can play an important role in the expansion of treatment and harm-reduction options available to assist people who use drugs and who are at high risk of drug poisoning.

Impact of the COVID-19 Controlled Drugs and Substances Act exemption on pharmacist prescribing of opioids, benzodiazepines and stimulants in Ontario: A cross-sectional time-series analysis.

Background: Due to the coronavirus disease 2019 (COVID-19) pandemic, Health Canada issued an exemption to the Controlled Drugs and Substances Act (CDSA) on March 19, 2020, enabling pharmacists to act as prescribers of controlled substances to support continuity of care. Our study investigates utilization of the CDSA exemption by Ontario pharmacists with the intent to inform policy on pharmacist scope of practice and to improve future patient outcomes. Methods: We conducted a time-series analysis of pharmacist-prescribed opioid, benzodiazepine and stimulant claims data using Ontario Narcotics Monitoring System (NMS) data between January 2019 and December 2021. We used ARIMA modelling to measure the change to these classes of claims and to opioid claims containing quantities greater than a 30-day supply. Results: Postexemption, the average weekly number of pharmacist-prescribed opioid, benzodiazepine and stimulant claims rose by 146% (160 to 393 claims/week), 960% (49 to 515 claims/week) and 2150% (8 to 177 claims/week), respectively. There was a 2-week lag period between the time of announcement and the statistically significant increase in claims on April 5, 2020(p < 0.0001). The total number of claims for opioid quantities exceeding a 30-day supply decreased by 60%. Cumulative pharmacist-prescribed claims accounted for under 2% of the total NMS claims. Interpretation: Ontario pharmacists used the CDSA exemption but were prescribing at low rates. These findings suggest an effective change to pharmacy practice as the low rates show pharmacists used the exemption as a last line of defense. This may lead to further studies exploring treatment breaks during the COVID-19 pandemic and future changes to pharmacist scope to benefit patients.

Impact of a Publicly Funded Herpes Zoster Immunization Program on the Burden of Disease in Ontario, Canada: A Population-based Study.

BACKGROUND: In September 2009, a live attenuated herpes zoster vaccine (ZVL) became available in Canada. Beginning in September 2016, ZVL was made available to all Ontario residents aged 65-70 through a publicly funded immunization program. We assessed the impact of ZVL availability and its subsequent public funding on herpes zoster burden in this population. METHODS: A population-based study of Ontario residents aged 65-70 between January 2005 and September 2018. We used interventional autoregressive integrated moving average models to examine the impact of ZVL market availability and the publicly funded ZVL program on monthly incidence rate of medically attended herpes zoster, defined as an outpatient visit for herpes zoster with a prescription for a herpes zoster antiviral dispensed ≤5 days before or after the visit, or a herpes zoster-related emergency department (ED) visit or hospitalization. In secondary analyses, we examined impacts on any herpes zoster-related ED visits and hospitalizations. RESULTS: We found no association between ZVL market availability and monthly incidence of herpes zoster (P = .32) or monthly rates of ED visits and hospitalizations (P = .88). Conversely, the introduction of publicly funded ZVL reduced the monthly rate of medically attended herpes zoster by 19.1% (from 4.8 to 3.8 per 10 000 population; P < .01) and herpes zoster-related ED visits and hospitalizations by 38.2% (from 1.7 to 1.0 per 10 000 population; P < .05). CONCLUSIONS: The introduction of a publicly funded immunization program for herpes zoster was associated with reduced disease burden and related acute healthcare service use.

Impact of COVID-19 on Prescribing Trends of Direct-Acting Antivirals for the Treatment of Hepatitis C in Ontario, Canada.

INTRODUCTION: Direct-acting antivirals (DAAs) are curative treatments for hepatitis C. However, initiation of these treatments requires adequate healthcare access. Coronavirus 2019 (COVID-19) resulted in restrictions to healthcare services in March 2020. We examined the impact of COVID-19 on the number of individuals dispensed DAAs. METHODS: This is a cross-sectional study examining the number of individuals dispensed DAAs in Ontario, Canada, from 2018 to 2020. Time-series models determined the impact of healthcare restrictions on DAA dispensations. RESULTS: Healthcare restrictions resulted in a 49.3% decrease in DAA dispensations (P = 0.026). DISCUSSION: COVID-19-related healthcare restrictions significantly affected access to DAAs. Studies exploring the long-term effects on reduced treatment are needed.

Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study.

OBJECTIVES: To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. DESIGN: Retrospective cohort study using population-level administrative data. SETTING: Ontario, Canada. PARTICIPANTS: Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). RESULTS: A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. CONCLUSIONS: A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.

Prevalence of prescribed opioid claims among persons with nontraumatic spinal cord dysfunction in Ontario, Canada: a population-based retrospective cohort study.

STUDY DESIGN: Cohort study. OBJECTIVE: To determine the prevalence and to identify predictors of prescription opioid use among persons with nontraumatic spinal cord dysfunction within 1 year after discharge from inpatient rehabilitation. SETTING: Ontario, Canada. METHODS: We conducted a retrospective cohort study using administrative data to determine predictors of receiving prescription opioids during the 1 year after discharge from inpatient rehabilitation among persons with nontraumatic spinal cord dysfunction between April 1, 2004 and March 31, 2015. We modeled the outcome using a Poisson multivariable regression and reported relative risks with 95% confidence intervals. RESULTS: We identified 3468 individuals with nontraumatic spinal cord dysfunction (50% male) with 67% who were aged ≥66. Over half of the cohort (60%) received opioids during the observation period. Older adults (≥66 years old) were significantly more likely to experience comorbidities (p < 0.05) but less likely to be dispensed opioids following rehabilitation discharge. Being female, previous opioid use before rehabilitation, experiencing lower continuity of care, increasing comorbidity level, low functional status, and having a previous diagnosis of osteoarthritis or mental illness were significant risk factors for receiving opioids after discharge, as shown in a multivariable analysis. Increasing length of rehabilitation stay and higher income were protective against opioid receipt after discharge. CONCLUSION: Many individuals with nontraumatic spinal cord dysfunction in Ontario are prescribed opioids after discharge from inpatient rehabilitation. This may be problematic due to the number of severe complications that may arise from opioid use and their use in this population warrants future research.

Prescription medications dispensed following a nontraumatic spinal cord dysfunction: a retrospective population-based study in Ontario, Canada.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To examine the prevalence of polypharmacy for individuals with nontraumatic spinal cord dysfunction (NTSCD) following inpatient rehabilitation and to determine associated risk factors. SETTING: Ontario, Canada. METHODS: Administrative data housed at ICES, Toronto, Ontario were used. Between 2004 and 2015, we investigated prescription medications dispensed over a 1-year period for persons following an NTSCD-related inpatient rehabilitation admission. Descriptive and analytical statistics were conducted. Using a robust Poisson multivariable regression model, relative risks related to polypharmacy (ten or more drug classes) were calculated. Main independent variables were sex, age, income quintile, and continuity of care with outpatient physician visits. RESULTS: We identified 3468 persons with NTSCD during the observation window. The mean number of drug classes taken post-inpatient rehabilitation was 11.7 (SD = 6.0), with 4.0 different prescribers (SD = 2.5) and 1.8 unique pharmacies (SD = 1.0). Significant predictors for post-discharge polypharmacy were: being female, lower income, higher comorbidities prior to admission, lower Functional Independence Measure at discharge, previous number of medication classes dispensed in year prior to admission, and lower continuity of care with outpatient physician visits. The most common drugs dispensed post-inpatient rehabilitation were antihypertensives (70.0%), laxatives (61.6%), opioids (59.5%), and antibiotics (57.8%). CONCLUSION: Similar to previous research with traumatic spinal cord injury, our results indicate that polypharmacy is prevalent among persons with NTSCD. Additional research examining medication therapy management for NTSCD is suggested.

Socioeconomic Status and Days Alive and Out of Hospital after Major Elective Noncardiac Surgery: A Population-based Cohort Study.

BACKGROUND: Socioeconomic status is an important but understudied determinant of preoperative health status and postoperative outcomes. Previous work has focused on the impact of socioeconomic status on mortality, hospital stay, or complications. However, individuals with low socioeconomic status are also likely to have fewer supports to facilitate them remaining at home after hospital discharge. Thus, such patients may be less likely to return home over the short and intermediate term after major surgery. The newly validated outcome, days alive and out of hospital, may be highly suited to evaluating the impact of socioeconomic status on this postdischarge period. The study aimed to determine the association of socioeconomic status with short and intermediate term postoperative recovery as measured by days alive and out of hospital. METHODS: The authors evaluated data from 724,459 adult patients who had one of 13 elective major noncardiac surgical procedures between 2006 and 2017. Socioeconomic status was measured by median neighborhood household income (categorized into quintiles). Primary outcome was days alive and out of hospital at 30 days, while secondary outcomes included days alive and out of hospital at 90 and 180 days, and 30-day mortality. RESULTS: Compared to the highest income quintile, individuals in the lowest quintile had higher unadjusted risks of postoperative complications (6,049 of 121,099 [5%] vs. 6,216 of 160,495 [3.9%]) and 30-day mortality (731 of 121,099 [0.6%] vs. 701 of 160,495 [0.4%]) and longer mean postoperative length of stay (4.9 vs. 4.4 days). From lowest to highest income quintile, the mean adjusted days alive and out of hospital at 30 days after surgery varied between 24.5 to 24.9 days. CONCLUSIONS: Low socioeconomic status is associated with fewer days alive and out of hospital after surgery. Further research is needed to examine the underlying mechanisms and develop posthospital interventions to improve postoperative recovery in patients with fewer socioeconomic resources.

Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study.

BACKGROUND: Addressing nonmedical reasons for delays in hospital discharge is important for improving the flow of patients through acute care hospital beds. Because this problem is understudied among adult surgical patients, we examined the incidence of and identified factors associated with delayed hospital discharge after major elective and emergency surgical procedures in acute care institutions. METHODS: Using health administrative data, we retrospectively compared adults with and without delayed discharge after 18 major elective and emergency surgical procedures between 2006 and 2016 in Ontario hospitals. We identified delayed discharge using the alternate level of care code, applied to patients who are medically fit for discharge but remain in an acute care hospital bed. We used hierarchical logistic regression modelling to determine factors associated with delayed discharge. RESULTS: Our cohort included 595 782 patients who underwent elective procedures and 180 478 who underwent emergency procedures. Delayed discharge accounted for 635 607 hospital days, of which 81.7% were related to admissions for emergency surgery. Delayed discharge affected 3.1% of patients who underwent elective surgery and 19.6% of those who underwent emergency procedures. Days attributed to delayed discharge formed about one-third of patients' total hospital stay for both surgical groups. The rate of delayed discharge across surgical specialties showed high variability (from 0.9% for lung resection or nephrectomy to 9.3% for peripheral arterial disease procedures in the elective surgery group, and from 3.8% for cardiac procedures to 33.8% for peripheral arterial disease procedures in the emergency surgery group). Risk factors for delayed discharge were older age, female sex, chronic disease burden and increasing hospital size. INTERPRETATION: Delayed discharge for nonmedical reasons was more common after emergency surgery than after elective surgery, and rates varied across surgery type. Optimizing early discharge planning, evaluating the variation in delayed discharge at the hospital level and improving local access to community care services could be next steps to addressing this problem.

90-90-90 for everyone?: Access to HIV care and treatment for people with HIV who experience imprisonment in Ontario, Canada.

We examined HIV care and treatment in prison and after release for people with HIV in Ontario, Canada, and compared HIV care and treatment with the general population. We used administrative data to identify people with HIV released from provincial prison in 2010 and in the general population. We calculated the proportion of people with HIV who accessed HIV care in prison. We compared HIV care use between people with HIV on prison release and in the general population. We estimated the proportion of people with HIV on antiretroviral therapy in prison as the ratio of the average numbers of people prescribed antiretroviral therapy in prison in 2009/2010 and people with HIV in prison in January 2010. We compared the proportion of people with HIV on public drug benefits that filled an antiretroviral therapy prescription within 6 months for people postrelease and in the general population. Of 344 people with HIV on prison admission, 34.0% received HIV care in prison. Over 1 year, 63.6% of 330 people with HIV on prison release and 67.7% of 15,819 people with HIV in the general population accessed HIV care (p = 0.118), and 43.3% of people with HIV on prison release and 55.2% of people with HIV in the general population had 2 or more HIV care visits (p < 0.001). In prison, 52.4% of people with HIV (39.5/75.4) were on antiretroviral therapy. Of those accessing drug benefits, 60.1% of 226 people with HIV on prison release and 79.6% of 7458 people with HIV in the general population claimed an antiretroviral therapy prescription within 6 months (p < 0.001). Access to HIV care and treatment were suboptimal in prison, and sustained HIV care and treatment were worse for people post-release compared to the general population. Interventions are needed to support HIV care for this population.

Determinants of vitamin D supplement use in Canadians.

OBJECTIVE: To determine the prevalence of vitamin D supplement use in Canadian adults and associations with demographic and socio-economic variables. DESIGN: Data from the Healthy Aging module of the Canadian Community Health Survey were used to investigate the prevalence of vitamin D supplement use in Canadians aged 45 years and over. The prevalence of supplement use stratified by various behavioural and demographic characteristics was calculated and adjusted models were used to find associations with those factors. SETTING: The ten provinces of Canada. SUBJECTS: Canadians aged 45 years and over who participated in the Healthy Aging module of the Canadian Community Health Survey from 2008-2009. RESULTS: The highest observed prevalence for women was 48·0 % in the 65-69 years age group and the highest prevalence for men was 25·3 % in the 70-74 years age group. Women had higher odds of vitamin D supplement use than men in all age groups. Not using supplements was more common in smokers, those who did not engage in leisure-time physical activities and who were either overweight or obese. Vitamin D supplement use increased with household income and level of education, and decreased with self-perceived health. Supplement use was higher in those with chronic conditions. CONCLUSIONS: The inverse association with self-perceived health could be partly explained by age, chronic conditions and increased use of health-care services. Associations with higher income and education suggest a strong socio-economic influence and that individuals may not have the expendable income to purchase vitamin D supplements or knowledge of their health benefits.

Alpha-1 adrenergic antagonists and the risk of hospitalization or death in non-hospitalized patients with COVID-19: A population-based study.

BACKGROUND: Alpha-1 receptor antagonists may interfere with IL-6 signaling and could therefore be a potential treatment for COVID-19. However, the effectiveness of these drugs in mitigating the risk of clinical deterioration among non-hospitalized patients with COVID-19 is unknown. OBJECTIVES: The aim of this study is to examine the association between alpha-1 antagonist exposure and the 30-day risk of a hospital encounter or death in nonhospitalized patients with COVID-19. METHODS: We conducted a population-based cohort study of Ontario residents aged 35 years and older who were eligible for public drug coverage and who had a positive test for SARS-CoV-2 between January 1, 2020, and March 1, 2021. We matched each individual receiving an alpha-1 antagonist at the time of their positive test with two non-exposed individuals using propensity scores. Our outcome was a composite of a hospital admission, emergency department visit, or death, 1 to 30 days following the positive test. RESULTS: We matched 3289 alpha-1 antagonist exposed patients to 6189 unexposed patients. Overall, there was no difference in the 30-day risk of the primary outcome among patients exposed to alpha-1 antagonists at the time of their diagnosis relative to unexposed individuals (28.8% vs. 28.0%; OR 1.00, 95% CI 0.91 to 1.11). In a secondary analysis, individuals exposed to alpha-1 antagonists had a lower risk of death in the 30 days following a COVID diagnosis (OR 0.79; 95% CI 0.66 to 0.93). CONCLUSION: Alpha-1 antagonists did not mitigate the 30-day risk of clinical deterioration in non-hospitalized patients with COVID-19. Our findings do not support the general repurposing of alpha-1 antagonists as a treatment for such patients, although there may be subgroups of patients in whom further research is warranted.