Impact of physician-based palliative care delivery models on health care utilization outcomes: A population-based retrospective cohort study.

BACKGROUND: Increasing involvement of palliative care generalists may improve access to palliative care. It is unknown, however, if their involvement with and without palliative care specialists are associated with different outcomes. AIM: To describe physician-based models of palliative care and their association with healthcare utilization outcomes including: emergency department visits, acute hospitalizations and intensive care unit (ICU) admissions in last 30 days of life; and, place of death. DESIGN: Population-based retrospective cohort study using linked health administrative data. We used descriptive statistics to compare outcomes across three models (generalist-only palliative care; consultation palliative care, comprising of both generalist and specialist care; and specialist-only palliative care) and conducted a logistic regression for community death. SETTING/PARTICIPANTS: All adults aged 18-105 who died in Ontario, Canada between April 1, 2012 and March 31, 2017. RESULTS: Of the 231,047 decedents who received palliative services, 40.3% received generalist, 32.3% consultation and 27.4% specialist palliative care. Across models, we noted minimal to modest variation for decedents with at least one emergency department visit (50%-59%), acute hospitalization (64%-69%) or ICU admission (7%-17%), as well as community death (36%-40%). In our adjusted analysis, receipt of a physician home visit was a stronger predictor for increased likelihood of community death (odds ratio 9.6, 95% confidence interval 9.4-9.8) than palliative care model (generalist vs consultation palliative care 2.0, 1.9-2.0). CONCLUSION: The generalist palliative care model achieved similar healthcare utilization outcomes as consultation and specialist models. Including a physician home visit component in each model may promote community death.

Five-year risk of admission to long-term care home and death for older adults given a new diagnosis of dementia: a population-based retrospective cohort study.

BACKGROUND: After diagnosis of a health condition, information about survival and potential transition from community into institutional care can be helpful for patients and care providers. We sought to describe the association between a new diagnosis of dementia and risk of admission to a long-term care home and death at 5 years. METHODS: We conducted a population-based retrospective cohort study using linked health administrative databases. We identified individuals aged 65 years or older, living in the community, with a first documented diagnosis of dementia between Jan. 1, 2010, and Dec. 31, 2012, in Ontario, Canada. Dementia diagnosis was captured using diagnostic codes from hospital discharges, physician billings, assessments conducted for home care and long-term care, and dispensed prescriptions for cholinesterase inhibitors. Our primary outcome measures were 5-year risk of death and placement in a long-term care home, adjusted for sociodemographic and clinical factors. RESULTS: We identified 108 757 individuals in our study cohort. By the end of 5 years, 24.4% remained alive in the community and 20.5% were living in a long-term care home. Of the 55.1% who died, about half (27.9%) were admitted to a long-term care home before death. Three risk factors were associated with increased odds of death: older age (age ≥ 90 yr; odds ratio [OR] 9.5, 95% confidence interval [CI] 8.8-10.2 [reference: age 65-69 yr]), male sex (OR 1.7, 95% CI 1.6-1.7), and the presence of organ failure, including chronic obstructive pulmonary disease (OR 1.7, 95% CI 1.7-1.8), congestive heart failure (OR 2.0, 95% CI 1.9-2.0) and renal failure (OR 1.7, 95% CI 1.6-1.8). Groups formed by combinations of these 3 factors had an observed 5-year risk of death varying between 22% and 91%. INTERPRETATION: Among community-dwelling older adults with newly identified dementia in Ontario, the majority died or were admitted to a long-term care home within 5 years. This information may be helpful for discussions on prognosis and need for admission to long-term care.

Access to cannabis retail stores across Canada 6 months following legalization: a descriptive study.

BACKGROUND: On Oct. 17, 2018, Canada legalized recreational cannabis with the dual goals of reducing youth use and eliminating the illicit cannabis market. We examined factors associated with access to physical cannabis stores across Canada 6 months following legalization. METHODS: We extracted the address and operating hours of all legal cannabis stores in Canada from online government and private listings. We conducted a descriptive study examining the association between private/hybrid (mixture of government and private stores) and government-only retail models with 4 measures of physical access to cannabis: store density, weekly hours of operation, median distance to the nearest school and relative availability of cannabis stores between low- and high-income neighbourhoods. RESULTS: Six months after legalization, there were 260 cannabis retail stores across Canada: 181 privately run stores, 55 government-run stores and 24 stores in the hybrid retail system. Compared to jurisdictions with a government-run model, jurisdictions with a private/hybrid retail model had 49% (95% confidence interval 10%-200%) more stores per capita, retailers were open on average 9.2 more hours per week, and stores were located closer to schools (median 166.7 m). In both retail models, there was over twice the concentration of cannabis stores in neighbourhoods in the lowest income quintile compared to the highest income quintile. INTERPRETATION: Marked differences in physical access to cannabis retail are emerging between jurisdictions with private/hybrid retail models and those with government-only retail models. Ongoing surveillance including monitoring differences in cannabis use and harms across jurisdictions is needed.

Factors influencing the reasons why mothers stop breastfeeding.

OBJECTIVES: To explore the reasons why women stop breastfeeding completely before their infants are six months of age and to identify the factors associated with cessation and the timing of cessation. METHODS: For all singleton live newborns born between January 1, 2008 and December 31, 2009 in two district health authorities in Nova Scotia, Canada, mother's self-reported breastfeeding status was collected at hospital discharge and at five follow-up visits until infants were six months of age. Mothers who stopped breastfeeding before six months were also questioned about the time of weaning and the reason they discontinued all breastfeeding. Eleven categories were created from the open-ended responses women provided. These data were linked with the Nova Scotia Atlee Perinatal Database in order to obtain information on maternal and neonatal characteristics. The relationship between maternal, obstetrical, and neonatal characteristics and each reason for stopping breastfeeding completely were examined. RESULTS: Of the 500 mothers who stopped breastfeeding completely before six months and provided a reason for discontinuing, the majority (73.6%) stopped within the first six weeks. The most common reasons cited were inconvenience or fatigue associated with breastfeeding (22.6%) and concerns about milk supply (21.6%). Return to work or school was associated with length of time that infants were breastfed: 20% of women who stopped after six weeks citing this as the reason. Most of the reasons, however, were not found to be associated with a specific duration of breastfeeding or with the examined maternal and infant characteristics. CONCLUSION: This study highlights factors associated with the reasons why women stop breastfeeding completely before six months and how these reasons varied with weaning age. The results will help inform future research aimed at identifying interventions to reduce early breastfeeding cessation.

Rates and determinants of exclusive breastfeeding in first 6 months among women in Nova Scotia: a population-based cohort study.

BACKGROUND: Despite compelling evidence that exclusive breastfeeding for the first 6 months of life provides important health benefits to both mothers and their infants, most mothers do not follow this practice. We conducted a study to identify predictors of early cessation of exclusive breastfeeding (before 6 months after delivery). METHODS: For this population-based longitudinal cohort study, we linked data from a perinatal database and a public health database for infants born between 2006 and 2009 in 2 regions in the province of Nova Scotia, Canada. The cohort was followed from the mother's first prenatal visit until her infant was 6 months old. Hazard ratios (HRs) for early cessation of exclusive breastfeeding were determined through Cox proportional hazards regression modelling. RESULTS: Overall, 64.1% (2907/4533) of the mothers in the cohort initiated breastfeeding. Only 10.4% (413/3957) exclusively breastfed for the recommended 6 months. The largest drop in exclusive breastfeeding occurred within the first 6 weeks after birth. Among the mothers who initiated breastfeeding, significant predictors of early cessation of exclusive breastfeeding identified by multivariable modelling included less than high school education (HR 1.66, 95% confidence interval [CI] 1.35-2.04), lowest neighbourhood income quintile (HR 1.35, 95% CI 1.13-1.60), single motherhood (HR 1.24, 95% CI 1.10-1.41), prepregnancy obesity (HR 1.43, 95% CI 1.23-1.65), smoking throughout pregnancy (HR 1.39, 95% CI 1.21-1.60), no early breast contact by the infant (< 1 hour after birth) (HR 1.44, 95% CI 1.29-1.62) and no intention to breastfeed (HR 1.78, 95% CI 1.44-2.16). INTERPRETATION: We found that most predictors of early cessation of breastfeeding were intertwined with social determinants of health. However, we identified potentially modifiable risk factors. Providing opportunities for early breast contact by the infant and continued efforts in smoking cessation and obesity reduction may contribute to a longer duration of exclusive breastfeeding.

Tracheostomy decannulation and cough peak flows in patients with neuromuscular weakness.

OBJECTIVE: The aim of this study was to examine the relationship between cough peak flows (CPFs) before and after tracheostomy tube removal (decannulation) in patients with neuromuscular respiratory muscle weakness. DESIGN: For 26 patients with occluded tracheostomies (capped or Passy-Muir valve), spontaneous CPF (CPF(sp)), CPF after lung volume recruitment (CPF(LVR)), and CPF after lung volume recruitment and a manually assisted cough (CPF(LVR) + MAC) were measured before and after decannulation. RESULTS: Decannulation resulted in a significant increase (P < 0.001) in CPF of 35.6, 34.5, and 42.6 l/min for CPF(sp), CPF(LVR), and CPF(LVR) + MAC, respectively. In addition, CPF(LVR) or CPF(LVR) + MAC with a capped tracheostomy in place were greater than spontaneous CPF with the tracheostomy tube removed. CONCLUSIONS: Our study suggests that assisted coughing with a capped tracheostomy tube in place can result in higher flows than removing the tube and relying on spontaneous cough alone. Postdecannulation CPF measured at the mouth can be predicted to be at least 34.5 l/min greater than predecannulation values, which may thereby lower the threshold of the CPF indicated for safe decannulation.