The impact of the COVID-19 pandemic on longitudinal trends of surgical mortality and inpatient quality of care in Ontario, Canada.

AIMS: Previous studies have shown the COVID-19 pandemic was associated with reductions in volume across a spectrum of non-SARS-CoV-2 hospitalizations. In the present study, we examine the impact of the pandemic on patient safety and quality of care. DESIGN: This is a retrospective population-based study of discharge abstracts. METHODS: We applied a set of nationally validated indicators for measuring the quality of inpatient care to hospitalizations in Ontario, Canada between January 2010 and December 2022. We measured 90-day mortality after selected types of higher risk admissions (such as cancer surgery and cardiovascular emergency) and the rate of patient harm events (such as delirium, pressure injuries and hospital-acquired infections) occurring during the hospital stay. RESULTS: A total 13,876,377 hospitalization episodes were captured. Compared with the pre-pandemic period, and independent of SARS-CoV-2 infection, the pandemic period was associated with higher rates of mortality after bladder cancer resection (adjusted risk ratio [aRR] 1.20 (1.07-1.34)) and open repair for abdominal aortic aneurysm (aRR 1.45 (1.06-1.99)). The pandemic was also associated with higher rates of delirium (adjusted odds ratio [aOR] 1.04 (1.02-1.06)), venous thromboembolism (aOR 1.10 (1.06-1.13)), pressure injuries (aOR 1.28 (1.24-1.33)), aspiration pneumonitis (aOR 1.15 (1.12-1.18)), urinary tract infections (aOR 1.02 (1.01-1.04)), Clostridiodes difficile infection (aOR 1.05 (1.02-1.09)), pneumothorax (aOR 1.08 (1.03-1.13)), and use of restraints (aOR 1.12 (1.10-1.14)), but was associated with lower rates of viral gastroenteritis (aOR 0.22 (0.18-0.28)). During the pandemic, SARS-CoV-2-positive admissions were associated with a higher likelihood of various harm events. CONCLUSION: The COVID-19 pandemic was associated with higher rates of patient harm for a wide range of non-SARS-CoV-2 inpatient populations. IMPACT: Understanding which quality measures are improving or deteriorating can help health systems prioritize quality improvement initiatives. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

SARS-CoV-2 infection among physicians over time in Ontario, Canada: a population-based retrospective cohort study.

AIM: To assess this risk of SARS-CoV-2 infection among Ontario physicians by specialty and in comparison with non-physician controls during the COVID-19 pandemic. METHODS: In this retrospective cohort study, the primary outcome was incident SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR). Secondary outcomes were hospitalization, use of critical care, and mortality. RESULTS: From March 1, 2020 to December 31, 2022, 6172/30 617 (20%) active Ontario physicians tested positive for SARS-CoV-2. Infection was less likely if physicians were older (OR 0.78 [0.76-0.81] per 10 years), rural residents (OR 0.70 [0.59-0.83]), and lived in more marginalized neighborhoods (OR 0.74 [0.62-0.89]), but more likely if they were female (OR 1.14 [1.07-1.22]), worked in long-term care settings (OR 1.16 [1.02-1.32]), had higher patient volumes (OR 2.05 [1.82-2.30] for highest vs lowest), and were pediatricians (OR 1.25 [1.09-1.44]). Compared with community-matched controls (n=29 763), physicians had a higher risk of infection during the first two waves of the pandemic (OR 1.38 [1.20-1.59]) but by wave 3 the risk was no longer significantly different (OR 0.93 [0.83-1.05]). Physicians were less likely to be hospitalized within 14 days of their first positive PCR test than non-physicians (P<0.0001), but there was no difference in the use of critical care (P=0.48) or mortality (P=0.15). CONCLUSION: Physicians had higher rates of infection than community-matched controls during the first two waves of the pandemic in Ontario, but not from wave 3 onward. Physicians practicing in long-term care facilities and pediatricians were more likely to test positive for SARS-CoV-2 than other physicians.

Pushing the envelope: Advancing Canadian healthcare payment models through evaluation.

When health systems aim to improve, two key considerations tend to be front and centre: cost and quality. On the cost side, health spending in Canada continues to rise. On the quality side, improvement is needed across the country. As the primary funder of healthcare, governments' historical role has focused on managing costs through their powers to set budgets, decide who gets paid, and how. Increasingly, governments are recognizing that the ways in which they choose to pay providers and organizations can also have an impact on the quality of care provided. Using Ontario as an example, we present a Canadian vision for modernizing how healthcare is organized and reimbursed and for using evidence and evaluation as the backbone for iterating new models. Realizing this vision will move Canada closer to international leadership in delivering high-quality, affordable care.

Improving hospital quality through payment reforms: A policy impact analysis in British Columbia.

Among the most devastating and costly consequences of fragmented care is unplanned readmissions. This study adapts Medicare's incentive program and applies the policy to hospitals in British Columbia. The financial implications for hospitals affected by these policies would be small and it is questionable whether the disincentive is worth the trade-offs.

A cohort study of patients hospitalised with SARS-CoV-2 infection in Ontario: patient characteristics and outcomes by wave.

INTRODUCTION: Each wave of the COVID-19 pandemic exhibited a unique combination of epidemiological, social and structural characteristics. We explore similarities and differences in wave-over-wave characteristics of patients hospitalised with COVID-19. METHODS: This was a population-based study in Ontario province, Canada. Patients hospitalised with SARS-CoV-2 between 26 February 2020 and 31 March 2022 were included. An admission was considered related to SARS-CoV-2 infection if the provincial inpatient or outpatient hospital databases contained the ICD-10 diagnostic codes U071/U072 or the Ontario Laboratories Information System indicated a positive SARS-CoV-2 test result (PCR or rapid antigen testing) during the admission or up to two weeks prior. The primary outcome was 90-day mortality (modified Poisson regression). Secondary outcomes were use of critical care during the admission (logistic regression) and total length-of-stay (linear regression with heteroskedastic-consistent standard-error estimators). All models were adjusted for demographic characteristics, neighbourhood socioeconomic factors and indicators of illness severity. RESULTS: There were 73,201 SARS-CoV-2-related admissions: 6127 (8%) during wave 1 (wild-type), 14,371 (20%) during wave 2 (wild-type), 16,653 (23%) during wave 3 (Alpha), 5678 (8%) during wave 4 (Delta) and 30,372 (42%) during wave 5 (Omicron). SARS-CoV-2 was the most responsible diagnosis for 70% of admissions during waves 1-2 and 42% in wave 5. The proportion of admitted patients who were long-term care residents was 18% (n = 1111) during wave 1, decreasing to 10% (n = 1468) in wave 2 and <5% in subsequent waves. During waves 1-3, 46% of all admitted patients resided in a neighbourhood assigned to the highest ethnic diversity quintile, which declined to 27% during waves 4-5. Compared to wave 1, 90-day mortality was similar during wave 2 (adjusted risk ratio [aRR]: 1.00 [95% CI: 0.95-1.04]), but lower during wave 3 (aRR: 0.89 [0.85-0.94]), wave 4 (aRR: 0.85 [0.79-0.91]) and wave 5 (aRR: 0.83 [0.80-0.88]). Improvements in survival over waves were observed among elderly patients (p-interaction <0.0001). Critical care admission was significantly less likely during wave 5 than previous waves (adjusted odds ratio: 0.50 [0.47-0.54]). The length of stay was a median of 8.5 (3.6-23.8) days during wave 1 and 5.3 (2.2-12.6) during wave 5. After adjustment, the mean length of stay was on average -10.4 (-11.1 to -9.8) days, i.e. shorter, in wave 5 vs wave 1. CONCLUSION: Throughout the pandemic, sociodemographic characteristics of patients hospitalised with SARS-CoV-2 changed over time, particularly in terms of ethnic diversity, but still disproportionately affected patients from more marginalised regions. Improved survival and reduced use of critical care during the Omicron wave are reassuring.

The successful and safe conversion of joint arthroplasty to same-day surgery: A necessity after the COVID-19 pandemic.

INTRODUCTION: A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting. METHODS: This was a retrospective cohort and case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision. RESULTS: 204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty [hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97)]; ED visits [hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96)]; and mortality, infection, or revision [hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26)]. CONCLUSION: Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.

The effect of the COVID-19 pandemic on hospital admissions and outpatient visits in Ontario, Canada.

INTRODUCTION: The wave-over-wave effect of the COVID-19 pandemic on hospital visits for non-COVID-19-related diagnoses in Ontario, Canada remains unknown. METHODS: We compared the rates of acute care hospitalizations (Discharge Abstract Database), emergency department (ED) visits, and day surgery visits (National Ambulatory Care Reporting System) during the first five "waves" of Ontario's COVID-19 pandemic with prepandemic rates (since January 1, 2017) across a spectrum of diagnostic classifications. RESULTS: Patients admitted in the COVID-19 era were less likely to reside in long-term-care facilities (OR 0.68 [0.67-0.69]), more likely to reside in supportive housing (OR 1.66 [1.63-1.68]), arrive by ambulance (OR 1.20 [1.20-1.21]) or be admitted urgently (OR 1.10 [1.09-1.11]). Since the start of the COVID-19 pandemic (February 26, 2020), there were an estimated 124,987 fewer emergency admissions than expected based on prepandemic seasonal trends, representing reductions from baseline of 14% during Wave 1, 10.1% in Wave 2, 4.6% in Wave 3, 2.4% in Wave 4, and 10% in Wave 5. There were 27,616 fewer medical admissions to acute care, 82,193 fewer surgical admissions, 2,018,816 fewer ED visits, and 667,919 fewer day-surgery visits than expected. Volumes declined below expected rates for most diagnosis groups, with emergency admissions and ED visits associated with respiratory disorders exhibiting the greatest reduction; mental health and addictions was a notable exception, where admissions to acute care following Wave 2 increased above prepandemic levels. CONCLUSIONS: Hospital visits across all diagnostic categories and visit types were reduced at the onset of the COVID-19 pandemic in Ontario, followed by varying degrees of recovery.

Scheduled and urgent inguinal hernia repair in Ontario, Canada between 2010 and 2022: Population-based cross sectional analysis of trends and outcomes.

INTRODUCTION: We examine trends in inguinal hernia repairs with respect to the COVID-19 pandemic and secular trends in Ontario, Canada. METHODS: This was a retrospective cohort study. Hernia repairs performed January 1, 2010-December 31, 2022 were captured from health administrative inpatient and outpatient databases. Patients managed in three clinical settings were examined: public hospital in-patient, semi-private hospital in-patient (Shouldice Hospital), and public hospital out-patient. We examined the effect of the COVID-19 pandemic on surgical volumes, clinical setting, patient characteristics by setting, time from diagnosis until surgery, hospital length-of-stay, and patient outcomes (90-day readmissions, 1-year reoperations). We used multivariable logistic regression to examine whether patient outcomes were comparable between the COVID-19 period and the pre-pandemic period, adjusted sociodemographic and clinical factors. Shouldice Hospital is the only semi-private hospital in Ontario specializing in hernia repair (patients pay for the mandated admission, but not for the procedure). RESULTS: During the pandemic (March 2020-December 2022), there were 8,162 fewer (15%) scheduled inguinal hernia repairs than expected, but the age-sex standardized rate of urgent repairs remained unchanged. Shouldice Hospital performed more surgeries in the COVID-19 era than pre-pandemic and had a shorter average LOS by 24 hours, despite treating more patients with older age, higher ASA score [adjusted odds ratio (aOR) 2.13 (1.93-2.35) III vs I-II] and greater comorbidity [aOR 1.36 (1.08-1.70) for 2 vs none] than pre-pandemic. Patients treated in the COVID-19 era experienced a longer time until surgery, being the longest in 2022 (median 133 days). Ninety-day readmissions and 1-year reoperations were lower in the COVID-19 era and lower for patients receiving surgery at Shouldice Hospital. CONCLUSION: During the COVID-19 pandemic, there were 8,162 fewer scheduled hernia repairs than expected, longer wait-times until surgery, shorter length-of-stay, and more patients with comorbidities, but outcomes were not worse compared with the pre-pandemic period.

Changes in hospitalizations and emergency department respiratory viral diagnosis trends before and during the COVID-19 pandemic in Ontario, Canada.

INTRODUCTION: Population-level surveillance systems have demonstrated reduced transmission of non-SARS-CoV-2 respiratory viruses during the COVID-19 pandemic. In this study, we examined whether this reduction translated to reduced hospital admissions and emergency department (ED) visits associated with influenza, respiratory syncytial virus (RSV), human metapneumovirus, human parainfluenza virus, adenovirus, rhinovirus/enterovirus, and common cold coronavirus in Ontario. METHODS: Hospital admissions were identified from the Discharge Abstract Database and exclude elective surgical admissions and non-emergency medical admissions (January 2017-March 2022). Emergency department (ED) visits were identified from the National Ambulatory Care Reporting System. International Classification of Diseases (ICD-10) codes were used to classify hospital visits by virus type (January 2017-May 2022). RESULTS: At the onset of the COVID-19 pandemic, hospitalizations for all viruses were reduced to near-trough levels. Hospitalizations and ED visits for influenza (9,127/year and 23,061/year, respectively) were nearly absent throughout the pandemic (two influenza seasons; April 2020-March 2022). Hospitalizations and ED visits for RSV (3,765/year and 736/year, respectively) were absent for the first RSV season during the pandemic, but returned for the 2021/2022 season. This resurgence of hospitalizations for RSV occurred earlier in the season than expected, was more likely among younger infants (age ≤6 months), more likely among older children (aged 6.1-24 months), and less likely to comprise of patients residing in higher areas of ethnic diversity (p<0.0001). CONCLUSION: During the COVID-19 pandemic, there was a reduced the burden of other respiratory infections on patients and hospitals. The epidemiology of respiratory viruses in the 2022/23 season remains to be seen.

What "Value" Should We Pay For? A Path Toward Value-Based Payment in Canadian Healthcare Systems.

There is broad consensus that achieving a "value-based" healthcare system requires a shift toward "value-based payment," but less agreement on what this entails beyond moving away from fee-for-service reimbursement. Opinions diverge on the ideal end-state payment model, and the evidence base remains equivocal. We propose a framework for Canadian payers interested in pursuing value-based payment reforms that draws lessons from two widely recognized examples of paying for value in healthcare: the US Center for Medicare & Medicaid Innovation and Canada's own experience using health technology assessment to inform payment policy.

New pricing approaches for bundled payments: Leveraging clinical standards and regional variations to target avoidable utilization.

OBJECTIVES: Develop pricing models for bundled payments that draw inputs from clinician-defined best practice standards and benchmarks set from regional variations in utilization. DATA: Health care utilization and claims data for a cohort of incident Ontario ischemic and hemorrhagic stroke episodes. Episodes of care are created by linking incident stroke hospitalizations with subsequent health service utilization across multiple datasets. STUDY DESIGN: Costs are estimated for episodes of care and constituent service components using setting-specific case mix methodologies and provincial fee schedules. Costs are estimated for five areas of potentially avoidable utilization, derived from best practice standards set by an expert panel of stroke clinicians. Alternative approaches for setting normative prices for stroke episodes are developed using measures of potentially avoidable utilization and benchmarks established by the best performing regions. PRINCIPAL FINDINGS: There are wide regional variations in the utilization of different health services within episodes of stroke care. Reconciling the best practice standards with regional utilization identifies significant amounts of potentially avoidable utilization. Normative pricing models for stroke episodes result in increasingly aggressive redistributions of funding. CONCLUSIONS: Bundled payment pilots to date have been based on the costs of historical service patterns, which effectively 'bake in' unwarranted and inefficient variations in utilization. This study demonstrates the feasibility of novel clinically informed episode pricing approaches that leverage these variations to target reductions in potentially avoidable utilization.

Constructing an episode of care from acute hospitalization records for studying effects of timing of hip fracture surgery.

Episodes of care defined by the event of hip fracture surgery are widely used for the assessment of surgical wait times and outcomes. However, this approach does not consider nonoperative deaths, implying that survival time begins at the time of procedure. This approach makes treatment effect implicitly conditional on surviving to treatment. The purpose of this article is to describe a novel conceptual framework for constructing an episode of hip fracture care to fully evaluate the incidence of adverse events related to time after admission for hip fracture. This admission-based approach enables the assessment of the full harm of delay by including deaths while waiting for surgery, not just deaths after surgery. Some patients wait until their conditions are optimized for surgery, whereas others have to wait until surgical service becomes available. We provide definitions, linkage rules, and algorithms to capture all hip fracture patients and events other than surgery. Finally, we discuss data elements for stratifying patients according to administrative factors for delay to allow researchers and policymakers to determine who will benefit most from expedited access to surgery.

An economic evaluation of perioperative adverse events associated with spinal surgery.

BACKGROUND CONTEXT: Besides their clinical impact, the economic impact of health care-related adverse events (AEs) is significant. Although a number of studies have attempted to estimate the economic impact of AEs, few have directly linked costs to clinician-reported event severity. PURPOSE: To estimate the economic impact in terms of the incremental cost and length of stay (LOS), attributable to different severity grades of AEs that occurred during perioperative spinal surgery. STUDY DESIGN: Health economic evaluation of data from a prospective observational study from the perspective of an academic hospital. PATIENT SAMPLE: Consecutive patients at a single, tertiary-quaternary care institution who have undergone inpatient spinal surgery. OUTCOME MEASURES: The cost and LOS impacts with respect to the severity of the AEs. METHODS: We analyzed 4 years of patient discharges between January 1, 2007 and December 31, 2010. The Spine Adverse Events Severity instrument was completed by the surgical team at discharge. Clinical impacts of the AEs were graded as I (requires no/minimal treatment), II (requires treatment and is not likely to cause long-term [>6 months] sequelae), III (requires treatment and is most likely to cause long-term sequelae), and IV (death). A total of 1,815 records were linked with the patient-level costing information. We matched each AE case with four control cases based on their propensity score for the risk of experiencing an AE, regressed against case characteristics. We estimated an incremental cost and LOS for each severity grade by calculating the differences in means across cases and controls. We conducted a sensitivity analysis by estimating the alternate models using generalized linear model (GLM) regression with a gamma log link. RESULTS: Adverse events were reported in 316 (17.4%) cases, with 126 of these patients (40.2%) experiencing multiple events. The incremental cost/LOS for each severity grade are as follows: I=$4,224 (p=.0351)/3.63 days (p=.0001); II=$23,500 (p<.0001)/14.03 days (p<.0001); III=$147,285 (p=.0036)/74.50 days (p=.0018); and IV=$121,366 (p=.0323)/46.44 days (p=.0036). The total cost in millions/LOS (days) associated with each grade over the 4-year study period are as follows: I=$0.66 million/569.9 days; II=$2.96 million/1,767.8 days; III=$4.27 million/2,160.5 days; and IV=$0.49 million/185.8 days. Our sensitivity analysis produced comparable overall results using alternate modeling techniques. Overall, AEs contributed an estimated $8.38 million (16.0% of the total costs for all patients in the sample) in incremental costs and 4,684 additional bed days over the 4-year study period. CONCLUSIONS: In this surgical spine cohort, AEs accounted for 16% of the total cost of in-hospital care. Higher severity AEs were progressively more costly on a per-case basis; however, the more frequent lower severity events (ie, Grade I and II) also had a substantial aggregate cost (43%). These results suggest that a strong business case exists for patient safety strategies focused not only on severe AEs but also on the reduction of lower severity events that may be more amenable to prevention efforts.

Bundles: an opportunity to align incentives for continuing care in Canada?

Over the past three decades, diagnosis related groups (DRG) have revolutionized hospital funding by successfully focusing hospitals attention on the 'production' process. However, using DRG for funding acute hospitals does little to create incentives outside of the hospital, or coordinate health care across providers and settings. With many health care quality and efficiency issues stemming from failures at the 'seams' in the system, there is increasing interest in creating new 'bundles' of care which includes acute and post-acute care services that align economic incentives for care coordination. Analysis of Ontario (Canada) datasets demonstrates that linking existing sources of clinical, administrative and cost data to create 'bundles' is technically feasible. However, key implementation challenges need to be addressed, such as administrative and contractual arrangements across multiple provider organizations, pricing and relations with physicians. Nonetheless, this analysis of Ontario data demonstrates that bundles provide an alternative policy option to DRG's in Canada's move toward activity-based funding.