Abortion Safety and Use with Normally Prescribed Mifepristone in Canada.

BACKGROUND: In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017. METHODS: Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020). RESULTS: A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10). CONCLUSIONS: After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).

Assessing the impact of psychiatric genetic counseling on psychiatric hospitalizations.

Psychiatric genetic counseling (pGC) can improve patient empowerment and self-efficacy. We explored the relationship between pGC and psychiatric hospitalizations, for which no prior data exist. Using Population Data BC (a provincial dataset), we tested two hypotheses: (1) among patients (>18 years) with psychiatric conditions who received pGC between May 2010 and Dec 2016 (N = 387), compared with the year pre-pGC, in the year post-pGC there would be fewer (a) individuals hospitalized and (b) total hospital admissions; and (2) using a matched cohort design, compared with controls (N = 363, matched 1:4 for sex, diagnosis, time since diagnosis, region, and age, and assigned a pseudo pGC index date), the pGC cohort (N = 91) would have (a) more individuals whose number of hospitalizations decreased and (b) fewer hospitalizations post-pGC/pseudo-index. We also explored total days in hospital. Within the pGC cohort, there were fewer hospitalizations post-pGC than pre- pGC (p = 0.011, OR = 1.69), and total days in hospital decreased (1085 to 669). However, when compared to matched controls, the post-pGC/pseudo index change in hospitalizations among pGC cases was not statistically significant, even after controlling for the higher number of hospitalizations prior. pGC may lead to fewer psychiatric hospitalizations and cost savings; further studies exploring this are warranted.

Validating use of diagnostic codes in Canadian administrative data for identification of adverse drug events.

AIMS: While diagnostic codes from administrative health data might be a valuable source to identify adverse drug events (ADEs), their ability to identify unintended harms remains unclear. We validated claims-based diagnosis codes for ADEs based on events identified in a prospective cohort study and assessed whether key attributes predicted their documentation in administrative data. METHODS: This was a retrospective analysis of 3 prospective cohorts in British Columbia, from 2008 to 2015 (n = 13 969). We linked prospectively identified ADEs to administrative insurance data to examine the sensitivity and specificity of different diagnostic code schemes. We used logistic regression to assess which key attributes (e.g., type of event, symptoms and culprit medications) were associated with better documentation of ADEs in administrative data. RESULTS: Among 1178 diagnosed events, the sensitivity of the diagnostic codes in administrative data ranged from 3.4 to 52.6%, depending on the database and codes used. We found that documentation was worse for certain types of ADEs (dose-related: odds ratio [OR]: 0.32, 95% confidence interval [CI]: 0.15, 0.69; nonadherence events (OR: 0.35, 95% CI: 0.20, 0.62), and better for those experiencing arrhythmias (OR: 4.19, 95% CI: 0.96, 18.28). CONCLUSION: ADEs were not well documented in administrative data. Alternative methods should be explored to capture ADEs for health research.

Validating methods used to identify non-adherence adverse drug events in Canadian administrative health data.

AIMS: Medication non-adherence is a type of adverse drug event that can lead to untreated and exacerbated chronic illness, and that drives healthcare utilization. Research using medication claims data has attempted to identify instances of medication non-adherence using the proportion of days covered or by examining gaps between medication refills. We sought to validate these measures compared to a gold standard diagnosis of non-adherence made in hospital. METHODS: This was a retrospective analysis of adverse drug events diagnosed during three prospective cohorts in British Columbia between 2008 and 2015 (n = 976). We linked prospectively identified adverse drug events to medication claims data to examine the sensitivity and specificity of typical non-adherence measures. RESULTS: The sensitivity of the non-adherence measures ranged from 22.4% to 37.5%, with a proportion of days covered threshold of 95% performing the best; the non-persistence measures had sensitivities ranging from 10.4% to 58.3%. While a 7-day gap was most sensitive, it classified 61.2% of the sample as non-adherent, whereas only 19.6% were diagnosed as such in hospital. CONCLUSIONS: The methods used to identify non-adherence in administrative databases are not accurate when compared to a gold standard diagnosis by healthcare providers. Research that has relied on administrative data to identify non-adherent patients both underestimates the magnitude of the problem and may label patients as non-adherent who were in fact adherent.

Prevalence and predictors of primary nonadherence to medications prescribed in primary care.

BACKGROUND: Most research on medication adherence has focused on secondary nonadherence and persistence to therapy. Medication prescriptions that are never filled by patients (primary nonadherence) remain understudied in the general population. METHODS: We linked prescribing data from primary care electronic medical records to comprehensive pharmacy dispensing claims between January 2013 and April 2019 in British Columbia (BC) to estimate primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date. We used hierarchical multivariable logistic regression to determine prescriber, patient and medication factors associated with primary nonadherence among community-dwelling patients in primary care. RESULTS: Among 150 565 new prescriptions to 34 243 patients, 17% of prescriptions were never filled. Primary nonadherence was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%). In multivariable analysis, primary nonadherence was lower for prescriptions issued by male prescribers (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.50-0.88). Primary nonadherence decreased with patient age (OR 0.91, 95% CI 0.90-0.92 for each additional 10 years) but increased with polypharmacy among patients aged 65 years or older. Patients filled more than 82% of their medication prescriptions within 2 weeks after their primary care provider visit. INTERPRETATION: The prevalence of primary nonadherence to new prescriptions was 17%. Interventions to address primary nonadherence could target older patients with multiple medication use and within the first 2 weeks of the prescription issue date.

Declining Comprehensiveness of Services Delivered by Canadian Family Physicians Is Not Driven by Early-Career Physicians.

We describe changes in the comprehensiveness of services delivered by family physicians in 4 Canadian provinces (British Columbia, Manitoba, Ontario, Nova Scotia) during the periods 1999-2000 and 2017-2018 and explore if changes differ by years in practice. We measured comprehensiveness using province-wide billing data across 7 settings (home, long-term care, emergency department, hospital, obstetrics, surgical assistance, anesthesiology) and 7 service areas (pre/postnatal care, Papanicolaou [Pap] testing, mental health, substance use, cancer care, minor surgery, palliative home visits). Comprehensiveness declined in all provinces, with greater changes in number of service settings than service areas. Decreases were no greater among new-to-practice physicians.

Population level administrative data evidence of visits to the emergency department by youth with intellectual/developmental disabilities in BC, Canada.

INTRODUCTION: The literature indicates that youth with intellectual/developmental disabilities (IDD) have poor health and that access to health services decreases as they transition from pediatric to adult services. At the same time their use of emergency department services increases. The objective of this study was to compare use of emergency department services by youth with IDD to youth without IDD, with particular emphasis on the transition period from pediatric to adult health care services. METHODS: This research used a population level administrative health data base for the province of British Columbia Canada for 2010-2019 to examine the use of emergency departments by youth with IDD (N = 20,591) compared to a population group of youth without IDD (N = 1,293,791). Using the ten years of data, odds ratios for visits to the emergency department were calculated adjusting for sex, income and geographical area within the Province. In addition, difference-in-differences analyses were calculated for age matched subsets of the two cohorts. RESULTS: Over the ten year period, 40.60% of youth with IDD visited an emergency department at least once, compared to 29.10% of youth without IDD. Youth with IDD had an odds ratio of visiting an emergency department 1.697 (1.649, 1.747) times that of youth without IDD. However, when odds were adjusted for a diagnosis of either psychotic illness or anxiety/depression, the odds for youth with IDD visiting emergency compared to youth without IDD were reduced to 1.063 (1.031, 1.096). Use of emergency services increased as youth aged. Type of IDD also affected use of emergency services. Youth with Fetal Alcohol Syndrome had the greatest odds of using emergency services compared to youth with other types of IDD. DISCUSSION: The findings from this study indicate that youth with IDD have higher odds of using emergency services than youth without IDD although these increased odds appear to be largely driven by mental illness. In addition, use of emergency services increases as the youth age and transition from pediatric to adult health services. Better treatment of mental health issues within this population may reduce their use of emergency services.

Costs of major depression covered / not covered in British Columbia, Canada.

BACKGROUND: Major depressive disorder (MDD) is one of the world's leading causes of disability. Our purpose was to characterize the total costs of MDD and evaluate the degree to which the British Columbia provincial health system meets its objective to protect people from the financial impact of illness. METHODS: We performed a population-based cohort study of adults newly diagnosed with MDD between 2015 and 2020 and followed their health system costs over two years. The expenditure proportion of MDD-related, patient paid costs relative to non-subsistence income was estimated, incidences of financial hardship were identified and the slope index of inequality (SII) between the highest and lowest income groups compared across regions. RESULTS: There were 250,855 individuals diagnosed with MDD in British Columbia over the observation period. Costs to the health system totalled >$1.5 billion (2020 CDN), averaging $138/week for the first 12 weeks following a new diagnosis and $65/week to week 52 and $55/week for weeks 53-104 unless MDD was refractory to treatment ($125/week between week 12-52 and $101/week over weeks 53-104). The proportion of MDD-attributable costs not covered by the health system was 2-15x greater than costs covered by the health system, exceeding $700/week for patients with severe MDD or MDD that was refractory to treatment. Population members in lower-income groups and urban homeowners had disadvantages in the distribution of financial protection received by the health system (SII reached - 8.47 and 15.25, respectively); however, financial hardship and inequities were mitigated province-wide if MDD went into remission (SII - 0.07 to 0.6). CONCLUSIONS: MDD-attributable costs to health systems and patients are highest in the first 12 weeks after a new diagnosis. During this time, lower income groups and homeowners in urban areas run the risk of financial hardship.

The Use of Medically Required Dental Services by Youth with Intellectual/Developmental Disabilities in British Columbia, Canada.

INTRODUCTION: The literature indicates that youth with intellectual/developmental disabilities (IDD), such as Down syndrome or autism, have poor oral health. A number of factors influence their oral health, including the use of medically required dental treatments. METHODS: This paper describes the first use of population-level administrative health data to examine the use of medically required dental services by youth with IDD compared with youth without IDD in Canada. RESULTS: Youth with IDD had 4-9 times the odds of a medically required dental treatment compared with youth without IDD. Odds varied with age and type of IDD. CONCLUSIONS: Youth with IDD used medically required dental services to a greater extent than youth without IDD. Use of medically required dental treatments by youth with IDD declined with age; this may indicate greater difficulty accessing services when youth transition from pediatric to adult services. These findings provide baseline information on the use of medically required dental treatments and can contribute to future assessments of dental services for youth with IDD.

Changes in comprehensiveness of services delivered by Canadian family physicians: Analysis of population-based linked data in 4 provinces.

OBJECTIVE: To describe changes in the comprehensiveness of services delivered by family physicians across service settings and service areas in 4 Canadian provinces, to identify which settings and areas have changed the most, and to compare the magnitude of changes by physician characteristics. DESIGN: Descriptive analysis of province-wide, population-based billing data linked to population and physician registries. SETTING: British Columbia, Manitoba, Ontario, and Nova Scotia. PARTICIPANTS: Family physicians registered to practise in the 1999-2000 and 2017-2018 fiscal years. MAIN OUTCOME MEASURES: Comprehensiveness was measured across 7 service settings (home care, long-term care, emergency departments, hospitals, obstetric care, surgical assistance, anesthesiology) and in 7 service areas consistent with office-based practice (prenatal and postnatal care, Papanicolaou testing, mental health, substance use, cancer care, minor surgery, palliative home visits). The proportion of physicians with activity in each setting and area are reported and the average number of service settings and areas by physician characteristics is described (years in practice, sex, urban or rural practice setting, and location of medical degree training). RESULTS: Declines in comprehensiveness were observed across all provinces studied. Declines were greater for comprehensiveness of settings than for areas consistent with office-based practice. Changes were observed across all physician characteristics. On average across provinces, declines in the number of service settings and service areas were highest among physicians in practice 20 years or longer, male physicians, and physicians practising in urban areas. CONCLUSION: Declining comprehensiveness was observed across all physician characteristics, pointing to changes in the practice and policy contexts in which all family physicians work.

Primary care practice characteristics associated with team functioning in primary care settings in Canada: A practice-based cross-sectional survey.

Team-based care is recognized as a foundational building block of high-performing primary care. The purpose of this study was to identify primary care practice characteristics associated with team functioning and examine whether there is relationship between team composition or size and team functioning. We sought to answer the following research questions: (1) are primary care practice characteristics associated with team functioning; and (2) does team composition or size influence team functioning. This cross-sectional correlational study was conducted in Fraser East, British Columbia, Eastern Ontario Health Unit, Ontario and Central Zone, Nova Scotia in Canada. Data were collected from primary care practices using an organization survey and the Team Climate Inventory (TCI) as a measure team functioning. The independent variables of interest were: physicians' payment model, internal clinic meetings to discuss clinical issues, care coordination through informal and ad hoc exchange, care coordination through electronic medical records and sharing clinic mission, values and objectives among health professionals. Potentially confounding variables were as follows: team size, composition, and practice panel size. A total of 63 practices were included in these analyses. The overall mean score of team climate was 73 (SD: 10.75) out of 100. Regression analyses showed that care coordination through human interaction and sharing the practice's mission, values, and objectives among health professionals were positively associated with higher functioning teams. Care coordination through electronic medical records and larger team size were negatively associated with team climate. This study provides baseline data on what practice characteristics are associated with highly functioning teams in Canada.

Caregivers' Concerns About Assisted Living Residents' Mental Health During the COVID-19 Pandemic: A Cross-Sectional Survey Study.

Family or friend caregivers' concerns about assisted living (AL) residents' mental health are reflective of poor resident and caregiver mental health. COVID-19-related visiting restrictions increased caregiver concerns, but research on these issues in AL is limited. Using web-based surveys with 673 caregivers of AL residents in Western Canada, we assessed the prevalence and correlates of moderate to severe caregiver concerns about residents' depressed mood, loneliness, and anxiety in the 3 months before and after the start of the COVID-19 pandemic. Caregiver concerns doubled after the start of the pandemic (resident depressed mood: 23%-50%, loneliness: 29%-62%, anxiety: 24%-47%). Generalized linear mixed models identified various modifiable risk factors for caregiver concerns (e.g., caregivers' perception that residents lacked access to counseling services or not feeling well informed about and involved in resident care). These modifiable factors can be targeted in efforts to prevent or mitigate caregiver concerns and resident mental health issues.

The best defence is a good offence: Ensuring equitable access to primary care in Canada.

Ensuring access to primary care is a persistent challenge in Canada, and the COVID-19 pandemic exacerbated existing gaps. Public policy reform that only partially addresses these access issues, technological opportunities, workforce desires, or patient preferences creates an opportunity for private, investor-owned corporations to take ownership of primary care delivery systems. This article summarizes the history of the "public-private" conversation as it pertains to primary care, with a particular focus on investor-owned corporations. We outline how profit-driven, corporate healthcare impacts equitable access to care, increases spending on low-value services, and undermines the underlying values of Canadian healthcare systems. All of healthcare delivery requires rapid regulation and oversight by policy-makers, which would increase transparency of corporate care. There also must be parallel efforts placed on addressing the long-standing issues in publicly funded delivery of primary care that created the space for corporate care to grow.

Gaps in the System: Supporting People Living with Dementia.

Persons living with dementia and their caregivers often face challenges in accessing support for their complex needs. This study aims to understand how program administrators, people living with dementia, unpaid caregivers, and decision-makers perceive specific dementia care programs and whether they are adequately meeting the needs of individuals living with dementia. Forty semi-structured interviews were conducted between 2018 and 2020 in five North American jurisdictions. Three main gaps were identified (1) disconnected system infrastructure, (2) lack of comprehensive services to meet diverse needs, and (3) inconsistent understandings of dementia. Despite having programs in place, there remain significant limitations in systems that could be addressed to adequately meet the needs of individuals living with dementia and their caregivers.

Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study.

BACKGROUND: Family and friend caregivers play significant roles in advocating for and ensuring quality health and social care of residents in Assisted Living (AL) homes. However, little is known about how the COVID-19 pandemic and related visitor restrictions affected their health and mental well-being. We examined the prevalence and correlates of anxiety and depressive symptoms among caregivers of AL residents during the initial wave of COVID-19 in two Canadian provinces. METHODS: A cross-sectional web-based survey was conducted among family/friend caregivers of AL residents in Alberta and British Columbia (Oct 28, 2020-Mar 31, 2021) to collect data on their sociodemographic, health and caregiving characteristics, as well as concerns about residents' health and social care before and during the first wave of the pandemic. A clinically significant anxiety disorder and depressive symptoms were assessed with the GAD-7 and CES-D10 instruments, respectively. Separate multivariable (modified) Poisson regression models identified caregiver correlates of each mental health condition. RESULTS: Among the 673 caregivers completing the survey (81% for Alberta residents), most were women (77%), white (90%) and aged ≥ 55 years (81%). Clinically significant anxiety and depression were present in 28.6% and 38.8% of caregivers respectively. Both personal stressors (comorbidity level, income reduction, low social support) and caregiving stressors exacerbated by the pandemic were independently associated with caregiver anxiety and depression. The latter included increased concern about the care recipients' depression (adjusted risk ratio [adjRR] = 1.84, 95% confidence interval [CI] 1.19-2.85 for caregiver anxiety and adjRR = 1.75, 95% CI 1.26-2.44 for caregiver depressive symptoms) and reported intention to withdraw the resident from AL because of COVID-19 (adjRR = 1.24, 95%CI 0.95-1.63 for caregiver anxiety and adjRR = 1.37, 95%CI 1.13-1.67 for caregiver depressive symptoms). CONCLUSIONS: Caregivers of residents in AL homes reported significant personal and caregiving-related stressors during the initial wave of COVID-19 that were independently associated with an increased likelihood of experiencing clinically significant anxiety and depressive symptoms. Healthcare providers and AL staff should be aware of the prevalence and varied correlates of caregivers' mental health during public health crises so that appropriate screening and support may identified and implemented.

A Framework for Understanding How Variation in Health Care Service Delivery Affects Work Disability Management.

Introduction Differences in disability duration after work injury have been observed across jurisdictions, regions and urban and rural settings. A key aspect of effective disability management is the access and utilization of appropriate and high quality health care. This paper presents a framework for analyzing and thus understanding how health service spending and utilization vary across and within work disability management schemes and affect work disability management. Methods Our framework was developed through a literature review and policy analysis. Existing frameworks describing geographic variation in general health care systems identified factors believed to drive that variation. A review of policy and practice documents from Canada's no-fault cause-based work disability management system identified factors relevant to work disability systems. Results We expand on previous frameworks by taking a systems approach that centers on factors relevant to the work disability management system. We further highlight predisposing, enabling, workplace environment and need-based factors that could lead to variation in health care spending and utilization across and within jurisdictions. These factors are described as shaping the interactions between workers, health care providers, employers and work disability management system actors, and influencing work disability management health and employment outcomes. Conclusion Our systems-focused approach offers a guide for researchers and policymakers to analyze how various factors may influence spending and utilization across regions and to identify areas for improvement in health care delivery within work disability management systems. Next steps include testing the framework in an analysis looking at geographic variation in spending and utilization across and within Canadian work disability management systems.

Characterizing people with frequent emergency department visits and substance use: a retrospective cohort study of linked administrative data in Ontario, Alberta, and B.C., Canada.

BACKGROUND: Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces. METHODS: This was a retrospective cohort study (April 1st, 2013 to March 31st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use. We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1st, 2014 to March 31st, 2015. RESULTS: In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37-43 years; 60.9-63.0% male), whose ED visits and hospitalizations were higher than comparison groups. In all provinces, cluster analyses identified subgroups with "extreme" and "moderate" frequent visits (median 13-19 versus 4-6 visits/year). "Extreme" versus "moderate" subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups. CONCLUSIONS: Subgroups of people with "extreme" (13-19 visits/year) and "moderate" (4-6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the "extreme" subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare.

Trajectory of psychosocial symptoms among home care patients with cancer at end-of-life.

PURPOSE: Understanding the end-of-life psychosocial needs of cancer patients at home is a knowledge gap. This study describes the trajectory of psychosocial symptoms in the last 6 months of life among cancer decedents who were receiving home care. METHODS: Observational population-based cohort study of cancer decedents who were receiving home care services between 2007 and 2014. Decedents had to have at least one home care assessment in the last 6 months of life for inclusion. Outcomes were the presence of psychosocial symptoms (i.e., anxiety, loneliness, depression, social decline, caregiver distress, and cognitive decline) at each week before death. RESULTS: Our cohort included 27,295 unique cancer decedents (30,368 assessments), of which 58% died in hospital. Fifty-six percent were older than 74, and 47% were female. The prevalence of all symptoms increased approaching death, except loneliness. Social decline (48%-78%) was the most prevalent psychosocial symptom, though loneliness was reported in less than 10% of the cohort. Caregiver distress rose over time from 15%-27%. A third of the cohort reported issues with cognitive impairment. Multivariate regression showed that physical symptoms such as uncontrolled pain, impairment in independent activities of daily living, and a high level of health instability all significantly worsened the odds of having a psychosocial symptom in the last 3 months of life. CONCLUSION: In this large home care cancer cohort, trajectories of psychosocial symptoms worsened close to death. Physical symptoms, such as uncontrolled pain, were associated with having worse psychosocial symptoms at end of life.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital.

BACKGROUND: Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. AIM: The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. SETTINGS AND PARTICIPANTS: We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died. RESULTS: Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. CONCLUSIONS: Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study.

BACKGROUND: The retirement of a family physician can represent a challenge in accessibility and continuity of care for patients. In this population-based, longitudinal cohort study, we assess whether and how long it takes for patients to find a new majority source of primary care (MSOC) when theirs retires, and we investigate the effect of demographic and clinical characteristics on this process. METHODS: We used provincial health insurance records to identify the complete cohort of patients whose majority source of care left clinical practice in either 2007/2008 or 2008/2009 and then calculated the number of days between their last visit with their original MSOC and their first visit with their new one. We compared the clinical and sociodemographic characteristics of patients who did and did not find a new MSOC in the three years following their original physician's retirement using Chi-square and Fisher's exact test. We also used Cox proportional hazards models to determine the adjusted association between patient age, sex, socioeconomic status, location and morbidity level (measured using Johns Hopkins' Aggregated Diagnostic Groupings), and time to finding a new primary care physician. We produce survival curves stratified by patient age, sex, income and morbidity. RESULTS: Fifty-four percent of patients found a new MSOC within the first 12 months following their physician's retirement. Six percent of patients still had not found a new physician after 36 months. Patients who were older and had higher levels of morbidity were more likely to find a new MSOC and found one faster than younger, healthier patients. Patients located in more urban regional health authorities also took longer to find a new MSOC compared to those in rural areas. CONCLUSIONS: Primary care physician retirements represent a potential threat to accessibility; patients followed in this study took more than a year on average to find a new MSOC after their physician retired. Providing programmatic support to retiring physicians and their patients, as well as addressing shortages of longitudinal primary care more broadly could help to ensure smoother retirement transitions.