Surgeon- and hospital-level variation in wait times for scheduled non-urgent surgery in Ontario, Canada: A cross-sectional population-based study.

BACKGROUND: Canadian health systems fare poorly in providing timely access to elective surgical care, which is crucial for quality, trust, and satisfaction. METHODS: We conducted a cross-sectional analysis of surgical wait times for adults receiving non-urgent cataract surgery, knee arthroplasty, hip arthroplasty, gallbladder surgery, and non-cancer uterine surgery in Ontario, Canada, between 2013 and 2019. We obtained data from the Wait Times Information System (WTIS) database. Inter- and intra-hospital and surgeon variations in wait time were described graphically with caterpillar plots. We used non-nested 3-level hierarchical random effects models to estimate variation partition coefficients, quantifying the proportion of wait time variance attributable to surgeons and hospitals. RESULTS: A total of 942,605 procedures at 107 healthcare facilities, conducted by 1,834 surgeons, were included in the analysis. We observed significant intra- and inter-provider variations in wait times across all five surgical procedures. Inter-facility median wait time varied between six-fold for gallbladder surgery and 15-fold for knee arthroplasty. Inter-surgeon variation was more pronounced, ranging from a 17-fold median wait time difference for cataract surgery to a 216-fold difference for non-cancer uterine surgery. The proportion of variation in wait times attributable to facilities ranged from 6.2% for gallbladder surgery to 23.0% for cataract surgery. In comparison, surgeon-related variation ranged from 16.0% for non-cancer uterine surgery to 28.0% for cataract surgery. IMPLICATIONS: There is extreme variability in surgical wait times for five common, high-volume, non-urgent surgical procedures. Strategies to address surgical wait times must address the variation between service providers through better coordination of supply and demand. Approaches such as single-entry models could improve surgical system performance.

Health care utilization and costs for frail vs nonfrail patients with diffuse large B-cell lymphoma.

ABSTRACT: Half of older patients with diffuse large B-cell lymphoma (DLBCL) receiving curative-intent treatment are frail. Understanding the differences in health care utilization including costs between frail and nonfrail patients can inform appropriate models of care. A retrospective cohort study was conducted using population-based data in Ontario, Canada. Patients aged ≥66 years with DLBCL who received frontline curative-intent chemoimmunotherapy between 2006 and 2017 were included. Frailty was defined using a cumulative deficit-based frailty index. Health care utilization and costs were grouped into 5 phases: (1) 90 days preceding first treatment; (2) early treatment (0 to +90 days after starting treatment); (3) late treatment (+91 to +180 days); (4) follow-up (+181 to -181 days before death); and (5) end of life (last 180 days before death). Costs were standardized to 30-day intervals (2019 Canadian dollars). A total of 5527 patients were included (median age, 75 years; 48% female). A total of 2699 patients (49%) were classified as frail. The median costs for frail vs nonfrail patients per 30 days based on phase of care were (1) $5683 vs $2586 ; (2) $13 090 vs $11 256; (3) $5734 vs $4883; (4) $1138 vs $686; and (5) $11 413 vs $9089; statistically significant in all phases. In multivariable modeling, frail patients had higher rates of emergency department visits and hospitalizations and increased costs than nonfrail patients through all phases except end-of-life phase. During end-of-life phase, a substantial portion of patients (n = 2569 [84%]) required admission to hospital; 684 (27%) required intensive care unit admission. Future work could assess whether certain hospitalizations are preventable, particularly for patients identified as frail.

Indolent lymphoma care delivery and outcomes during the COVID-19 pandemic in Ontario, Canada.

The treatment pattern and outcomes in patients with indolent B-cell lymphoma treated during the coronavirus disease 2019 (COVID-19) pandemic period compared to the prepandemic period are unclear. This was a retrospective population-based study using administrative databases in Ontario, Canada (follow-up to 31 March 2022). The primary outcome was treatment pattern; secondary outcomes were death, toxicities, healthcare utilization (emergency department [ED] visit, hospitalization) and SARS-CoV-2 outcomes. Adjusted hazard ratios (aHR) from Cox proportional hazards models were used to estimate associations. We identified 4143 patients (1079 pandemic, 3064 prepandemic), with a median age of 69 years. In both time periods, bendamustine (B) + rituximab (BR) was the most frequently prescribed regimen. During the pandemic, fewer patients received R maintenance or completed the full 2-year course (aHR 0.81, 95% CI 0.71-0.92, p = 0.001). Patients treated during the pandemic had less healthcare utilization (ED visit aHR 0.77, 95% CI 0.68, 0.88, p < 0.0001; hospitalization aHR 0.81, 95% CI 0.70-0.94, p = 0.0067) and complications (infection aHR 0.69, 95% CI 0.57-0.82, p < 0.0001; febrile neutropenia aHR 0.66, 95% CI 0.47-0.94, p = 0.020), with no difference in death. Independent of vaccination, active rituximab use was associated with a higher risk of COVID-19 complications. Despite similar front-line regimen use, healthcare utilization and admissions for infection were less in the pandemic cohort.

Social determinants of access to timely elective surgery in Ontario, Canada: a cross-sectional population level study.

BACKGROUND: Equitable access to surgical care has clinical and policy implications. We assess the association between social disadvantage and wait times for elective surgical procedures in Ontario. METHODS: We conducted a cross-sectional analysis using administrative data sets of adults receiving nonurgent inguinal hernia repair, cholecystectomy, hip arthroplasty, knee arthroplasty, arthroscopy, benign uterine surgery and cataract surgery from April 2013 to December 2019. We assessed the relation between exceeding target wait times and the highest versus lowest quintile of marginalization dimensions by use of generalized estimating equations logistic regression. RESULTS: Of the 1 385 673 procedures included, 174 633 (12.6%) exceeded the target wait time. Adjusted analysis for cataract surgery found significantly increased odds of exceeding wait times for residential instability (adjusted odd ratio [OR] 1.16, 95% confidence interval [CI] 1.11-1.21) and recent immigration (adjusted OR 1.12, 95% CI 1.07-1.18). The highest deprivation quintile was associated with 18% (adjusted OR 1.18, 95% CI 1.12-1.24) and 20% (adjusted OR 1.20, 95% CI 1.12-1.28) increased odds of exceeding wait times for knee and hip arthroplasty, respectively. Residence in areas where higher proportions of residents self-identify as being part of a visible minority group was independently associated with reduced odds of exceeding target wait times for hip arthroplasty (adjusted OR 0.82, 95% CI 0.75-0.91), cholecystectomy (adjusted OR 0.68, 95% CI 0.59-0.79) and hernia repair (adjusted OR 0.65, 95% CI 0.56-0.77) with an opposite effect in benign uterine surgery (adjusted OR 1.28, 95% CI 1.17-1.40). INTERPRETATION: Social disadvantage had a small and inconsistent impact on receiving care within wait time targets. Future research should consider these differences as they relate to resource distribution and the organization of clinical service delivery.

Mortality among patients with diffuse large B-cell lymphoma and mental disorders: a population-based study.

BACKGROUND: Mental disorders have been reported in patients with diffuse large B-cell lymphoma (DLBCL), but studies examining their association with mortality are lacking. METHODS: We conducted a population-based study using linked administrative health-care databases from Ontario, Canada. All patients with DLBCL 18 years of age or older treated with rituximab-based therapy between January 1, 2005, and December 31, 2017, were identified and followed until March 1, 2020. Mental disorders were defined as either preexisting or postdiagnosis (after lymphoma treatment initiation). Cox proportional hazards models were used to estimate the adjusted hazard ratio (HR) between mental disorders and 1-year and all-cause mortality while controlling for covariates. RESULTS: We identified 10 299 patients with DLBCL. The median age of the cohort was 67 years; 46% of patients were female, and 28% had a preexisting mental disorder. At 1-year follow-up, 892 (9%) had a postdiagnosis mental disorder, and a total of 2008 (20%) patients died. Preexisting mental disorders were not associated with 1-year mortality (adjusted HR = 1.06, 95% confidence interval [CI] = 0.96 to 1.17, P = .25), but postdiagnosis disorders were (adjusted HR = 1.51, 95% CI = 1.26 to 1.82, P = .0001). During a median follow-up of 5.2 years, 2111 (22%) patients had a postdiagnosis mental disorder, and 4084 (40%) patients died. Both preexisting and postdiagnosis mental disorders were associated with worse all-cause mortality (preexisting adjusted HR = 1.12, 95% CI = 1.04 to 1.20, P = .0024; postdiagnosis adjusted HR = 1.63, 95% CI = 1.49 to 1.79, P < .0001). CONCLUSIONS: Patients with DLBCL and mental disorders had worse short-term and long-term mortality, particularly those with postdiagnosis mental disorders. Further studies are needed to examine mental health service utilization and factors mediating the relationship between mental disorders and inferior mortality.

Association of COVID-19 Vaccination With Breakthrough Infections and Complications in Patients With Cancer.

Importance: Patients with cancer are known to have increased risk of COVID-19 complications, including death. Objective: To determine the association of COVID-19 vaccination with breakthrough infections and complications in patients with cancer compared to noncancer controls. Design, Setting, and Participants: Retrospective population-based cohort study using linked administrative databases in Ontario, Canada, in residents 18 years and older who received COVID-19 vaccination. Three matched groups were identified (based on age, sex, type of vaccine, date of vaccine): 1:4 match for patients with hematologic and solid cancer to noncancer controls (hematologic and solid cancers separately analyzed), 1:1 match between patients with hematologic and patients with solid cancer. Exposures: Cancer diagnosis. Main Outcomes and Measures: Outcomes occurring 14 days after receipt of second COVID-19 vaccination dose: primary outcome was SARS-CoV-2 breakthrough infection; secondary outcomes were emergency department visit, hospitalization, and death within 4 weeks of SARS-CoV-2 infection (end of follow-up March 31, 2022). Multivariable cumulative incidence function models were used to obtain adjusted hazard ratio (aHR) and 95% CIs. Results: A total of 289 400 vaccinated patients with cancer (39 880 hematologic; 249 520 solid) with 1 157 600 matched noncancer controls were identified; the cohort was 65.4% female, and mean (SD) age was 66 (14.0) years. SARS-CoV-2 breakthrough infection was higher in patients with hematologic cancer (aHR, 1.33; 95% CI, 1.20-1.46; P < .001) but not in patients with solid cancer (aHR, 1.00; 95% CI, 0.96-1.05; P = .87). COVID-19 severe outcomes (composite of hospitalization and death) were significantly higher in patients with cancer compared to patients without cancer (aHR, 1.52; 95% CI, 1.42-1.63; P < .001). Risk of severe outcomes was higher among patients with hematologic cancer (aHR, 2.51; 95% CI, 2.21-2.85; P < .001) than patients with solid cancer (aHR, 1.43; 95% CI, 1.24-1.64; P < .001). Patients receiving active treatment had a further heightened risk for COVID-19 severe outcomes, particularly those who received anti-CD20 therapy. Third vaccination dose was associated with lower infection and COVID-19 complications, except for patients receiving anti-CD20 therapy. Conclusions and Relevance: In this large population-based cohort study, patients with cancer had greater risk of SARS-CoV-2 infection and worse outcomes than patients without cancer, and the risk was highest for patients with hematologic cancer and any patients with cancer receiving active treatment. Triple vaccination was associated with lower risk of poor outcomes.

Incidence and Mortality of Emergency General Surgery Conditions Among Solid Organ Transplant Recipients in Ontario, Canada: A Population-based Analysis.

BACKGROUND: Emergency general surgery (EGS) conditions and their outcomes are perceived to be disproportionately high among solid organ transplant recipients (SOTRs). However, this has not been adequately investigated at a population level. We characterized the incidence and mortality of EGS conditions among SOTRs compared with nontransplant patients. METHODS: Data were collected through linked administrative population-based databases in Ontario, Canada. We included all adult SOTRs (kidney, liver, heart, and lung) who underwent transplantation between 2002 and 2017. We then identified posttransplantation emergency department visits for EGS conditions (appendicitis, cholecystitis, choledocolithiasis, perforated diverticulitis, incarcerated/strangulated hernias, small bowel obstruction, and perforated peptic ulcer). Age-, sex-, and year-standardized incidence rate ratios (SIRRs) were generated. Logistic regression models were used to evaluate association between transplantation status and 30 d mortality after adjusting for demographics, year, and comorbidities. RESULTS: Ten thousand seventy-three SOTRs and 12 608 135 persons were analyzed. SOTRs developed 881 EGS conditions (non-SOTRs: 552 194 events). The incidence of all EGS conditions among SOTR was significantly higher compared with the nontransplant patients [SIRR 3.56 (95% confidence interval [CI] 3.32-3.82)], even among those with high Aggregated Diagnosis Groups scores ( > 10) [SIRR 2.76 (95% CI 2.53-3.00)]. SOTRs were 1.4 times more likely to die at 30 d [adjusted odds ratio 1.44 (95% CI 1.08-1.91)] after an EGS event compared with nontransplant patients, predominantly amongst lung transplant recipients [adjusted odds ratio 3.28 (95% CI 1.72-6.24)]. CONCLUSIONS: The incidence of EGS conditions is significantly higher in SOTRs even after stratifying by comorbidity burden. This is of particular importance as SOTRs also have a higher likelihood of death after an EGS condition, especially lung transplant recipients.

Background incidence rates of adverse events of special interest related to COVID-19 vaccines in Ontario, Canada, 2015 to 2020, to inform COVID-19 vaccine safety surveillance.

BACKGROUND: Background incidence rates are critical in pharmacovigilance to facilitate identification of vaccine safety signals. We estimated background incidence rates of 11 adverse events of special interest related to COVID-19 vaccines in Ontario, Canada. METHODS: We conducted a population-based retrospective observational study using linked health administrative databases for hospitalizations and emergency department visits among Ontario residents. We estimated incidence rates of Bell's palsy, idiopathic thrombocytopenia, febrile convulsions, acute disseminated encephalomyelitis, myocarditis, pericarditis, Kawasaki disease, Guillain-Barré syndrome, transverse myelitis, acute myocardial infarction, and anaphylaxis during five pre-pandemic years (2015-2019) and 2020. RESULTS: The average annual population was 14 million across all age groups with 51% female. The pre-pandemic mean annual rates per 100,000 population during 2015-2019 were 191 for acute myocardial infarction, 43.9 for idiopathic thrombocytopenia, 28.8 for anaphylaxis, 27.8 for Bell's palsy, 25.0 for febrile convulsions, 22.8 for acute disseminated encephalomyelitis, 11.3 for myocarditis/pericarditis, 8.7 for pericarditis, 2.9 for myocarditis, 2.0 for Kawasaki disease, 1.9 for Guillain-Barré syndrome, and 1.7 for transverse myelitis. Females had higher rates of acute disseminated encephalomyelitis, transverse myelitis and anaphylaxis while males had higher rates of myocarditis, pericarditis, and Guillain-Barré syndrome. Bell's palsy, acute disseminated encephalomyelitis, and Guillain-Barré syndrome increased with age. The mean rates of myocarditis and/or pericarditis increased with age up to 79 years; males had higher rates than females: from 12 to 59 years for myocarditis and ≥12 years for pericarditis. Febrile convulsions and Kawasaki disease were predominantly childhood diseases and generally decreased with age. CONCLUSIONS: Our estimated background rates will permit estimating numbers of expected events for these conditions and facilitate detection of potential safety signals following COVID-19 vaccination.

Health care costs associated with chronic hepatitis C virus infection in Ontario, Canada: a retrospective cohort study.

BACKGROUND: High-quality estimates of health care costs are required to understand the burden of illness and to inform economic models. We estimated the costs associated with hepatitis C virus (HCV) infection from the public payer perspective in Ontario, Canada. METHODS: In this population-based retrospective cohort study, we identified patients aged 18-105 years diagnosed with chronic HCV infection in Ontario from 2003 to 2014 using linked administrative data. We allocated the time from diagnosis until death or the end of follow-up (Dec. 31, 2016) to 9 mutually exclusive health states using validated algorithms: no cirrhosis, no cirrhosis (RNA negative) (i.e., cured HCV infection), compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, both decompensated cirrhosis and hepatocellular carcinoma, liver transplantation, terminal (liver-related) and terminal (non-liver-related). We estimated direct medical costs (in 2018 Canadian dollars) per 30 days per health state and used regression models to identify predictors of the costs. RESULTS: We identified 48 239 patients with chronic hepatitis C, of whom 30 763 (63.8%) were men and 35 891 (74.4%) were aged 30-59 years at diagnosis. The mean 30-day costs were $798 (95% confidence interval [CI] $780-$816) (n = 43 568) for no cirrhosis, $661 (95% CI $630-$692) (n = 6422) for no cirrhosis (RNA negative), $1487 (95% CI $1375-$1599) (n = 4970) for compensated cirrhosis, $3659 (95% CI $3279-$4039) (n = 3151) for decompensated cirrhosis, $4238 (95% CI $3480-$4996) (n = 550) for hepatocellular carcinoma, $8753 (95% CI $7130-$10 377) (n = 485) for both decompensated cirrhosis and hepatocellular carcinoma, $4539 (95% CI $3746-$5333) (n = 372) for liver transplantation, $11 202 (95% CI $10 645-$11 760) (n = 3201) for terminal (liver-related) and $8801 (95% CI $8331-$9271) (n = 5278) for terminal (non-liver-related) health states. Comorbidity was the most significant predictor of total costs for all health states. INTERPRETATION: Our findings suggest that the financial burden of HCV infection is substantially higher than previously estimated in Canada. Our comprehensive, up-to-date cost estimates for clinically defined health states of HCV infection should be useful for future economic evaluations related to this disorder.

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.

Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination.

Importance: The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date. Objective: To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE). Design, Setting, and Participants: This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019. Exposures: Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE. Main Outcomes and Measures: Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested). Results: Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively. Conclusions and Relevance: Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.

Prescription drug claims following a traumatic spinal cord injury for older adults: a retrospective population-based study in Ontario, Canada.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The objectives for this study were to examine the prevalence of polypharmacy for people with traumatic spinal cord injury (SCI) following injury and to determine risk factors. SETTING: Ontario, Canada METHODS: We used provincial-level administrative health services data of publicly funded healthcare encounters housed at the Institute for Clinical Evaluative Sciences, Toronto, Ontario. We examined prescription medications dispensed over a 1 year period post injury for persons 66+ years with an index traumatic SCI between 2004 and 2014. Polypharmacy was defined as being on 10 or more drug classes. Descriptive and analytical statistics were conducted. Relative risks and 95% confidence limits for factors related to polypharmacy were calculated using a robust Poisson multivariate regression model. RESULTS: We identified 418 cases of persons with traumatic SCI during the observation window. A total of 233 patients (56%) were taking at least 10 drug classes in the year following discharge from care for traumatic SCI. The mean number of drug classes taken post injury was 11 (SD = 6). Continuity of care was significantly associated with polypharmacy, with a higher continuity of care (having at least 75% of visits with the same doctor) reducing the risk of polypharmacy. The most common drugs prescribed were laxatives, opioids and cardiovascular-related drugs. CONCLUSION: Findings suggest that polypharmacy is extensive among older adults with traumatic SCI. Persons with better continuity of care are less likely to have polypharmacy compared to those with less continuity. SPONSORSHIP: This project was funded by a Connaught New Investigator Award (University of Toronto), and the Craig H. Neilsen Foundation Psychosocial Research Pilot Grant (Grant #441259).

A population-based study of homicide deaths in Ontario, Canada using linked death records.

BACKGROUND: Homicide - a lethal expression of violence - has garnered little attention from public health researchers and health policy makers, despite the fact that homicides are a cause of preventable and premature death. Identifying populations at risk and the upstream determinants of homicide are important for addressing inequalities that hinder population health. This population-based study investigates the public health significance of homicides in Ontario, Canada, over the period of 1999-2012. We quantified the relative burden of homicides by comparing the socioeconomic gradient in homicides with the leading causes of death, cardiovascular disease (CVD) and neoplasm, and estimated the potential years of life lost (PYLL) due to homicide. METHODS: We linked vital statistics from the Office of the Registrar General Deaths register (ORG-D) with Census and administrative data for all Ontario residents. We extracted all homicide, neoplasm, and cardiovascular deaths from 1999 to 2012, using International Classification of Diseases codes. For socioeconomic status (SES), we used two dimensions of the Ontario Marginalization Index (ON-Marg): material deprivation and residential instability. Trends were summarized across deprivation indices using age-specific rates, rate ratios, and PYLL. RESULTS: Young males, 15-29 years old, were the main victims of homicide with a rate of 3.85 [IC 95%: 3.56; 4.13] per 100,000 population and experienced an upward trend over the study period. The socioeconomic neighbourhood gradient was substantial and higher than the gradient for both cardiovascular and neoplasms. Finally, the PYLL due to homicide were 63,512 and 24,066 years for males and females, respectively. CONCLUSIONS: Homicides are an important cause of death among young males, and populations living in disadvantaged neighbourhoods. Our findings raise concerns about the burden of homicides in the Canadian population and the importance of addressing social determinants to address these premature deaths.

Relation between primary care physician supply and diabetes care and outcomes: a cross-sectional study.

BACKGROUND: Higher primary care physician supply is associated with lower mortality due to heart disease, cancer and stroke, but its relation to diabetes care and outcomes is unknown. We examined the association between primary care physician supply and evidence-based testing and hospital visits for people with diabetes in naturally occurring multispecialty physician networks in Ontario, Canada. METHODS: We conducted a cross-sectional analysis between Apr. 1, 2009, and Mar. 31, 2011, using linked administrative data. We included all Ontario residents over 40 years of age with a diagnosis of diabetes before Apr. 1, 2007, who were alive on Apr. 1, 2009 (N = 712 681). We tested the association between physician supply and outcomes at the network level using separate Poisson regression models for urban and nonurban physician networks. We accounted for clustering at the physician and network level and adjusted for patient characteristics. RESULTS: Patients in physician networks with a high supply of primary care physicians were more likely to receive the optimal number of evidence-based tests for diabetes than patients in networks with low primary care physician supply (urban relative risk [RR] 1.06, 95% confidence interval [CI] 1.04-1.07; nonurban RR 1.17, 95% CI 1.14-1.21) but were no different regarding emergency department visits (urban RR 1.05, 95% CI 0.94-1.17; nonurban RR 0.96, 95% CI 0.85-1.08) or hospital admissions for diabetes complications (urban RR 1.01, 95% CI 0.89-1.14; nonurban RR 0.91, 95% CI 0.77-1.07). INTERPRETATION: Having more primary care physicians per capita is associated with better diabetes care but not with reduced hospital visits in this setting. Further research to understand this relation and how it varies by setting is important for resource planning.

Narrowing mortality gap between men and women over two decades: a registry-based study in Ontario, Canada.

BACKGROUND: Historically, women have lower all-cause mortality than men. It is less understood that sex differences have been converging, particularly among certain subgroups and causes. This has implications for public health and health system planning. Our objective was to analyse contemporary sex differences over a 20-year period. METHODS: We analysed data from a population-based death registry, the Ontario Registrar's General Death file, which includes all deaths recorded in Canada's most populous province, from 1992 to 2012 (N=1 710 080 deaths). We calculated absolute and relative mortality sex differences for all-cause and cause-specific mortality, age-adjusted and age-specific, including the following causes: circulatory, cancers, respiratory and injuries. We used negative-binomial regression of mortality on socioeconomic status with direct age adjustment for the overall population. RESULTS: In the 20-year period, age-adjusted mortality dropped 39.2% and 29.8%, respectively, among men and women. The age-adjusted male-to-female mortality ratio dropped 41.4%, falling from 1.47 to 1.28. From 2000 onwards, all-cause mortality rates of high-income men were lower than those seen among low-income women. Relative mortality declines were greater among men than women for cancer, respiratory and injury-related deaths. The absolute decline in circulatory deaths was greater among men, although relative deciles were similar to women. The largest absolute mortality gains were seen among men over the age of 85 years. CONCLUSIONS: The large decline in mortality sex ratios in a Canadian province with universal healthcare over two decades signals an important population shift. These narrowing trends varied according to cause of death and age. In addition, persistent social inequalities in mortality exist and differentially affect men and women. The observed change in sex ratios has implications for healthcare and social systems.

Looking Beyond Income and Education: Socioeconomic Status Gradients Among Future High-Cost Users of Health Care.

INTRODUCTION: Healthcare spending occurs disproportionately among a very small portion of the population. Research on these high-cost users (HCUs) of health care has been overwhelmingly cross-sectional in nature and limited to the few sociodemographic and clinical characteristics available in health administrative databases. This study is the first to bridge this knowledge gap by applying a population health lens to HCUs. We investigate associations between a broad range of SES characteristics and future HCUs. METHODS: A cohort of adults from two cycles of large, nationally representative health surveys conducted in 2003 and 2005 was linked to population-based health administrative databases from a universal healthcare plan for Ontario, Canada. Comprehensive person-centered estimates of annual healthcare spending were calculated for the subsequent 5 years following interview. Baseline HCUs (top 5%) were excluded and healthcare spending for non-HCUs was analyzed. Adjusted for predisposition and need factors, the odds of future HCU status (over 5 years) were estimated according to various individual, household, and neighborhood SES factors. Analyses were conducted in 2014. RESULTS: Low income (personal and household); less than post-secondary education; and living in high-dependency neighborhoods greatly increased the odds of future HCUs. After adjustment, future HCU status was most strongly associated with food insecurity, personal income, and non-homeownership. Living in highly deprived or low ethnic concentration neighborhoods also increased the odds of becoming an HCU. CONCLUSIONS: Findings suggest that addressing social determinants of health, such as food and housing security, may be important components of interventions aiming to improve health outcomes and reduce costs.

Initial uptake of the Ontario Pharmacy Smoking Cessation Program: Descriptive analysis over 2 years.

BACKGROUND: Smoking is a significant public health concern. The Ontario Pharmacy Smoking Cessation Program was launched in September 2011 to leverage community pharmacists and expand access to smoking cessation services for public drug plan beneficiaries. METHODS: We examined health care utilization data in Ontario to describe public drug plan beneficiaries receiving, and pharmacies providing, smoking cessation services between September 2011 and September 2013. Patient characteristics were summarized, stratified by drug plan group: seniors (age ≥65 years) or social assistance. Trends over time were examined by plotting the number of services, unique patients and unique pharmacies by month. We then examined use of follow-up services and prescription smoking cessation medications. RESULTS: We identified 7767 residents receiving pharmacy smoking cessation services: 28% seniors (mean age = 69.9, SD = 4.8; 53% male) and 72% social assistance (mean age = 44.4 years, SD = 11.8; 48% male). Cumulative patient enrollment increased over time with an average of 311 (SD = 61) new patients per month, and one-third (n = 1253) of pharmacies participated by the end of September 2013. Regions with the highest number of patients were Erie St. Clair (n = 1328) and Hamilton Niagara Haldimand Brant (n = 1312). Sixteen percent of all patients received another pharmacy service (e.g., MedsCheck) on the same day as smoking cessation program enrollment. Among patients with follow-up data, 56% received follow-up smoking cessation services (60% seniors, 55% social assistance) and 74% received a prescription smoking cessation medication. One-year quit status was reported for 12%, with a 29% success rate. CONCLUSIONS: Program enrollment has increased steadily since its launch, yet only a third of pharmacies participated and 56% of patients received follow-up services.

Depression and use of health care services in patients with advanced cancer.

OBJECTIVE: To examine whether depression in patients with advanced cancer is associated with increased rates of physician visits, especially to primary care. DESIGN: Retrospective, observational study linking depression survey data to provincial health administration data. SETTING: Toronto, Ont. PARTICIPANTS: A total of 737 patients with advanced cancer attending Princess Margaret Hospital, who participated in the Will to Live Study from 2002 to 2008. MAIN OUTCOME MEASURES: Frequency of visits to primary care, oncology, surgery, and psychiatry services, before and after the depression assessment. RESULTS: Before the assessment, depression was associated with an almost 25% increase in the rate of primary care visits for reasons not related to mental health (rate ratio [RR] = 1.23, 95% CI 1.00 to 1.50), adjusting for medical morbidity and other factors. After assessment, depression was associated with a 2-fold increase in the rate of primary care visits for mental health-related reasons (RR = 2.35, 95% CI 1.18 to 4.66). However, depression was also associated during this time with an almost 25% reduction in the rate of oncology visits (RR = 0.78, 95% CI 0.65 to 0.94). CONCLUSION: Depression affects health care service use in patients with advanced cancer. Individuals with depression were more likely to see primary care physicians but less likely to see oncologists, compared with individuals without depression. However, the frequent association of disease-related factors with depression in patients with advanced cancer highlights the need for communication between oncologists and primary care physicians about the medical and psychosocial care of these patients.

Detection and treatment of post stroke depression: results from the registry of the Canadian stroke network.

BACKGROUND: Depression occurs in approximately one-third of patients following stroke based on studies that screen entire stroke populations. Less is known about the detection and treatment of post stroke depression (PSD) in routine clinical practice. METHODS: This was a prospective cohort study of 7643 consecutive stroke patients >66 years of age, from 13 designated stroke centres in Ontario, Canada. PSD was defined as (a) presence of strong evidence of depression documented in the patient chart plus a prescribed antidepressant and a psychiatric consult, or (b) prescription of a new antidepressant following admission. The prevalence of PSD was determined and patients with and without PSD were compared on a variety of measures. Patients admitted to specialized stroke units were compared to patients admitted to standard units in order to determine if PSD detection and treatment rates differed. RESULTS: PSD was diagnosed in 4.8%, and 6.7% were treated with a new antidepressant. Patients with PSD had more severe strokes, more functional handicap, longer hospital stays and were less likely to be discharged home (all p < 0.001). Patients admitted to specialized stroke units were more likely to be diagnosed with depression (5.2% vs 4.0%, p < 0.014) and were more likely to receive a new prescription for an antidepressant (7.8% vs 4.5%; p < 0.001). CONCLUSIONS: Rates of diagnosed and treated PSD in routine clinical practice are low and appear significantly lower than those from studies that utilize active screening of entire stroke populations. These results support the routine screening of all patients for PSD using validated instruments. Specialized stroke unit care may improve PSD detection and treatment rates.