Patient and provider determinants of breast cancer screening among Ontario women aged 40-49: a population-based retrospective cohort study.

PURPOSE: Canadian breast cancer screening guidelines state that mammography screening for women 40-49 should be individualized based on risk assessment and preferences. This retrospective cohort study describes the frequency of screening in women aged 40-49 and identifies patient and provider-level associations with screening. METHODS: Administrative databases were linked. The overall cohort included Ontario women aged 40-49 between April 1, 2009 and March 31, 2019. Subgroups were created: the "screen" group included women who received a mammogram defined as screening (using a set of exclusion criteria) and the "routine screen" group included women with three or more screening mammograms. A multivariable multilevel logistic regression model accounting for patient and provider characteristics was fit to determine characteristics associated with routine screening. The intracluster correlation co-efficient was used to quantify the degree of variation across providers. RESULTS: Of approximately 2 million eligible women, there were 532,596 (25.5%) in the screen group and 90,651 (4.3%) the routine screen group. There was an average of 0.30 and 0.52 screening mammograms per woman year, in the screen and routine screen groups, respectively. Routine screening was associated with periodic health exams (OR 1.21, 95% CI 1.20-1.22), receiving pap smears (OR 1.38, 95% CI 1.37-1.39), and fee-for-service models of care (OR 1.32, 95% CI 1.27-1.36). Over 20% of the variation in screening was due to systematic between-provider differences. CONCLUSIONS: Approximately 4.3% of women aged 40-49 in Ontario received routine breast cancer screening with substantial variation across providers. Routine screening is associated with periodic health examinations, receipt of pap smears, and fee-for-service models of care.

Trends in HIV care cascade engagement among diagnosed people living with HIV in Ontario, Canada: A retrospective, population-based cohort study.

BACKGROUND: The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada. METHODS: We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions. RESULTS: The number of diagnosed PLWH increased from 8,859 (8,859-11,389) in 2000 to 16,110 (16,110-17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63-81%) to 87% (81-87%), on ART increased from 55% (34-60%) to 81% (70-82%) and virally suppressed increased from 41% (23-46%) to 80% (67-81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals. DISCUSSION: HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain-particularly for younger individuals.

Increased risk of mycobacterial infections associated with anti-rheumatic medications.

RATIONALE: Anti-tumour necrosis factor (TNF) agents and other anti-rheumatic medications increase the risk of TB in rheumatoid arthritis (RA). Whether they increase the risk of infections with nontuberculous mycobacteria (NTM) is uncertain. OBJECTIVES: To determine the effect of anti-TNF therapy and other anti-rheumatic drugs on the risk of NTM disease and TB in older patients with RA. METHODS: Population-based nested case-control study among Ontario seniors aged ≥67 years with RA who were prescribed at least one anti-rheumatic medication between 2001 and 2011. We identified cases of TB and NTM disease microbiologically and identified drug exposures using linked prescription drug claims. We estimated ORs using conditional logistic regression, controlling for several potential confounders. MEASUREMENTS AND MAIN RESULTS: Among 56 269 older adults with RA, we identified 37 cases of TB and 211 cases of NTM disease; each case was matched to up to 10 controls. Individuals with TB or NTM disease were both more likely to be using anti-TNF therapy (compared with non-use); adjusted ORs (95% CIs) were 5.04 (1.27 to 20.0) and 2.19 (1.10 to 4.37), respectively. Exposure to leflunomide and other anti-rheumatic drugs with high immunosuppressing potential also were associated with both TB and NTM disease, while oral corticosteroids and hydroxychloroquine were associated with NTM disease. CONCLUSIONS: Anti-TNF use is associated with increased risk of both TB and NTM disease, but appears to be a relatively greater risk for TB. Several other anti-rheumatic drugs were also associated with mycobacterial infections.