COVID-19 vaccine equity: a retrospective population-based cohort study examining primary series and first booster coverage among persons with a history of immigration and other residents of Ontario, Canada.

Introduction: Immigrants were disproportionately impacted by COVID-19 and experience unique vaccination barriers. In Canada (37 million people), 23% of the population is foreign-born. Immigrants constitute 60% of the country's racialized (non-white) population and over half of immigrants reside in Ontario, the country's most populous province. Ontario had several strategies aimed at improving vaccine equity including geographic targeting of vaccine supply and clinics, as well as numerous community-led efforts. Our objectives were to (1) compare primary series vaccine coverage after it was widely available, and first booster coverage 6 months after its availability, between immigrants and other Ontario residents and (2) identify subgroups experiencing low coverage. Materials and methods: Using linked immigration and health administrative data, we conducted a retrospective population-based cohort study including all community-dwelling adults in Ontario, Canada as of January 1, 2021. We compared primary series (two-dose) vaccine coverage by September 2021, and first booster (three-dose) coverage by March 2022 among immigrants and other Ontarians, and across sociodemographic and immigration characteristics. We used multivariable log-binomial regression to estimate adjusted risk ratios (aRR). Results: Of 11,844,221 adults, 22% were immigrants. By September 2021, 72.6% of immigrants received two doses (vs. 76.4%, other Ontarians) and by March 2022 46.1% received three doses (vs. 58.2%). Across characteristics, two-dose coverage was similar or slightly lower, while three-dose coverage was much lower, among immigrants compared to other Ontarians. Across neighborhood SARS-CoV-2 risk deciles, differences in two-dose coverage were smaller in higher risk deciles and larger in the lower risk deciles; with larger differences across all deciles for three-dose coverage. Compared to other Ontarians, immigrants from Central Africa had the lowest two-dose (aRR = 0.60 [95% CI 0.58-0.61]) and three-dose coverage (aRR = 0.36 [95% CI 0.34-0.37]) followed by Eastern Europeans and Caribbeans, while Southeast Asians were more likely to receive both doses. Compared to economic immigrants, resettled refugees and successful asylum-claimants had the lowest three-dose coverage (aRR = 0.68 [95% CI 0.68-0.68] and aRR = 0.78 [95% CI 0.77-0.78], respectively). Conclusion: Two dose coverage was more equitable than 3. Differences by immigrant region of birth were substantial. Community-engaged approaches should be re-invigorated to close gaps and promote the bivalent booster.

Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial.

Importance: Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care. Objective: To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care. Design, Setting, and Participants: This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months. Intervention: Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care. Main Outcomes and Measures: Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost. Results: Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01). Conclusions and Relevance: The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions. Trial Registration: ClinicalTrials.gov Identifier: NCT02928757.

Health Care Use and System Costs Among Pediatric Refugees in Canada.

BACKGROUND: Resettled refugees land in Canada through 3 sponsorship models with similar health insurance and financial supports but differences in how resettlement is facilitated. We examined whether health system utilization, costs, and aggregate 1-year morbidity differed by resettlement model. METHODS: Population-based matched cohort study in Ontario, 2008 to 2018, including pediatric (0-17 years) resettled refugees and matched Ontario-born peers and categorized refugees by resettlement model: (1) private sponsorship (PSRs), (2) Blended Visa Office-Referred program (BVORs), and (3) government-assisted refugee (GAR). Primary outcomes were health system utilization and costs in year 1 in Canada. Multivariable logistic regression was used to test the associations between sponsorship model and major illnesses. RESULTS: We included 23 287 resettled refugees (13 360 GARs, 1544 BVORs, 8383 PSRs) and 93 148 matched Ontario-born. Primary care visits were highest among GARs and lowest in PSRs (median visits [interquartile range], GARs 4[2-6]; BVORs 3[2-5]; PSRs 3[2-5]; P <.001). Emergency department visits and hospitalizations were more common among GARs and BVORs versus PSRs (emergency department: GARs 19.2%; BVORs 23.4%; PSRs 13.8%; hospitalizations: GARs 2.5%; BVORs 3.2%; PSRs 1.1%, P <.001). Mean 1-year health system costs were highest among GARs (mean [standard deviation] $1278 [$7475]) and lowest among PSRs ($555 [$2799]; Ontario-born $851 [9226]). Compared with PSRs, GARs (adjusted odds ratio 1.63, 95% confidence interval 1.47-1.81) and BVORs (adjusted odds ratio 1.52, 95% confidence interval 1.26-1.84) were more likely to have major illnesses. CONCLUSIONS: Health care use and morbidity of PSRs suggests they are healthier and less costly than GARs and BVOR model refugees. Despite a greater intensity of health care utilization than Ontario-born, overall excess demand on the health system for all resettled refugee children is low.

Pediatric primary care in Ontario and Manitoba after the onset of the COVID-19 pandemic: a population-based study.

BACKGROUND: There were large disruptions to health care services after the onset of the COVID-19 pandemic. We sought to describe the extent to which pandemic-related changes in service delivery and access affected use of primary care for children overall and by equity strata in the 9 months after pandemic onset in Manitoba and Ontario. METHODS: We performed a population-based study of children aged 17 years or less with provincial health insurance in Ontario or Manitoba before and during the COVID-19 pandemic (Jan. 1, 2017-Nov. 28, 2020). We calculated the weekly rates of in-person and virtual primary care well-child and sick visits, overall and by age group, neighbourhood material deprivation level, rurality and immigrant status, and assessed changes in visit rates after COVID-19 restrictions were imposed compared to expected baseline rates calculated for the 3 years before pandemic onset. RESULTS: Among almost 3 million children in Ontario and more than 300 000 children in Manitoba, primary care visit rates declined to 0.80 (95% confidence interval [CI] 0.77-0.82) of expected in Ontario and 0.82 (95% CI 0.79-0.84) of expected in Manitoba in the 9 months after the onset of the pandemic. Virtual visits accounted for 53% and 29% of visits in Ontario and Manitoba, respectively. The largest monthly decreases in visits occurred in April 2020. Although visit rates increased slowly after April 2020, they had not returned to prerestriction levels by November 2020 in either province. Children aged more than 1 year to 12 years experienced the greatest decrease in visits, especially for well-child care. Compared to prepandemic levels, visit rates were lowest among rural Manitobans, urban Ontarians and Ontarians in low-income neighbourhoods. INTERPRETATION: During the study period, the pandemic contributed to rapid, immediate and inequitable decreases in primary care use, with some recovery and a substantial shift to virtual care. Postpandemic planning must consider the need for catch-up visits, and the long-term impacts warrant further study.

Health Care Use and Costs of Children, Adolescents, and Young Adults With Somatic Symptom and Related Disorders.

Importance: Somatic symptom and related disorders are highly prevalent mental health disorders among young people. Presentation can be varied, and patients often face long delays and see multiple practitioners to receive a diagnosis. Objective: To evaluate the health care use and costs in a population-based sample of children and young people with somatic symptom and related disorders in Ontario, Canada. Design, Setting, and Participants: This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal single-payer health insurance plan. Participants included children aged 4 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 to 24 years residing in Ontario, Canada, during the period of April 1, 2008, to March 31, 2015. Included participants had a first health record diagnosis of somatic symptom and related disorders and were grouped based on the setting of their index somatic symptom and related disorders contact: outpatient, emergency department, or inpatient. Data were analyzed from August 1, 2017, to February 1, 2018. Exposures: One year before and 1 year after diagnosis of somatic symptom and related disorders. Main Outcomes and Measures: Outcome measures included overall and mental health-specific ambulatory and acute care visits and overall health system costs and sector-specific costs. Results: A total of 33 272 patients (median [interquartile range {IQR}] age, 20 [16-22] years; 17 387 female [52.3%]) were included in the analysis. Among these patients, 3875 (11.6%) were aged 4 to 12 years, 7273 (21.9%) were aged 13 to 17 years, and 22 124 (66.5%) were aged 18 to 24 years. A total of 17 893 (53.8%) had their index visit as outpatients, whereas 13 310 (40.0%) and 2069 (6.2%) were diagnosed in the emergency department and inpatient settings, respectively. Ambulatory physician visits were frequent and persisted 1 year after diagnosis within each setting (before vs after 1 year, median [IQR] visits, inpatient setting: 7 [3-13] vs 7 [3-13]; emergency department setting: 4 [2-8] vs 4 [2-9]; outpatient setting: 3 [1-7] vs 4 [2-7]; P < .001). After diagnosis, many did not receive physician-delivered mental health care (35.3% [730 of 2069] in an inpatient setting, 59.1% [7866 of 13 310] in an emergency department setting, 58.5% [10 467 of 17 893] in an outpatient setting; P < .001). Acute care use was frequent and remained so after diagnosis across settings. Of those hospitalized as inpatients at diagnosis, 37.7% (779 of 2069) were readmitted within 1 year. Mean (SD) 2-year patient costs were CAD$9845 ($39 725) (median [IQR], $2401 [$960-$7019]). Hospitalized patients had a 2-year mean (SD) cost of $51 424 ($100 416) (median [IQR], $21 997 [$12 510-$45 841]) per-patient expenditure. Conclusion and Relevance: This study found that children and young people with somatic symptom and related disorders frequently used the health system with substantial health system costs before and after diagnosis. Many of these patients did not receive physician-delivered mental health care. These findings suggest that this population may be under-recognized, and initiatives for early recognition and engagement with mental health support may be warranted.

Implementation of a Physician Incentive Program for 18-Month Developmental Screening in Ontario, Canada.

OBJECTIVES: To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada. STUDY DESIGN: Population-based cohort study using linked administrative data of children (17-24 months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics. RESULTS: Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5 years in practice vs ≥21 years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening. CONCLUSIONS: In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

Comorbidity and its relationship with health service use and cost in community-living older adults with diabetes: A population-based study in Ontario, Canada.

AIMS: This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs. METHODS: This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services. RESULTS: There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities. CONCLUSIONS: Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning.

Patterns of health service use in community living older adults with dementia and comorbid conditions: a population-based retrospective cohort study in Ontario, Canada.

BACKGROUND: Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization. METHODS: This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts). RESULTS: Nearly all, 96.3 %, had at least one comorbid condition, while 18.4 % had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8 %), and arthritis (66.2 %). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity. CONCLUSIONS: Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community.

Increasing comorbidity and health services utilization in older adults with prior stroke.

OBJECTIVE: To characterize comorbid chronic conditions, describe health services use, and estimate health care costs among community-dwelling older adults with prior stroke. METHODS: This is a retrospective cohort study using administrative data from Ontario, Canada. We identified all community-dwelling individuals aged 66 and over on April 1, 2008 (baseline), who had experienced a stroke at least 6 months prior. We estimated the prevalence of 14 comorbid conditions at baseline; we captured all physician visits, emergency department visits, hospital admissions, home care contacts, and associated costs over 5 years stratifying by number of comorbid conditions. Where possible, we distinguished between health services use for stroke- and non-stroke-related reasons. RESULTS: A total of 29,673 individuals met our criteria. Only 1% had no comorbid conditions, while 74.9% had 3 or more. The most common conditions were hypertension (89.8%) and arthritis (65.8%); 5 other conditions had a prevalence of 20% or more (ischemic heart disease, diabetes, chronic obstructive pulmonary disease, inflammatory bowel disease, and dementia). Use of all health services doubled with increasing comorbidity and was largely attributed to non-stroke-related reasons. Total and per-patient costs increased with comorbidity. Main cost drivers shifted from physician and home care visits to hospital admissions with greater comorbidity. CONCLUSIONS: Our findings demonstrate the importance of community-based patient-centered care strategies for stroke survivors that address their range of health needs and prevent more costly acute care use.

Health Care Use During Transfer to Adult Care Among Youth With Chronic Conditions.

OBJECTIVE: To compare health care use and costs for youth with chronic health conditions before and after transfer from pediatric to adult health care services. METHODS: Youth born in Ontario, Canada, between April 1, 1989, and April 1, 1993, were assigned to 11 mutually exclusive, hierarchically arranged clinical groupings, including "complex" chronic conditions (CCCs), non-complex chronic conditions (N-CCCs), and chronic mental health conditions (CMHCs). Outcomes were compared between 2-year periods before and after transfer of pediatric services, the subjects' 18th birthday. RESULTS: Among 104,497 youth, mortality was highest in those with CCCs, but did not increase after transfer (1.3% vs 1.5%, P = .55). Costs were highest among youth with CCCs and decreased after transfer (before and after median [interquartile range]: $4626 [1253-21,435] vs $3733 [950-16,841], P < .001);Costs increased slightly for N-CCCs ($569 [263-1246] vs $589 [262-1333], P < .001), and decreased for CMHCs ($1774 [659-5977] vs $1545 [529-5128], P < .001). Emergency department visits increased only among youth with N-CCCs (P < .001). High-acuity emergency department visits increased CCCs (P = .04) and N-CCCs (P < .001), but not for CMHC (P = .59), who had the highest visit rate. Among the 11 individual conditions, costs only increased in youth with asthma (P < .001), and decreased (P < .05) in those with neurologic impairment, lupus, inflammatory bowel disease, and mood/affective disorders. CONCLUSIONS: Pediatric transfer to adult care is characterized by relatively stable short-term patterns of health service use and costs among youth with chronic conditions.