Characterizing worker compensation claims in long-term care and examining the association between facility characteristics and severe injury: a repeated cross-sectional study from Alberta, Canada.

BACKGROUND: Despite the physical demands and risks inherent to working in long-term care (LTC), little is known about workplace injuries and worker compensation claims in this setting. The purpose of this study was to characterize workplace injuries in LTC and to estimate the association between worker and organizational factors on severe injury. METHODS: We used a repeated cross-sectional design to examine worker compensation claims between September 1, 2014 and September 30, 2018 from 25 LTC homes. Worker compensation claim data came from The Workers Compensation Board of Alberta. LTC facility data came from the Translating Research in Elder Care program. We used descriptive statistics to characterize the sample and multivariable logistic regression to estimate the association between staff, organizational, and resident characteristics and severe injury, measured as 31+ days of disability. RESULTS: We examined 3337 compensation claims from 25 LTC facilities. Less than 10% of claims (5.1%, n = 170) resulted in severe injury and most claims did not result in any days of disability (70.9%, n = 2367). Most of the sample were women and over 40 years of age. Care aides were the largest occupational group (62.1%, n = 2072). The highest proportion of claims were made from staff working in voluntary not for profit facilities (41.9%, n = 1398) followed by public not for profit (32.9%, n = 1098), and private for profit (n = 25.2%, n = 841). Most claims identified the nature of injury as traumatic injuries to muscles, tendons, ligaments, or joints. In the multivariable logistic regression, higher staff age (50-59, aOR: 2.26, 95% CI 1.06-4.83; 60+, aOR: 2.70, 95% CI 1.20-6.08) was associated with more severe injury, controlling for resident acuity and other organizational staffing factors. CONCLUSIONS: Most claims were made by care aides and were due to musculoskeletal injuries. In LTC, few worker compensation claims were due to severe injury. More research is needed to delve into the specific features of the LTC setting that are related to worker injury.

Retrospective cross-sectional study examining the association between loneliness and unmet healthcare needs among middle-aged and older adults using the Canadian Longitudinal Study of Aging (CLSA).

OBJECTIVES: Our primary objective was to estimate the association between loneliness and unmet healthcare needs and if the association changes when adjusted for demographic and health factors. Our secondary objective was to examine the associations by gender (men, women, gender diverse). DESIGN, SETTING, PARTICIPANTS: Retrospective cross-sectional data from 44 423 community-dwelling Canadian Longitudinal Study on Aging participants aged 45 years and older were used. PRIMARY OUTCOME MEASURE: Unmet healthcare needs are measured by asking respondents to indicate (yes, no) if there was a time when they needed healthcare in the last 12 months but did not receive it. RESULTS: In our sample of 44 423 respondents, 8.5% (n=3755) reported having an unmet healthcare need in the previous 12 months. Lonely respondents had a higher percentage of unmet healthcare needs (14.4%, n=1474) compared with those who were not lonely (6.7%, n=2281). Gender diverse had the highest percentage reporting being lonely and having an unmet healthcare need (27.3%, n=3), followed by women (15.4%, n=887) and men (13.1%, n=583). In our logistic regression, lonely respondents had higher odds of having an unmet healthcare need in the previous 12 months than did not lonely (adjusted odd ratios (aOR) 1.80, 95% CI 1.64 to 1.97), adjusted for other covariates. In the gender-stratified analysis, loneliness was associated with a slightly greater likelihood of unmet healthcare needs in men (aOR 1.90, 95% CI 1.64 to 2.19) than in women (aOR 1.73, 95% CI 1.53 to 1.95). In the gender diverse, loneliness was also associated with increased likelihood of having an unmet healthcare need (aOR 1.38, 95% CI 0.23 to 8.29). CONCLUSIONS: Loneliness was related to unmet healthcare needs in the previous 12 months, which may suggest that those without robust social connections experience challenges accessing health services. Gender-related differences in loneliness and unmet needs must be further examined in larger samples.

The Aging, Community and Health Research Unit Community Partnership Program (ACHRU-CPP) for older adults with diabetes and multiple chronic conditions: study protocol for a randomized controlled trial.

BACKGROUND: Older adults (≥65 years) with diabetes and multiple chronic conditions (MCC) (> 2 chronic conditions) experience reduced function and quality of life, increased health service use, and high mortality. Many community-based self-management interventions have been developed for this group, however the evidence for their effectiveness is limited. This paper presents the protocol for a randomized controlled trial (RCT) comparing the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) to usual care in older adults with diabetes and MCC and their caregivers. METHODS: We will conduct a cross-jurisdictional, multi-site implementation-effectiveness type II hybrid RCT. Eligibility criteria are: ≥65 years, diabetes diagnosis (Type 1 or 2) and at least one other chronic condition, and enrolled in a primary care or diabetes education program. Participants will be randomly assigned to the intervention (ACHRU-CPP) or control arm (1:1 ratio). The intervention arm consists of home/telephone visits, monthly group wellness sessions, multidisciplinary case conferences, and system navigation support. It will be delivered by registered nurses and registered dietitians/nutritionists from participating primary care or diabetes education programs and program coordinators from community-based organizations. The control arm consists of usual care provided by the primary care setting or diabetes education program. The primary outcome is the change from baseline to 6 months in mental functioning. Secondary outcomes will include, for example, the change from baseline to 6 months in physical functioning, diabetes self-management, depressive symptoms, and cost of use of healthcare services. Analysis of covariance (ANCOVA) models will be used to analyze all outcomes, with intention-to-treat analysis using multiple imputation to address missing data. Descriptive and qualitative data from older adults, caregivers and intervention teams will be used to examine intervention implementation, site-specific adaptations, and scalability potential. DISCUSSION: An interprofessional intervention supporting self-management may be effective in improving health outcomes and client/caregiver experience and reducing service use and costs in this complex population. This pragmatic trial includes a scalability assessment which considers a range of effectiveness and implementation criteria to inform the future scale-up of the ACHRU-CPP. TRIAL REGISTRATION: Clinical Trials.gov Identifier NCT03664583 . Registration date: September 10, 2018.

Resident loneliness, social isolation and unplanned emergency department visits from supportive living facilities: a population-based study in Alberta, Canada.

BACKGROUND: Supportive living (SL) facilities are intended to provide a residential care setting in a less restrictive and more cost-effective way than nursing homes (NH). SL residents with poor social relationships may be at risk for increased health service use. We describe the demographic and health service use patterns of lonely and socially isolated SL residents and to quantify associations between loneliness and social isolation on unplanned emergency department (ED) visits. METHODS: We conducted a retrospective cohort study using population-based linked health administrative data from Alberta, Canada. All SL residents aged 18 to 105 years who had at least one Resident Assessment Instrument-Home Care (RAI-HC) assessment between April 1, 2013 and March 31, 2018 were observed. Loneliness and social isolation were measured as a resident indicating that he/she feels lonely and if the resident had neither a primary nor secondary caregiver, respectively. Health service use in the 1 year following assessment included unplanned ED visits, hospital admissions, admission to higher levels of SL, admission to NH and death. Multivariable Cox proportional hazard models examined the association between loneliness and social isolation on the time to first unplanned ED visit. RESULTS: We identified 18,191 individuals living in Alberta SL facilities. The prevalence of loneliness was 18% (n = 3238), social isolation was 4% (n = 713). Lonely residents had the greatest overall health service use. Risk of unplanned ED visit increased with loneliness (aHR = 1.10, 95% CI: 1.04-1.15) but did not increase with social isolation (aHR = 0.95, 95% CI: 0.84-1.06). CONCLUSIONS: Lonely residents had a different demographic profile (older, female, cognitively impaired) from socially isolated residents and were more likely to experience an unplanned ED visit. Our findings suggest the need to develop interventions to assist SL care providers with how to identify and address social factors to reduce risk of unplanned ED visits.

Management of Sleep Disorders in Community-Dwelling Older Women and Men at the Time of Diagnosis.

OBJECTIVES: Sedative and hypnotic medications are associated with harm, and guidelines suggest limiting their use. Only limited evidence has described how older adults are managed following an initial sleep disorder diagnosis. We aimed to describe clinical management patterns of sleep disorders in older women and men at the time of initial diagnosis. DESIGN: Population-based retrospective cohort study using linked administrative databases. SETTING: Ontario, Canada. PARTICIPANTS: Community-dwelling adults aged 66 and older, diagnosed with a new sleep disorder by a primary care provider (n = 30 729; 56% women and 44% men). We compared women and men for each outcome. MEASUREMENTS: The primary outcome was prescription of a medication used for sleep within 30 days of a new sleep disorder diagnosis. Additional analysis included medical investigations such as sleep studies and visits to specialists who manage obstructive sleep disorders within 90 days of diagnosis. RESULTS: Among the 30 729 older adults with a new sleep disorder diagnosis, 5512 (17.9% total; 18.8% of women and 16.9% of men) were prescribed a medication used for sleep. Compared with men, women were somewhat more likely to be prescribed at least one sedative medication (adjusted odds ratio = 1.09; 95% confidence interval = 1.03-1.16). A total of 2573 (8.4%) older adults underwent a sleep study, and 3743 (12.2%) were evaluated by a specialist; both occurred more commonly in men. CONCLUSION: In our cohort, almost 1 in 5 older adults with a new sleep disorder diagnosis were prescribed a medication used for sleep; of these, a higher proportion were women. Comparatively few older adults were further evaluated; of these, a higher proportion were men. Our study highlights the high rates at which medications are prescribed to older adults with a new sleep disorder diagnosis and identifies potential sex differences in the management of such diagnoses. J Am Geriatr Soc 1-8, 2019. J Am Geriatr Soc 67:2094-2101, 2019.

Insights on multimorbidity and associated health service use and costs from three population-based studies of older adults in Ontario with diabetes, dementia and stroke.

BACKGROUND: Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period. METHODS: We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs. RESULTS: We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts. CONCLUSIONS: Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused.

Key factors to consider when measuring multimorbidity: Results from an expert panel and online survey.

BACKGROUND: There are multiple multimorbidity measures but little consensus on which measures are most appropriate for different circumstances. OBJECTIVE: To share insights gained from discussions with experts in the fields of ageing research and multimorbidity on key factors to consider when measuring multimorbidity. DESIGN: Descriptive study of expert opinions on multimorbidity measures, informed by literature to identify available measures followed by a face-to-face meeting and an online survey. RESULTS: The expert group included clinicians, researchers and policymakers in Canada with expertise in the fields of multimorbidity and ageing. Of the 30 experts invited, 15 (50%) attended the in-person meeting and 14 (47%) responded to the subsequent online survey. Experts agreed that there is no single multimorbidity measure that is suitable for all research studies. They cited a number of factors that need to be considered in selecting a measure for use in a research study including: (1) fit with the study purpose; (2) the conditions included in multimorbidity measures; (3) the role of episodic conditions or diseases; and (4) the role of social factors and other concepts missing in existing approaches. CONCLUSIONS: The suitability of existing multimorbidity measures for use in a specific research study depends on factors such as the purpose of the study, outcomes examined and preferences of the involved stakeholders. The results of this study suggest that there are areas that require further building out in both the conceptualization and measurement of multimorbidity for the benefit of future clinical, research and policy decisions.

Effect of socio-demographic factors on the association between multimorbidity and healthcare costs: a population-based, retrospective cohort study.

OBJECTIVES: To estimate the attributable costs of multimorbidity and assess whether the association between the level of multimorbidity and health system costs varies by socio-demographic factors in young (<65 years) and older (≥65 years) adults living in Ontario, Canada. DESIGN: A population-based, retrospective cohort study SETTING: The province of Ontario, Canada PARTICIPANTS: 6 639 089 Ontarians who were diagnosed with at least one of 16 selected medical conditions on 1 April 2009. MAIN OUTCOME MEASURES: From the perspective of the publicly funded healthcare system, total annual healthcare costs were derived from linked provincial health administrative databases using a person-level costing method. We used generalised linear models to examine the association between the level of multimorbidity and healthcare costs and the extent to which socio-demographic variables modified this association. RESULTS: Attributable total costs of multimorbidity ranged from C$377 to C$2073 for young individuals and C$1026 to C$3831 for older adults. The association between the degree of multimorbidity and healthcare costs was significantly modified by age (p<0.001), sex (p<0.001) and neighbourhood income (p<0.001) in both age groups, and the positive association between healthcare costs and levels of multimorbidity was statistically stronger for older than younger adults. For individuals aged 65 years or younger, the increase in healthcare costs was more gradual in women than in their male counterparts, however, for those aged 65 years or older, the increase in healthcare costs was significantly greater among women than men. Lastly, we also observed that the positive association between the level of multimorbidity and healthcare costs was significantly greater at higher levels of marginalisation. CONCLUSION: Socio-demographic factors are important effect modifiers of the relationship between multimorbidity and healthcare costs and should therefore be considered in any discussion of the implementation of healthcare policies and the organisation of healthcare services aimed at controlling healthcare costs associated with multimorbidity.

The ACHRU-CPP versus usual care for older adults with type-2 diabetes and multiple chronic conditions and their family caregivers: study protocol for a randomized controlled trial.

BACKGROUND: Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends). METHODS/DESIGN: The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration. DISCUSSION: This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014.

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.

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.

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.

Comorbidity Burden and Health Services Use in Community-Living Older Adults with Diabetes Mellitus: A Retrospective Cohort Study.

OBJECTIVES: Diabetes frequently coexists with other conditions, resulting in poorer diabetes self-management and quality of life, higher risk for diabetes-related complications and higher health service use compared to those with diabetes only. Few Canadian studies have undertaken a comprehensive, population-level analysis of comorbidity and health service utilization by older adults with diabetes. This study examined comorbidity and its association with a broad range of health services in a cohort of community-dwelling older adults with diabetes in Ontario, Canada. METHODS: We linked multiple administrative databases to create a cohort of 448,736 older adults with diabetes, described their comorbidities and obtained their 1-year use of health services (physician visits, emergency department visits, inpatient hospital admissions, home care use, nursing home admissions). We examined comorbidity patterns by age and gender and estimated the prevalence of 20 comorbid conditions and the most common condition clusters. The association between number of comorbidities and health service use was also examined. RESULTS: More than 90% of the cohort had at least 1 comorbid condition. The number of comorbidities increased with age for both genders, and hypertension was the most common, affecting 79.1% of the cohort. Other common conditions included other cardiovascular conditions, ischemic heart disease, arthritis and anxiety. Utilization of all health services increased with the number of comorbid conditions. CONCLUSIONS: Health service use was driven by the number of comorbid conditions, including diabetes and nondiabetes-related conditions, highlighting the importance of aligning diabetes care plans with patients' comorbidities.

Absence of a Socioeconomic Gradient in Older Adults' Survival with Multiple Chronic Conditions.

BACKGROUND: Individuals of low socioeconomic status experience a disproportionate burden of chronic conditions; however it is unclear whether chronic condition burden affects survival differently across socioeconomic strata. METHODS: This retrospective cohort study used health administrative data from all residents of Ontario, Canada aged 65 to 105 with at least one of 16 chronic conditions on April 1, 2009 (n = 1,518,939). Chronic condition burden and unadjusted mortality were compared across neighborhood income quintiles. Multivariable Cox proportional hazards models were used to examine the effect of number of chronic conditions on two-year survival across income quintiles. FINDINGS: Prevalence of five or more chronic conditions was significantly higher among older adults in the poorest neighborhoods (18.2%) than the wealthiest (14.3%) (Standardized difference > 0·1). There was also a socioeconomic gradient in unadjusted mortality over two years: 10.1% of people in the poorest neighborhoods died compared with 7.6% of people in the wealthiest neighborhoods. In adjusted analyses, having more chronic conditions was associated with a statistically significant increase in hazard of death over two years, however the magnitude of this effect was comparable across income quintiles. Individuals in the poorest neighborhoods with four chronic conditions had 2.07 times higher hazard of death (95% CI: 1.97-2.19) than those with one chronic condition, but this was comparable to the hazard associated with four chronic conditions in the wealthiest neighborhoods (HR: 2.29, 95% CI: 2.16-2.43). INTERPRETATION: Among older adults with universal access to health care, the deleterious effect of increasing chronic condition burden on two-year hazard of death was consistent across neighborhood income quintiles once baseline differences in condition burden were accounted for. This may be partly attributable to equal access to, and utilization of, health care. Alternate explanations for these findings, including study limitations, are also discussed.

Adherence to osteoporosis pharmacotherapy is underestimated using days supply values in electronic pharmacy claims data.

PURPOSE: Days supply (prescription duration) values are commonly used to estimate drug exposure and quantify adherence to therapy, yet accuracy is not routinely assessed, and potential inaccurate reporting has been previously identified. We examined the impact of cleaning days supply values on the measurement of adherence to oral bisphosphonates. METHODS: We identified new users of oral bisphosphonates among Ontario seniors (April 2001-March 2011). Days supply values were examined by dose, and we identified misclassification by comparing observed values to dose-specific expected values. Days supply values not matching expected values were cleaned using dose-specific algorithms. One-year adherence to therapy was defined using measures of compliance (mean proportion of days covered [PDC], and categorized into high [PDC ≥ 80%], medium [50% < PDC < 80%], low [PDC ≤ 50%]) and persistence (30-day permissible gap). Estimates were compared using the observed and cleaned days supply values, stratified by site of patient residence (community or long-term care [LTC]). RESULTS: We identified 337 729 (5% LTC) eligible new users. Among LTC patients, adherence estimates increased significantly following data cleaning: mean PDC (59 to 83%), proportion with high compliance (47 to 76%), and proportion persisting with therapy (62 to 78%). Modest increases were identified among community-dwelling patients following data cleaning (mean PDC, 71 to 74%; high compliance, 54 to 58%; and persistence, 56 to 61%). CONCLUSIONS: Data cleaning to correct for exposure misclassification can influence estimates of adherence with oral bisphosphonate therapy, particularly in LTC. Results highlight the importance of developing data cleaning strategies to correct for exposure misclassification and improve transparency in pharmacoepidemiologic studies.

Demographic characteristics and healthcare use of centenarians: a population-based cohort study.

OBJECTIVES: To better understand how centenarians use the healthcare system as an important step toward improving their service delivery. DESIGN: Population-based retrospective cohort study using linked health administrative data. SETTING: Ontario--Canada's largest province. PARTICIPANTS: All individuals living in Ontario aged 65 and older on April 1 of each year between 1995 and 2010 were identified and divided into three age groups (65-84, 85-99, ≥ 100). A detailed description was obtained on 1,842 centenarians who were alive on April 1, 2010. MEASUREMENTS: Sociodemographic characteristics and use of health services. RESULTS: The number of centenarians increased from 1,069 in 1995 to 1,842 in 2010 (72.3%); 6.7% were aged 105 and older. Over the same period, the number of individuals aged 85 to 99 grew from 119,955 to 227,703 (89.8%). Women represented 85.3% of all centenarians and 89.4% of those aged 105 and older. Almost half of centenarians lived in the community (20.0% independently, 25.3% with publicly funded home care). Preventive drug therapies (bisphosphonates and statins) were frequently dispensed. In the preceding year, 18.2% were hospitalized and 26.6% were seen in an emergency department. More than 95% saw a primary care provider, and 5.3% saw a geriatrician. CONCLUSION: The number of centenarians in Ontario increased by more than 70% over the last 15 years, with even greater growth among older people who could soon become centenarians. Almost half of centenarians live in the community, most are women, and almost all receive care from a primary care physician.

Adverse events associated with hospitalization or detected through the RAI-HC assessment among Canadian home care clients.

BACKGROUND: The occurrence of adverse events (AEs) in care settings is a patient safety concern that has significant consequences across healthcare systems. Patient safety problems have been well documented in acute care settings; however, similar data for clients in home care (HC) settings in Canada are limited. The purpose of this Canadian study was to investigate AEs in HC, specifically those associated with hospitalization or detected through the Resident Assessment Instrument for Home Care (RAI-HC). METHOD: A retrospective cohort design was used. The cohort consisted of HC clients from the provinces of Nova Scotia, Ontario, British Columbia and the Winnipeg Regional Health Authority. RESULTS: The overall incidence rate of AEs associated with hospitalization ranged from 6% to 9%. The incidence rate of AEs determined from the RAI-HC was 4%. Injurious falls, injuries from other than fall and medication-related events were the most frequent AEs associated with hospitalization, whereas new caregiver distress was the most frequent AE identified through the RAI-HC. CONCLUSION: The incidence of AEs from all sources of data ranged from 4% to 9%. More resources are needed to target strategies for addressing safety risks in HC in a broader context. Tools such as the RAI-HC and its Clinical Assessment Protocols, already available in Canada, could be very useful in the assessment and management of HC clients who are at safety risk.

Characteristics of older adults hospitalized in acute psychiatric units in ontario: a population-based study.

OBJECTIVE: As the numbers of older adults in Canada increases, there will be a growing need for mental health services for this population. Acute psychiatric units (APUs) provide inpatient psychiatric services for the management of serious mental illness. Understanding the characteristics of older adults in APUs is necessary to determine the range of inpatient services required for this population. METHOD: We conducted a population-based study of all adults discharged from APUs in Ontario in a 2-year period, 2008-2010, using administrative databases. We compared the characteristics of older adults (aged 66 years and older) in APUs to those of younger adults (aged 18 to 65 years), including sociodemographics, psychiatric and medical diagnoses, and measures of cognition and functioning. RESULTS: There were a total of 79 352 discharges from APUs, with older adults accounting for 8.8% of all discharges. Depressive disorder was the most common diagnosis, both in older and in younger populations (32.1% and 29.9%, respectively), while dementia accounted for 19.5% of discharges for older adults. Older adults, compared with younger adults, were more likely to have 2 or more chronic medical conditions (83.8% and 20.5%, respectively), significant cognitive impairment (47.0% and 14.5%, respectively), and moderate-to-severe functional impairment (21.8% and 3.3%, respectively). CONCLUSIONS: Older adults in APUs are a complex group, with mental health and medical care needs that differ from younger adults. APUs must be able to provide adequate psychiatric, medical, and interprofessional services to achieve optimal outcomes. Future studies are required to understand the quality of care and outcomes for older adults in APUs.

Short-term exposure to antidepressant drugs and risk of acute angle-closure glaucoma among older adults.

Acute angle-closure glaucoma (AACG) is an ocular emergency that may be precipitated by certain types of medications. Antidepressant drugs can affect a number of neurotransmitters, which are involved in the regulation of the iris, which may precipitate AACG. We used a case-crossover study design to investigate the association between recent exposure to antidepressant drugs and AACG. We identified patients with AACG among adults aged 66 years or older between 1998 and 2010 in Ontario using linked population-based administrative databases. We identified intermittent users of antidepressant medications through prescription drug claims in the year preceding AACG. We determined antidepressant exposure in the period immediately before AACG and compared it with antidepressant exposure in 2 earlier control periods. We used conditional logistic regression to determine the odds ratio for antidepressant exposure in the hazard period compared with the control periods. A total of 6470 patients with AACG occurred during the study period. The mean age of the patients was 74.3 years, and 66% were female. Overall, 5.6% of individuals were intermittent users of antidepressant drugs in the year preceding AACG. The odds ratio for any antidepressant exposure in the period immediately preceding AACG was 1.62 (95% confidence interval, 1.16-2.26). An increased risk of AACG was also observed in several subgroups. We conclude that recent exposure to antidepressant drugs is associated with an increased risk of AACG. Clinicians should remain vigilant for the development of this uncommon but potentially serious adverse event after initiating antidepressant therapy.

Investigator experiences with financial conflicts of interest in clinical trials.

BACKGROUND: Financial conflicts of interest (fCOI) can introduce actions that bias clinical trial results and reduce their objectivity. We obtained information from investigators about adherence to practices that minimize the introduction of such bias in their clinical trials experience. METHODS: Email survey of clinical trial investigators from Canadian sites to learn about adherence to practices that help maintain research independence across all stages of trial preparation, conduct, and dissemination. The main outcome was the proportion of investigators that reported full adherence to preferred trial practices for all of their trials conducted from 2001-2006, stratified by funding source. RESULTS: 844 investigators responded (76%) and 732 (66%) provided useful information. Full adherence to preferred clinical trial practices was highest for institutional review of signed contracts and budgets (82% and 75% of investigators respectively). Lower rates of full adherence were reported for the other two practices in the trial preparation stage (avoidance of confidentiality clauses, 12%; trial registration after 2005, 39%). Lower rates of full adherence were reported for 7 practices in the trial conduct (35% to 43%) and dissemination (53% to 64%) stages, particularly in industry funded trials. 269 investigators personally experienced (n = 85) or witnessed (n = 236) a fCOI; over 70% of these situations related to industry trials. CONCLUSION: Full adherence to practices designed to promote the objectivity of research varied across trial stages and was low overall, particularly for industry funded trials.