A cohort study evaluating the association between concurrent mental disorders, mortality, morbidity, and continuous treatment retention for patients in opioid agonist treatment (OAT) across Ontario, Canada, using administrative health data.

BACKGROUND: Due to the high prevalence of mental disorders among people with opioid use disorder, the objective of this study was to determine the association between concurrent mental disorders, mortality, morbidity, and continuous treatment retention for patients in opioid agonist treatment in Ontario, Canada. METHODS: We conducted a retrospective cohort study of patients enrolled in opioid agonist treatment between January 1, 2011, and December 31, 2015. Patients were stratified into two groups: those diagnosed with concurrent mental disorders and opioid use disorder and those with opioid use disorder only, using data from the Ontario Health Insurance Plan Database, Ontario Drug Benefit Plan Database. The primary outcome studied was all-cause mortality using data from the Registered Persons Database. Emergency department visits from the National Ambulatory Care Database, hospitalizations Discharge Abstract Database, and continuous retention in treatment, defined as 1 year of uninterrupted opioid agonist treatment using data from the Ontario Drug Benefit Plan Database were measured as secondary outcomes. Encrypted patient identifiers were used to link information across databases. RESULTS: We identified 55,924 individuals enrolled in opioid agonist treatment, and 87% had a concurrent mental disorder diagnosis during this period. We observed that having a mental disorder was associated with an increased likelihood of all-cause mortality (odds ratio (OR) 1.4; 95% confidence interval (CI) 1.2-1.5). For patients diagnosed with mental disorders, the estimated rate of ED visits per year was 2.25 times higher and estimated rate of hospitalization per year was 1.67 times higher than for patients with no mental disorders. However, there was no association between having a diagnosis of a mental disorder and 1-year treatment retention in OAT-adjusted hazard ratio (HR) = 1.0; 95% CI 0.9 to 1.1. CONCLUSION: Our findings highlight the consequences of the high prevalence of mental disorders for individuals with opioid use disorder in Ontario, Canada.

The impact of benzodiazepine use in patients enrolled in opioid agonist therapy in Northern and rural Ontario.

BACKGROUND: Benzodiazepine use is common among patients in opioid agonist therapy; this puts patients at an increased risk of overdose and death. In this study, we examine the impact of baseline and ongoing benzodiazepine use, and whether patients are more likely to terminate treatment with increasing proportion of benzodiazepine positive urine samples. We also study whether benzodiazepine use differs by geographic location. METHODS: We conducted a retrospective cohort study using anonymized electronic medical records from 58 clinics offering opioid agonist therapy in Ontario. One-year treatment retention was the primary outcome of interest and was measured for patients who did and did not have a benzodiazepine positive urine sample in their first month of treatment, and as a function of the proportion of benzodiazepine-positive urine samples throughout treatment. Cox proportional hazard model was used to characterize one-year retention. RESULTS: Our cohort consisted of 3850 patients, with the average retention rate of 43.4%. Baseline benzodiazepine users had a retention rate of 39.9% and non-users had a retention rate of 44%. Patients who were benzodiazepine negative on admission benefited from an increased median days retained of 265 vs. 215 days. Patients with more than 75% of urines positive for benzodiazepines were 175% more likely to drop out of treatment than those patients with little or no benzodiazepine use. CONCLUSIONS: Baseline benzodiazepine use is predictive of decreased retention. Patients who have a higher proportion of benzodiazepine-positive urine samples are more likely to drop out of treatment compared to those who have little or no benzodiazepine detection in their urine.

Natural resource-based industries and prostate cancer risk in Northeastern Ontario: a case-control study.

OBJECTIVE: Prostate cancer continues to be the most commonly diagnosed cancer in men, and there is limited knowledge on its preventable risk factors. A number of occupational exposures in natural resource-based industries are suspected to be related to prostate cancer risk. This study investigates associations between employment in these industries and prostate cancer. METHODS: Data were from a population-based, case-control study previously conducted in Northeastern Ontario. Incident cases (N=760) aged 45-85 years and diagnosed with prostate cancer between 1995 and 1998 were identified from the Ontario Cancer Registry. Controls (N=1632) were recruited using telephone listings, and were frequency matched to cases by age. Lifetime occupational history was collected for all participants. Logistic regression was used to estimate ORs and their associated 95% CIs. RESULTS: Elevated risks were observed for employment in forestry and logging industries (OR=1.87, 95% CI 1.32 to 2.73) and occupations (OR=1.71, 95% CI 1.24 to 2.35), and these risks increased with duration of employment for ≥10 years. Elevated risks were also found for employment in wood products industries (OR=1.45, 95% CI 1.07 to 1.97), and paper and allied products industries (OR=1.43, 95% CI 1.03 to 2.00), and when duration of employment was ≥10 years. There were also elevated risks in agriculture and mining-related work; however, these findings were not consistent across industry and occupation categories. CONCLUSIONS: Prostate cancer risk may be associated with work in several natural resource industries, primarily in the forest industries. To further evaluate observed associations, studies should focus on natural resource-based exposures in larger populations with improved exposure assessment.

A "Simple" Evidence-Based Intervention to Improve Care Transitions for Frail Patients with Complex Health Conditions: Why Didn't It Work as Expected?

The transition from hospital to home is a vulnerable period for patients with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Care transition interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. A study was undertaken to evaluate the effectiveness of a care transition intervention involving a hand-off between a hospital-based care transitions nurse and a community-based rapid response nurse. Two focus groups were held, one involving rapid response nurses and the other involving care transition nurses. Individual interviews were conducted with the managers (n = 2) and executives (n = 2) to identify the factors that facilitated or were barriers to its implementation. Using thematic content analysis, it was found that the effectiveness of transitional coordination efforts was thwarted by ineffective communication, which affected the quality of the underlying relationships between the two teams. Other barriers to achieving the desired outcomes included the following: issues of role clarity, role awareness and acceptance, the adequacy and reinforcement of coordinating mechanisms, the effectiveness of the information exchange protocols and the absence of shared measures of accountability. Clinical integration initiatives have fewer human resource and financial implementation barriers compared with organizational integration efforts but are complex undertakings requiring clear alignment between organizations, shared accountability measures, effective communication processes and relationships of trust and respect between interprofessional teams.

Transition processes through a longitudinal integrated clerkship: a qualitative study of medical students' experiences.

CONTEXT: This paper describes the transition processes experienced by Year 3 medical students during their longitudinal integrated clerkship (LIC). The authors conceptualise the stages that encompass the transition through a LIC. OBJECTIVES: The purpose of this study was to understand the perspectives of 12 Northern Ontario School of Medicine (NOSM) Year 3 medical students about their transition process. METHODS: Data were collected longitudinally through three conversational interviews with each of these students, occurring before, during and after the clerkship. The authors used a guided walk methodology to explore students' everyday lives and elicit insights about the transition process, prompted by the locations and clinical settings in which the clerkship occurred. RESULTS: Participants identified three interconnected stages in the transition process: (i) shifting from classroom to clinical learning; (ii) dealing with disorientation and restoring balance, and (iii) seeing oneself as a physician. Interview data provided evidence for the adaptive strategies the participants developed in response to these stages. CONCLUSIONS: Based on these findings, the transition process during a LIC can be characterised as one of entering the unfamiliar, with few forewarnings about the changes, of experiencing moments of confusion and burnout, and of eventual gains in confidence and competence in the clinical roles of a physician. Recommendations are made regarding future research opportunities to further scholarship on transitions.

Interviewing in situ: employing the guided walk as a dynamic form of qualitative inquiry.

CONTEXT: The purpose of this paper is to provide a critical analysis of a mobile research method, the guided walk, and its potential suitability in medical education research. METHODS: The Northern Ontario School of Medicine's (NOSM) longitudinal integrated clerkship served as the research context in which the guided walk method was used to explore the lived experiences of 12 Year 3 medical students undertaking their clerkship in one of eight different communities across Northern Ontario, Canada. Informed by the social constructivist research paradigm, the guided walk method was employed to answer the research question: how do Year 3 medical students at NOSM describe their clerkship experiences as encountered in their placement and living contexts? Through an inductive thematic analysis of the data, the findings provided a rich description of the guided walk from the participants' and the researcher's perspectives. RESULTS: There were significant advantages to using the guided walk rather than other types of qualitative research approaches. The guided walk made it easier for participants to take part in the study, provided context-rich research interactions, and led to serendipitous encounters for both participants and the first author. There were also challenges and limitations associated with the guided walk method. For example, this method carries inherent challenges with reference to the safeguarding of confidentiality and anonymity for both participants and those encountered during the walk. CONCLUSIONS: The guided walk method is promising within medical education, particularly for researchers seeking to gain participants' stories in the contexts to which they refer. This method may be appropriate for use in medical education research in areas such as the evaluation and assessment of a student's clinical decision-making skills and competency development, as well as the consolidation of strategies to manage ethical and professional dilemmas.

The Lost Creek Fire: managing social relations under disaster conditions.

This paper examines some of the social processes associated with disaster conditions. Utilising an asset-based perspective of community capacity, it focuses on four types of normative systems to interpret the ability of communities to manage disasters through market-, bureaucratic-, associative-, and communal-based norms. Drawing on experience of a wildfire in the Crowsnest Pass region of southwest Alberta, Canada, in 2003, the tensions and compatibilities among these normative systems are evaluated through interviews with 30 community leaders. The results confirm the contributions of all types of social capital to resiliency, the necessity for rapid use of place-based knowledge, and the importance of communication among all types and levels of agents. In addition, they point to the value of identifying and managing potential conflicts among the normative systems as a means to maximising their contributions. The integration of local networks and groups into the more general disaster response minimised the impacts on health and property.

Workers' compensation experience in some Indigenous Northern Ontario communities.

BACKGROUND: There is a dearth of research about occupational health and safety experience in Indigenous communities and compensation applications from Indigenous workers appear limited. OBJECTIVE: This qualitative descriptive study was designed to explore workers' compensation experiences in some Canadian Indigenous communities. METHODS: A community-based participatory research approach was used to conduct focus groups (n = 25 participants) in three Northeastern Ontario (NEO) Indigenous communities and at one NEO Indigenous employment centre. Semi-structured focus group questions addressed community experience with workers' compensation, the compensation process, and discussion of a training session about the process. Reflexive thematic analysis followed Braun and Clarke procedures. RESULTS: Discussion with study participants resulted in these themes: 1) both lack of knowledge, and knowledge, about compensation demonstrated, 2) impact of lack of compensation coverage and need for universal coverage on reserve, 3) need for community training sessions about workers' compensation, 4) workload and financial impact of workers' compensation on reserve, and 5) requirement for cultural competence training in the compensation board. CONCLUSIONS: This qualitative descriptive study revealed the: need for more information about applying for workers' compensation and navigating the process, need for universal workplace insurance coverage in Indigenous communities, demand for community-based compensation process training, community costs of compensation, and the requirement for cultural safety and competence training for compensation organization employees. More education about the workers' compensation process would be of benefit to leadership, health care providers, administrative personnel, employers, and employees on reserves. Nurses in community health centres are well situated to provide further guidance.

Physical activity promotion in call centres: employers' perspectives.

This study followed a predominantly qualitative approach to explore the perspectives of employers in Sudbury, Ontario, Canada, call centres (CCs) regarding physical activity (PA) promotion in workplaces, by identifying current practices and employers' motivation to promote PA, as well as perceived facilitators and barriers. In-depth interviews were conducted with 15 managers in 10 of 12 local CCs and questionnaires were used to collect quantitative information about participants and their workplaces. Thematic analysis revealed that participants' responses to recommendations for PA promotion were generally positive and some CCs were engaged in some PA initiatives. Employers' motivations to promote PA included direct benefits to the employer, concern for employee well-being and the greater good. Barriers to PA promotion within CCs included the nature of CC work, managers' concerns regarding participation, fairness and cost and special limitations of the workspace. Results indicate additional actions and supports are required to facilitate implementation of PA in CCs according to governmental recommendations. Efforts are required to increase awareness and use of existing resources. Smaller organizations may require more assistance to promote PA than those with a larger number of employees and may benefit from enhanced interaction with existing networks and public health programs and resources.

Demographic, Lifestyle, and Physical Health Predictors of Sickness Absenteeism in Nursing: A Meta-Analysis.

BACKGROUND: Sickness absenteeism is an area of concern in nursing and is more concerning given the recent impacts of the COVID-19 pandemic on healthcare. This study is one of two meta-analyses that examined sickness absenteeism in nursing. In this study, we examined demographic, lifestyle, and physical health predictors. METHODS: We reviewed five databases (CINAHL, ProQuest Allied, ProQuest database theses, PsycINFO, and PubMed) for our search. We registered the systematic review (CRD de-identified) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Additionally, we used the Population/Intervention/Comparison/Outcome Tool to improve our searches. Results: Following quality testing, 17 articles were used for quantitative synthesis. Female employees were at higher risks of sickness absenteeism than their male counterparts (OR = 1.73; 95% CI: 1.33-2.25). Nursing staff who rated their health as poor had a greater likelihood of experiencing sickness absence (OR = 1.38; 95% CI: 1.19-1.60). Also, previous sick leave predicted future leaves (OR = 3.35; 95% CI: 1.37-8.19). Moreover, experiencing musculoskeletal pain (OR = 2.41 95% CI: 1.77-3.27) increased the likelihood of sickness absence with greater odds when it is a back pain (OR = 3.05; 95% CI: 1.66-5.62). Increased age, physical activity, and sleep were not associated with sick leave. CONCLUSION: Several variables were statistically associated with the occurrence of sickness absenteeism. One primary concern is the limited research in this area despite alarming rates of sick leave in healthcare. More research is required to identify predictors of sickness absence, and thereby, implement preventative measures.

Gold, nickel and copper mining and processing.

Ore mining occurs in all Canadian provinces and territories except Prince Edward Island. Ores include bauxite, copper, gold, iron, lead and zinc. Workers in metal mining and processing are exposed, not only to the metal of interest, but also to various other substances prevalent in the industry, such as diesel emissions, oil mists, blasting agents, silica, radon, and arsenic. This chapter examines cancer risk related to the mining of gold, nickel and copper. The human carcinogenicity of nickel depends upon the species of nickel, its concentration and the route of exposure. Exposure to nickel or nickel compounds via routes other than inhalation has not been shown to increase cancer risk in humans. As such, cancer sites of concern include the lung, and the nasal sinus. Evidence comes from studies of nickel refinery and leaching, calcining, and sintering workers in the early half of the 20th century. There appears to be little or no detectable risk in most sectors of the nickel industry at current exposure levels. The general population risk from the extremely small concentrations detectable in ambient air are negligible. Nevertheless, animal carcinogenesis studies, studies of nickel carcinogenesis mechanisms, and epidemiological studies with quantitative exposure assessment of various nickel species would enhance our understanding of human health risks associated with nickel. Definitive conclusions linking cancer to exposures in gold and copper mining and processing are not possible at this time. The available results appear to demand additional study of a variety of potential occupational and non-occupational risk factors.

Evaluation of cancer patient education and services.

On their first visit to the Regional Cancer Program, all patients are provided with the "Information for Patients and Families" binder that was designed by an interdisciplinary cancer patient education team. Patients were asked to complete a survey to evaluate the usefulness of this binder. Timely delivery of the "Information for Patients and Families" binder validates a higher level of satisfaction with oncology services because patients are better informed and this translates into a reduction of psychosocial problems. As a result of this study, a decision was made to provide the binder earlier in the patient's journey (e.g., post surgery for thoracic and brain tumor patients).

Mining-Related Lower Back Injuries and the Compensation Process: An Injured Worker's Journey.

Background: In Ontario, when an occupational injury occurs in the mining industry, there is often a need to interact with the Workplace Safety and Insurance Board (WSIB). During this process, miners experience economic, social, and mental health-related issues that can affect their overall well-being. This study aimed to determine the impact of a lower back injury and the WSIB claim process experience expressed by some male, underground miners in Sudbury, Ontario, Canada. Methods: A qualitative descriptive study design that utilized in-depth, individual qualitative interviews was conducted. Twelve male participants (underground miners) were interviewed in Sudbury, Ontario. Interviews were transcribed and thematically analyzed. Findings: The results emphasized the need for improved communication, the necessity for resources to be allocated to enhance public discussion about injury prevention, the social and economic burden that miners and their families face, and the power imbalances between injured miners and the companies that were meant to support them. Conclusion/Application to Practice: The findings indicate that several areas require improvement for an injured miner who submits a WSIB claim. Ideally, participants wanted an improved and streamlined process for reporting an injury and for WSIB claim management. These findings suggest that occupational health practices that foster a safe and healthy work environment in the mining industry must be promoted, which will help to guide future policies that enhance support for an injured worker and the WSIB claim process.

A qualitative descriptive study of underground workers who received aluminum dust treatment and its organizational level impact.

From 1943 to 1980, some underground gold and uranium workers in Ontario, Canada were required to inhale aluminum dust for silicosis prevention. Workers were exposed to the dust for up to 30 min daily. This study explored the perceived organizational impact on workers exposed to the aluminum dust treatment in Northeastern Ontario. This qualitative descriptive study included 16 respondents who participated in individual semi-structured interviews. All respondents were Northeastern Ontario workers who were exposed to aluminum dust treatment for at least 1 year. Interviews were transcribed verbatim and analyzed thematically. Themes that emerged were: 1) confidence and trust in companies, 2) lack of participants' and heath care providers' knowledge, and 3) need for compensation and formal apology. Workers' perceived that their long term health was impacted by exposure. The results will be used to help workers, companies, and unions address workplace exposures. The latest information about McIntyre powder will enhance the knowledge about the impact of the exposure.

Understanding sickness absence in nurses and personal support workers: Insights from frontline staff and key informants in Northeastern Ontario.

BACKGROUND: Nurses and personal support workers (PSWs) have high sickness absence rates in Canada. Whilst the evidence-based literature helped to identify the variables related to sickness absenteeism, understanding "why" remains unknown. This information could benefit the healthcare sector in northeastern Ontario and in locations where healthcare is one of the largest employment sectors and where nursing staff have high absence and turnover rates. OBJECTIVE: To identify and understand the factors associated with sickness absence among nurses and PSWs through several experiences while investigating if there are northern-related reasons to explain the high rates of sickness absence. METHODS: In this descriptive qualitative study, focus group sessions took place with registered nurses (n = 6), registered practical nurses (n = 4), PSWs (n = 8), and key informants who specialize in occupational health and nursing unions (n = 5). Focus group sessions were transcribed verbatim followed by inductive thematic analysis. RESULTS: Four main themes emerged, which were occupational/organizational challenges, physical health, emotional toll on mental well-being, and northern-related challenges. Descriptions of why such factors lead to sickness absence were addressed with staff shortage serving as an underlying factor. CONCLUSION: Despite the complexity of the manifestations of sickness absence, work support and timely debriefing could reduce sickness absence and by extension, staff shortage.

Evaluating the effectiveness of concurrent opioid agonist treatment and physician-based mental health services for patients with mental disorders in Ontario, Canada.

OBJECTIVE: The objective of this study was to evaluate the relationship between concurrent physician-based mental health services, all-cause mortality, and acute health service use for individuals enrolled in Opioid Agonist Treatment in Ontario, Canada. METHODS: A cohort study of patients enrolled in opioid agonist treatment in Ontario was conducted between January 1, 2011, and December 31, 2015, in Ontario with an inverse probability of treatment weights using the propensity score to estimate the effect of physician-based mental health services. Treatment groups were created based on opioid agonist treatment patients' utilization of physician-based mental health services. Propensity score weighted odds ratios were calculated to assess the relationship between the treatment groups and the outcomes of interest. The outcomes included all-cause mortality using data from the Registered Persons Database, Emergency Department visits from the National Ambulatory Care Database, and hospitalizations using data from the Discharge Abstract Database. Encrypted patient identifiers were used to link across databases. RESULTS: A total of 48,679 individuals in OAT with mental disorders. Opioid agonist treatment alone was associated with reduced odds of all-cause mortality (odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3-0.4). Patients who received mental health services from a psychiatrist and primary care physician while engaged in OAT, the estimated rate of ED visits per year was higher (OR = 1.3, 95% CI 1.2-1.4) and the rate of hospitalizations (OR = 0.5, 95% CI 0.4-0.6) than in the control group. CONCLUSION: Our findings support the view that opioid agonist treatment and concurrent mental health services can improve clinical outcomes for complex patients, and is associated with enhanced use of acute care services.

Concurrent psychiatry for patients enrolled in opioid agonist treatment: a propensity score matched cohort study in Ontario Canada.

OBJECTIVE: The objective was to characterize the relationship between geography, concurrent psychiatric services, all-cause mortality, and acute health care use for individuals enrolled in Opioid Agonist Treatment, in Ontario, Canada. METHODS: We conducted a propensity score matching study of patients enrolled in Opioid Agonist Treatment in Ontario for the first time between January 1, 2011, and December 31, 2015. We first compared outcomes between patients who were actively engaged and patients who were not actively engaged in Opioid Agonist Treatment. We created treatment and a control groups on the basis of an individual's access to psychiatric care within an episode of Opioid Agonist Treatment. Relative risk and number needed to treat were calculated to determine the correlation between psychiatric care and health outcomes among patients enrolled in Opioid Agonist Treatment at two time points within an episode of care and for two geographic regions in Ontario (north and south). RESULTS: During the first year of Opioid Agonist Treatment, concurrent psychiatric care was associated with a reduction in all-cause mortality in southern Ontario (RR 0.80, 95% CI, 0.73-0.87), a reduction in emergency department visits in both northern and southern Ontario (north: RR = 0.76, 95% CI, 0.72-0.81; south: RR = 0.87, 95% CI, 0.86-0.88), and a reduction in hospitalizations (north: RR = 0.88, 95% CI. 0.82-0.94, south: RR = 0.92, 95% CI, 0.91-0.93). CONCLUSION: Our findings have significant clinical and political implications for health system planning highlighting the need for integrated mental health and addiction services for individuals with Opioid Use Disorder.

Correction to: Concurrent psychiatry for patients enrolled in opioid agonist treatment: a propensity score matched cohort study in Ontario Canada.

Following publication of the original article [1], we have been notified that the following changes should occur in the content of the article. The details are below.

Injury mortality in a cohort of mining, smelting, and refining workers in Ontario.

Injury mortality was followed up from 1950 to 2000 in a cohort of 56,576 nickel workers. Injury fatalities were elevated throughout the cohort of never sinter plant workers (SMR = 134, 95% CI [129, 140]). Elevations were also observed in injury mortality subcategories of road, rail, and air (SMR = 137, 95% CI [127, 147]); boating and swimming (SMR = 150, 95% CI [128, 176]); suicide and possible suicide (SMR = 124, 95% CI [114, 135]); and possibly job-related accidents (SMR = 160, 95% CI [145, 175]). The results were largely attributed to underground miners, with 61.4% of all injury mortality (SMR = 162; 95% CI [153, 171]). Occupational etiology could not be ascertained; however, compiled workplace injury fatalities are presented separately. Recommendations include delivery of injury prevention and wellness programs in partnership with the local health unit and other stakeholders.