Impact of COVID-19 pandemic on prescription stimulant use among children and youth: a population-based study.

COVID-19 associated public health measures and school closures exacerbated symptoms in some children and youth with attention-deficit hyperactivity disorder (ADHD). Less well understood is how the pandemic influenced patterns of prescription stimulant use. We conducted a population-based study of stimulant dispensing to children and youth ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of stimulants occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected stimulant use. Our main outcome was the change in the monthly rate of stimulant use per 100,000 children and youth. Following an initial immediate decline of 60.1 individuals per 100,000 (95% confidence interval [CI] - 99.0 to - 21.2), the monthly rate of stimulant dispensing increased by 11.8 individuals per 100,000 (95% CI 10.0-13.6), with the greatest increases in trend observed among females, individuals in the highest income neighbourhoods, and those aged 20 to 24. Observed rates were between 3.9% (95% CI 1.7-6.2%) and 36.9% (95% CI 34.3-39.5%) higher than predicted among females from June 2020 onward and between 7.1% (95% CI 4.2-10.0%) and 50.7% (95% CI 47.0-54.4%) higher than expected among individuals aged 20-24 from May 2020 onward. Additional research is needed to ascertain the appropriateness of stimulant use and to develop strategies supporting children and youth with ADHD during future periods of long-term stressors.

Brief Report: A population-based study of the impact of the COVID-19 pandemic on benzodiazepine use among children and young adults.

The COVID-19 pandemic was associated with increases in the prevalence of depression and anxiety among children and young adults. We studied whether the pandemic was associated with changes in prescription benzodiazepine use. We conducted a population-based study of benzodiazepine dispensing to children and young adults ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in prescription benzodiazepine dispensing occurred, and interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected benzodiazepine use. A structural break occurs where there is a sudden change in the trend of a time series. We observed an immediate decline in benzodiazepine dispensing of 23.6 per 100,000 (95% confidence interval [CI]: -33.6 to -21.2) associated with a structural break in April 2020, followed by a monthly decrease in the trend of 0.3 per 100,000 (95% CI: -0.74 to 0.14). Lower than expected benzodiazepine dispensing rates were observed each month of the pandemic from April 2020 onward, with relative percent differences ranging from - 7.4% (95% CI: -10.1% to - 4.7%) to -20.9% (95% CI: -23.2% to -18.6%). Results were generally similar in analyses stratified by sex, age, neighbourhood income quintile, and urban versus rural residence. Further research is required to understand the clinical implications of these findings and whether these trends were sustained with further follow-up.

The relationship between rurality, travel time to care and death by suicide.

BACKGROUND: We previously found an association between rurality and death by suicide, where those living in rural areas were more likely to die by suicide. One potential reason why this relationship exists might be travel time to care. This paper examines the relationship between travel time to both psychiatric and general hospitals and suicide, and then determine whether travel time to care mediates the relationship between rurality and suicide. METHODS: This is a population-based nested case-control study. Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario. Suicides were captured using vital statistics. Travel time to care was calculated from the resident's home to the nearest hospital based on the postal codes of both locations. Rurality was measured using Metropolitan Influence Zones. RESULTS: For every hour in travel time a male resides from a general hospital, their risk of death by suicide doubles (AOR = 2.08, 95% CI = 1.61-2.69). Longer travel times to psychiatric hospitals also increases risk of suicide among males (AOR = 1.03, 95%CI = 1.02-1.05). Travel time to general hospitals is a significant mediator of the relationship between rurality and suicide among males, accounting for 6.52% of the relationship between rurality and increased risk of suicide. However, we also found that there is effect modification, where the relationship between travel time and suicide is only significant among males living in urban areas. CONCLUSIONS: Overall, these findings suggest that males who must travel longer to hospitals are at a greater risk of suicide compared to those who travel a shorter time. Furthermore, travel time to care is a mediator of the association between rurality and suicide among males.

Rurality as a Risk Factor for Attempted Suicide and Death by Suicide in Ontario, Canada.

OBJECTIVE: This study aims to examine rural and urban differences in attempted suicide and death by suicide in Ontario, Canada. METHOD: This is a population-based nested case-control study. Data were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario between 2007 and 2017. All adults living in Ontario who attempted suicide or died by suicide are included in the study, and controls were matched by sex and age. Suicides were captured using vital statistics. Suicide attempts were determined using emergency department service codes. RESULTS: Rurality is a risk factor for attempted suicide and death by suicide. Rural males are more likely to die by suicide compared with urban males (adjusted odds ratio(AOR) = 1.70, 95% confidence interval (CI), 1.49 to 1.95), and the odds of death by suicide increase with increasing levels of rurality. Rural males and females have an increased risk of attempted suicide compared with their urban counterparts (males: AOR = 1.37, 95% CI, 1.24 to 1.50) (females: AOR = 1.26, 95% CI, 1.14 to 1.39), with a pattern of increasing risk of suicide attempts with increasing rurality. Rural females are not at increased risk of suicide compared with urban females (AOR = 1.08, 95% CI, 0.80 to 1.45). Sensitivity analyses corroborated the results. CONCLUSIONS: Rural males are almost two times more likely to die by suicide compared with urban males, and both rural males and females have an elevated risk of suicide attempts compared with urban residents. Future research should examine potential mediators of the relationship between rurality and suicide.

Patient clustering in primary care settings: Outcomes and quality of care.

OBJECTIVE: To determine whether neighbours who share the same family physicians have better cardiovascular and health care outcomes. DESIGN: Retrospective cohort study using administrative health databases. SETTING: Ontario. PARTICIPANTS: The study population included 2,690,482 adult patients cared for by 1710 family physicians. INTERVENTIONS: Adult residents of Ontario were linked to their family physicians and the geographic distance between patients in the same panel or list was calculated. Using distance between patients within a panel to stratify physicians into quintiles of panel proximity, physicians and patients from close-proximity practices were compared with those from more-distant-proximity practices. Age- and sex-standardized incidence rates and hazard ratios from cause-specific hazards regression models were determined. MAIN OUTCOME MEASURES: The occurrence of a major cardiovascular event during a 5-year follow-up period (2008 to 2012). RESULTS: Patients of panels in the closest-proximity quintile lived an average of 3.9 km from the 10 closest patients in their panel compared with 12.4 km for the 10 closest patients of panels in the distant-proximity quintile. After adjusting for various patient and physician characteristics, patients in the most-distant-proximity practices had a 24% higher rate of cardiovascular events (adjusted hazard ratio=1.24 [95% CI 1.20 to 1.28], P<.001) than patients in the closest-proximity practices. Age- and sex-standardized all-cause mortality and total per patient health care costs were also lowest in the closest-proximity quintile. In sensitivity analyses restricted to large urban communities and to White long-term residents, results were similar. CONCLUSION: The better cardiovascular outcomes observed in close-proximity panels may be related to a previously unrecognized mechanism of social connectedness that extends the effectiveness of primary care practitioners.

Postpartum mental illness during the COVID-19 pandemic: a population-based, repeated cross-sectional study.

BACKGROUND: It is unclear whether the clinical burden of postpartum mental illness has increased during the COVID-19 pandemic. We sought to compare physician visit rates for postpartum mental illness in Ontario, Canada, during the pandemic with rates expected based on prepandemic patterns. METHODS: In this population-based, repeated cross-sectional study using linked health administrative databases in Ontario, Canada, we used negative binomial regression to model expected visit rates per 1000 postpartum people for March-November 2020 based on prepandemic data (January 2016-February 2020). We compared observed visit rates to expected visit rates for each month of the pandemic period, generating absolute rate differences, incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). The primary outcome was a visit to a primary care physician or a psychiatrist for any mental disorder. We stratified analyses by maternal sociodemographic characteristics. RESULTS: In March 2020, the visit rate was 43.5/1000, with a rate difference of 3.11/1000 (95% CI 1.25-4.89) and an IRR of 1.08 (95% CI 1.03-1.13) compared with the expected rate. In April, the rate difference (10.9/1000, 95% CI 9.14-12.6) and IRR (1.30, 95% CI 1.24-1.36) were higher; this level was generally sustained through November 2020. From April-November, we observed elevated visit rates across provider types and for diagnoses of anxiety, depressive and alcohol or substance use disorders. Observed increases from expected visit rates were greater for people 0-90 days postpartum compared with 91-365 days postpartum; increases were small among people living in low-income neighbourhoods. Public health units in the northern areas of the province did not see sustained elevations in visit rates after July; southern health units had elevated rates through to November. INTERPRETATION: Increased visits for mental health conditions among postpartum people during the first 9 months of the COVID-19 pandemic suggest an increased need for effective and accessible mental health care for this population as the pandemic progresses.

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada.

BACKGROUND: Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada. METHODS: We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers. RESULTS: Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT). CONCLUSIONS: Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.

Rurality and Risk of Suicide Attempts and Death by Suicide among People Living in Four English-speaking High-income Countries: A Systematic Review and Meta-analysis.

OBJECTIVE: Previous research indicates a potential relationship between rurality and suicide, indicating that those living in rural areas may be at increased risk of suicide. This relationship has not been reviewed systematically. This study aims to determine whether those living in rural areas are more likely to complete or attempt suicide. METHOD: This systematic review and meta-analysis included observational studies based on people living in Canada, the United States, the United Kingdom, and Australia. Data sources included PubMed, EMBASE, PsycINFO, and Google Scholar from January 2006 to December 2017. Studies must have compared rural and urban suicide or suicide attempts. Nonprimary research articles were excluded. RESULTS: A total of 6,259 studies were identified and 53 were included. Results indicate that males living in rural areas are more likely to complete suicide than their urban counterparts (RR = 1.41, 95% CI, 1.21 to 1.64, I2 = 96%). Females in rural areas are not significantly more likely to complete suicide (RR = 1.16, 95% CI, 0.98 to 1.37, I2 = 79%). Among studies that only reported combined estimates, rural individuals are more likely to complete suicide (RR = 1.22, 95% CI, 1.11 to 1.33, I2 = 98%). There is no association found between rurality and suicide attempts (RR = 0.93, 95% CI, 0.73 to 1.19, I2 = 85%). CONCLUSIONS: Those living in rural areas are more likely to complete suicide, with some studies indicating that only rural males are more likely to complete suicide; these findings are relatively consistent across all four countries. Public health initiatives should aim to overcome geographic variation in completed suicide, with a particular focus on rural males.

Association of Neighborhood Walkability With Change in Overweight, Obesity, and Diabetes.

IMPORTANCE: Rates of obesity and diabetes have increased substantially in recent decades; however, the potential role of the built environment in mitigating these trends is unclear. OBJECTIVE: To examine whether walkable urban neighborhoods are associated with a slower increase in overweight, obesity, and diabetes than less walkable ones. DESIGN, SETTING, AND PARTICIPANTS: Time-series analysis (2001-2012) using annual provincial health care (N ≈ 3 million per year) and biennial Canadian Community Health Survey (N ≈ 5500 per cycle) data for adults (30-64 years) living in Southern Ontario cities. EXPOSURES: Neighborhood walkability derived from a validated index, with standardized scores ranging from 0 to 100, with higher scores indicating more walkability. Neighborhoods were ranked and classified into quintiles from lowest (quintile 1) to highest (quintile 5) walkability. MAIN OUTCOMES AND MEASURES: Annual prevalence of overweight, obesity, and diabetes incidence, adjusted for age, sex, area income, and ethnicity. RESULTS: Among the 8777 neighborhoods included in this study, the median walkability index was 16.8, ranging from 10.1 in quintile 1 to 35.2 in quintile 5. Resident characteristics were generally similar across neighborhoods; however, poverty rates were higher in high- vs low-walkability areas. In 2001, the adjusted prevalence of overweight and obesity was lower in quintile 5 vs quintile 1 (43.3% vs 53.5%; P < .001). Between 2001 and 2012, the prevalence increased in less walkable neighborhoods (absolute change, 5.4% [95% CI, 2.1%-8.8%] in quintile 1, 6.7% [95% CI, 2.3%-11.1%] in quintile 2, and 9.2% [95% CI, 6.2%-12.1%] in quintile 3). The prevalence of overweight and obesity did not significantly change in areas of higher walkability (2.8% [95% CI, -1.4% to 7.0%] in quintile 4 and 2.1% [95% CI, -1.4% to 5.5%] in quintile 5). In 2001, the adjusted diabetes incidence was lower in quintile 5 than other quintiles and declined by 2012 from 7.7 to 6.2 per 1000 persons in quintile 5 (absolute change, -1.5 [95% CI, -2.6 to -0.4]) and 8.7 to 7.6 in quintile 4 (absolute change, -1.1 [95% CI, -2.2 to -0.05]). In contrast, diabetes incidence did not change significantly in less walkable areas (change, -0.65 in quintile 1 [95% CI, -1.65 to 0.39], -0.5 in quintile 2 [95% CI, -1.5 to 0.5], and -0.9 in quintile 3 [95% CI, -1.9 to 0.02]). Rates of walking or cycling and public transit use were significantly higher and that of car use lower in quintile 5 vs quintile 1 at each time point, although daily walking and cycling frequencies increased only modestly from 2001 to 2011 in highly walkable areas. Leisure-time physical activity, diet, and smoking patterns did not vary by walkability (P > .05 for quintile 1 vs quintile 5 for each outcome) and were relatively stable over time. CONCLUSIONS AND RELEVANCE: In Ontario, Canada, higher neighborhood walkability was associated with decreased prevalence of overweight and obesity and decreased incidence of diabetes between 2001 and 2012. However, the ecologic nature of these findings and the lack of evidence that more walkable urban neighborhood design was associated with increased physical activity suggest that further research is necessary to assess whether the observed associations are causal.

Geographic Variation Immediate and Delayed Breast Reconstruction Utilization in Ontario, Canada and Plastic Surgeon Availability: A Population-Based Observational Study.

BACKGROUND: Utilization of breast reconstruction (BR) is low in many jurisdictions. We studied the geographical and surgical workforce factors that contribute to access and use of BR using a small area analysis approach with a geographical unit of analysis. METHODS: We linked administrative data from Ontario Canada to calculate the age-standardized rates for immediate BR (IBR) (same time as mastectomy) between 2002 and 2011, and delayed BR (DBR) (within 3 years of mastectomy) for each county. The influence of plastic surgeon access on variation in county rates of BR was examined using Poisson random effects models. RESULTS: 12,663 women underwent mastectomy in Ontario; 2,948 had BR within 3 years (23.3%). Over 50% of the counties had no access to any plastic surgeon. County IBR rates ranged from 0 to 21.5%; plastic surgeon access explained 46% of geographic variation (p<0.0001). IBR rates in counties with very low, low, and moderate access to plastic surgeons were significantly less than counties with high access (relative rate [RR] 0.48 [95% confidence interval (CI) 0.35-0.66], RR 0.61 [CI 0.43-0.87] and RR 0.70 [CI 0.52-0.96], respectively) after adjusting for age and county socioeconomic characteristics. For DBR, while there was less geographic variation, very low access counties demonstrated reduced rates (RR 0.60 [CI 0.47-0.76]). INTERPRETATION: Geographic access to a plastic surgeon is a major determinant of BR. Targeted interventions for regions without high access to plastic surgeons may improve overall rates and reduce geographic disparities in care, particularly for IBR.

International incidence and outcomes of biliary atresia.

OBJECTIVES: International trends in incidence and outcomes of biliary atresia (BA) are controversial and a wide range of estimates have been reported worldwide. We reviewed the population-based literature to assess international variation of BA incidence and outcomes, and to assess the evidence for seasonal variation in incidence, centralization of Kasai hepatoportoenterostomy, and newborn screening. METHODS: We conducted a systematic review (registration number CRD42011001441) of observational or interventional research within MEDLINE, EMBASE, and the Cochrane Database, which reported incidence, prevalence, or outcomes of infants with BA. Population-based studies, defined by inclusion of an entire population or representative sample, were included. Outcomes included overall survival, native liver survival (NLS), and time to Kasai hepatoportoenterostomy. Single- or multicenter studies were excluded unless those centers captured all potential patients within a jurisdiction. Two independent data extractors reviewed the abstracts and articles. RESULTS: A total of 40 studies were included following review of 3128 references. A wide range of incidence was reported internationally. Ten-year overall survival ranged from 66.7% to 89%. NLS ranged from 20.3% to 75.8% at 1 to 3 years and 24% to 52.8% at 10 years. Earlier age at Kasai was a predictor of improved NLS. Seasonality was reported in 11 studies, and 3 reported an increased incidence during the months of August to March. The evidence for centralization of Kasai to high-volume centers is promising but does not account for all case-mix, provider, or health system factors involved in volume-outcome relations. Stool color card screening resulted in earlier Kasai and improved NLS in Taiwan. CONCLUSIONS: Large, international studies could help fill the gaps in knowledge identified by this review.

The role of geography and distance on physician follow-up after a first hospitalization with a diagnosis of a schizophrenia spectrum disorder: A retrospective population-based cohort study in Ontario, Canada.

BACKGROUND: Timely follow-up after hospitalization for a schizophrenia spectrum disorder (SSD) is an important quality indicator. We examined the proportion of individuals who received physician follow-up within 7 and 30 days post-discharge by health region and estimated the effect of distance between a person's residence and discharging hospital on follow-up. METHODS: We created a retrospective population-based cohort of incident hospitalizations with a discharge diagnosis of a SSD between 01/01/2012 and 30/03/2019. The proportion of follow-up with a psychiatrist and family physician within 7 and 30 days were calculated for each region. The effect of distance between a person's residence and discharging hospital on follow-up was estimated using adjusted multilevel logistic regression models. RESULTS: We identified 6,382 incident hospitalizations for a SSD. Only 14.2% and 49.2% of people received follow-up care with a psychiatrist within 7 and 30 days of discharge, respectively, and these proportions varied between regions. Although distance from hospital was not associated with follow-up within 7 days of discharge, increasing distance was associated with lower odds of follow-up with a psychiatrist within 30 days. CONCLUSION: Post-discharge follow-up is poor across the province. Geospatial factors may impact post-discharge care and should be considered in further evaluation of quality of care.

A cross-sectional study of community-level physician retention and hospitalization in rural Ontario, Canada.

PURPOSE: Many rural communities experience poor family physician retention. We examined the association between community-level physician retention and hospitalization for all causes and ambulatory care-sensitive conditions (ACSCs) in 2017 among residents of rural communities in Ontario, Canada. METHODS: We conducted a population-based cross-sectional study by linking administrative data from the public health insurance program in Ontario. To create the physician retention measure for each rural community, we divided the number of family physicians who worked in the community in both 2016 and 2017 by the total number of unique family physicians in the community in either year. We grouped retention level by tertile and added a fourth category, "no physician" to include communities that did not have any residing physicians in either 2016 or 2017. Outcomes were all-cause hospitalization and ACSC hospitalization between April 1, 2017 and March 31, 2018. FINDINGS: Among 1,436,794 rural residents, there were 93,752 all-cause hospitalizations and 8,691 ACSC hospitalizations in 2017. After controlling for other predictors, compared to residents in low-retention communities, residents of medium- and high-retention communities were 0.888 (95% CI: 0.868-0.909) and 0.937 (95% CI: 0.915-0.960) times as likely to have all-cause hospitalization, and residents of high-retention communities were 0.918 (95% CI: 0.858-0.981) times as likely to have ACSC hospitalization in 2017. CONCLUSIONS: Community-level physician retention is significantly associated with all cause and ACSC hospitalization in rural communities in Ontario, and may serve as an alternate measure to assess the impact of disrupted continuity of care.

A Cross-sectional Study of Community-level Physician Retention and Diabetes Management in Rural Ontario.

OBJECTIVE: Our aim in this study was to determine the impact of community-level physician retention on the quality of diabetes care in rural Ontario. METHODS: Using administrative data, we compared diabetes quality of care. We defined retention as the proportion of physicians in a community from one year to the next. We grouped retention level by tertile and added a category for those communities with no physician. RESULTS: Residents of high-retention communities were more likely to have had glycated hemoglobin (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.06 to 1.14) and low-density lipoprotein (OR, 1.17; 95% CI, 1.13 to 1.22) testing, but less likely to have had testing for urine albumin-to-creatine ratio (OR, 0.86; 95% CI, 0.83 to 0.89) or to have received an angiotensin-converting enzyme inhibitor or angiotensin-2 receptor blocker (OR, 0.91; 95% CI, 0.86 to 0.95) or a statin (OR, 0.91; 95% CI, 0.87 to 0.96), when compared with low-retention communities. Communities with no residing physician had care that was equivalent to or better than that in high-retention communities. CONCLUSIONS: Community-level physician retention, based on a 2-year time frame, was significantly related to quality of diabetes care. A closer look at models of care in communities with no residing physician is warranted. Community-level physician retention can be used to assess the impact of physician shortages on diabetes management in rural communities.

Help-seeking behavior among adults who attempted or died by suicide in Ontario, Canada.

INTRODUCTION: This study aims to determine the relationship between rurality and help-seeking behavior prior to a suicide or suicide attempt. METHODS: Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital, emergency department (ED), and general practitioner (GP) visits across Ontario. Rurality was defined using the Rurality Index of Ontario scores. Help-seeking was based on accessing health services 1 year prior to the event. RESULTS: Among those who died by suicide (N = 9848), those living in rural areas were less likely to seek help from a psychiatrist (rural males: AOR = 0.42, 95% CI = 0.31-0.57; rural females: AOR = 0.46, 95% CI = 0.29-0.97) compared with those living in urban areas. We found a similar association among those who attempted suicide (N = 82,480) (rural males: AOR = 0.49, 95% CI = 0.43-0.56; rural females: AOR = 0.51, 95% CI = 0.46-0.57). Rural males and females were more likely to seek care from an ED for mental health reasons compared with urban males and females. CONCLUSIONS: Among people who died by suicide, those living in rural areas are generally less likely to access psychiatrists and GPs and more likely to access EDs, suggesting that people living in rural areas may have less access to care than their urban counterparts.

Eviction filings during bans on enforcement throughout the COVID-19 pandemic: an interrupted time series analysis.

OBJECTIVE: Bans on evictions were implemented to reduce the spread of COVID-19 and to protect vulnerable populations during a public health crisis. Our objective was to examine how three bans on eviction enforcement impacted eviction filings from March 2020 through January 2022 in Ontario, Canada. METHODS: Data were derived from eviction application records kept by the Ontario Landlord and Tenant Board. We used segmented regression analysis to model changes in the average weekly filing rates for evictions due to non-payment of rent (L1 filings) and reasons other than non-payment of rent (L2 filings). RESULTS: The average number of weekly L1 and L2 applications dropped by 67.5 (95% CI: 55.2, 79.9) and 31.7 (95% CI: 26.7, 36.6) filings per 100,000 rental dwellings, respectively, following the first ban on eviction enforcement (p < 0.0001). Notably, they did not fall to zero. Level changes during the second and third bans were insubstantial and slope changes for L2 applications varied throughout the study period. The L1 filing rate appeared to increase towards the end of the study period (slope change: 1.3; 95% CI: 0.1, 2.6; p = 0.0387). CONCLUSION: Our findings suggest that while the first ban on eviction enforcement appeared to substantially reduce filing rates, subsequent bans were less effective and none of them eliminated eviction filings altogether. Enacting upstream policies that tackle the root causes of displacement would better equip jurisdictions during future public health emergencies.

RéSUMé: OBJECTIF: Les ordonnances d'expulsion résidentielles ont été suspendues pour réduire la propagation de la COVID-19 et pour protéger les populations vulnérables pendant une crise de santé publique. Notre objectif était d'examiner l'impact de trois interdictions d'exécution d'ordonnance d'éviction sur les requêtes d'expulsion de mars 2020 à janvier 2022 en Ontario, au Canada. MéTHODES: Les données ont été tirées des dossiers de requêtes d'expulsion conservés par la Commission de la location immobilière de l'Ontario. Nous avons utilisé une analyse de régression segmenté pour modéliser les changements dans les taux hebdomadaires moyens de requêtes d'expulsion pour non-paiement du loyer (requêtes L1) et pour des raisons autres que le non-paiement du loyer (requêtes L2). RéSULTATS: Le nombre moyen de demandes hebdomadaires de dépôts de requêtes L1 et L2 a chuté de 67,5 % (IC à 95% : 55,2, 79,9) et de 31,7 % (IC à 95% : 26,7, 36,6) pour 100 000 logements locatifs, respectivement, suite à la première interdiction d'exécution des expulsions. Il est à noter qu'elles ne sont pas tombées à zéro. Les changements du taux de requêtes au cours de la deuxième et la troisième interdictions n'étaient pas substantiels et les changements de pente pour les applications L2 ont varié tout au long de la période d'étude. Le taux de dépôt de L1 a semblé augmenter vers la fin de la période d'étude (changement de pente : 1,3; IC à 95% : 0,1, 2,6; p = 0,0387). CONCLUSION: Nos résultats suggèrent qu'alors que la première interdiction d'exécution des expulsions a semblé réduire considérablement les taux de dépôt d'expulsion, les interdictions ultérieures ont été moins efficaces et aucune d'entre elles n'a complètement éliminé les dépôts d'expulsion. L'adoption de politiques en amont qui s'attaquent plutôt aux causes profondes des expulsions permettrait de mieux équiper les juridictions lors de futures urgences de santé publique.

Impact of the COVID-19 pandemic on antidepressant and antipsychotic use among children and adolescents: a population-based study.

Background: The COVID-19 pandemic was associated with increases in the prevalence of depression, anxiety and behavioural problems among children and youth. Less well understood is the influence of the pandemic on antidepressant and antipsychotic use among children. This is important, as it is possible that antidepressants and antipsychotics were used as a "stop-gap" measure to treat mental health symptoms when in-person access to outpatient care and school-based supportive services was disrupted. Furthermore, antipsychotics and antidepressants have been associated with harm in children and youth. We examined trends in dispensing of these medications two years following the pandemic among children 18 years of age and under in Ontario, Canada. Methods: We conducted a population-based time-series study of antidepressant and antipsychotic medication dispensing to children and adolescents ≤18 years old between September 1, 2014, and March 31, 2022. We measured monthly population-adjusted rates of antidepressant and antipsychotics obtained from the IQVIA Geographic Prescription Monitor (GPM) database. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of antidepressants and antipsychotics occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected use of these drugs. Results: Overall, we found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. Specifically, we observed an immediate step decrease in antidepressant dispensing associated with a structural break in April 2020 (-55.8 units per 1,000 individuals; 95% confidence intervals [CI] CI: -117.4 to 5.8), followed by an increased monthly trend in the rate of antidepressant dispensing of 13.0 units per 1,000 individuals (95% CI: 10.2-15.9). Antidepressant dispensing was consistently greater than predicted from September 2020 onward. Antipsychotic dispensing increased immediately following a June 2020 structural break (26.4 units per 1,000 individuals; 95% CI: 15.8-36.9) and did not change appreciably thereafter. Antipsychotic dispensing was higher than predicted at all time points from June 2020 onward. Conclusion: We found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. These increases were sustained through nearly two years of observation and are especially concerning in light of the potential for harm with the long-term use of antipsychotics in children. Further research is required to understand the clinical implications of these findings.

Higher Neighborhood Drivability Is Associated With a Higher Diabetes Risk in Younger Adults: A Population-Based Cohort Study in Toronto, Canada.

OBJECTIVE: Car dependency contributes to physical inactivity and, consequently, may increase the likelihood of diabetes. We investigated whether neighborhoods that are highly conducive to driving confer a greater risk of developing diabetes and, if so, whether this differs by age. RESEARCH DESIGN AND METHODS: We used administrative health care data to identify all working-age Canadian adults (20-64 years) who were living in Toronto on 1 April 2011 without diabetes (type 1 or 2). Neighborhood drivability scores were assigned using a novel, validated index that predicts driving patterns based on built environment features divided into quintiles. Cox regression was used to examine the association between neighborhood drivability and 7-year risk of diabetes onset, overall and by age-group, adjusting for baseline characteristics and comorbidities. RESULTS: Overall, there were 1,473,994 adults in the cohort (mean age 40.9 ± 12.2 years), among whom 77,835 developed diabetes during follow-up. Those living in the most drivable neighborhoods (quintile 5) had a 41% higher risk of developing diabetes compared with those in the least drivable neighborhoods (adjusted hazard ratio 1.41, 95% CI 1.37-1.44), with the strongest associations in younger adults aged 20-34 years (1.57, 95% CI 1.47-1.68, P < 0.001 for interaction). The same comparison in older adults (55-64 years) yielded smaller differences (1.31, 95% CI 1.26-1.36). Associations appeared to be strongest in middle-income neighborhoods for younger residents (middle income 1.96, 95% CI 1.64-2.33) and older residents (1.46, 95% CI 1.32-1.62). CONCLUSIONS: High neighborhood drivability is a risk factor for diabetes, particularly in younger adults. This finding has important implications for future urban design policies.

Development of a neighborhood drivability index and its association with transportation behavior in Toronto.

BACKGROUND: Car driving is a form of passive transport that is associated with an increase in physical inactivity, obesity, air pollution and noise. Built environment characteristics may influence transport mode choice, but comprehensive indices for built environment characteristics that drive car use are still lacking, while such an index could provide tangible policy entry points. OBJECTIVE: We developed and validated a neighbourhood drivability index, capturing combined dimensions of the neighbourhood environment in the City of Toronto, and investigated its association with transportation choices (car, public transit or active transport), overall, by trip length, and combined for residential neighbourhood and workplace drivability. METHODS: We used exploratory factor analysis to derive distinct factors (clusters of one or more environmental characteristics) that reflect the degree of car dependency in each neighbourhood, drawing from candidate variables that capture density, diversity, design, destination accessibility, distance to transit, and demand management. Area-level factor scores were then combined into a single composite score, reflecting neighbourhood drivability. Negative binomial generalized estimating equations were used to test the association between driveability quintiles (Q) and primary travel mode (>50% of trips by car, public transit, or walking/cycling) in a population-based sample of 63,766 Toronto residents enrolled in the Transportation Tomorrow Survey (TTS) wave 2016, adjusting for individual and household characteristics, and accounting for clustering of respondents within households. RESULTS: The drivability index consisted of three factors: Urban sprawl, pedestrian facilities and parking availability. Relative to those living in the least drivable neighbourhoods (Q1), those in high drivability areas (Q5) had a significantly higher rate of car travel (adjusted Risk Ratio (RR): 1.80, 95%CI: 1.77-1.88), and lower rate of public transit use (RR: 0.90, 95%CI: 0.85-0.94) and walking/cycling (RR: 0.22, 95%CI: 0.19-0.25). Associations were strongest for short trips (<3 km) (RR: 2.72, 95%CI: 2.48-2.92), and in analyses where both residential and workplace drivability was considered (RR for car use in high/high vs. low/low residential/workplace drivability: 2.18, 95%CI: 2.08-2.29). CONCLUSION: This novel neighbourhood drivability index predicted whether local residents drive or use active modes of transportation and can be used to investigate the association between drivability, physical activity, and chronic disease risk.

Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030.

Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.