Pre-operative anemia prior to gynecologic surgery is associated with increased healthcare costs.

OBJECTIVE: To compare healthcare utilization costs between anemic and non-anemic patients undergoing elective hysterectomy and myomectomy for benign indications from the date of surgery to 30-days postoperatively. DESIGN: Retrospective population-based cohort study. SETTING: Single-payer publicly funded healthcare system in Ontario, Canada between 2013-2020. PARTICIPANTS: Adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) for benign indications. INTERVENTIONS: Our exposure of interest was pre-operative anemia, defined as the most recent hemoglobin value <12g/dL on the complete blood count measured before the date of surgery. Our primary outcome was healthcare costs (total and disaggregated) from the perspective of the single-payer publicly funded healthcare system. RESULTS: Of the 59,270 patients in the cohort, 11,802 (19.9%) had pre-operative anemia. After propensity matching, standardized differences in all baseline characteristics (N=10,103 per group) were <0.10. In the matched cohort, the mean total healthcare cost per anemic patient was higher compared to cost per non-anemic patient ($6,134.88 ± $2,782.38 vs. $6,009.97 ± $2,423.27, p<0.001). Anemic patients, compared to non-anemic patients, had a higher mean difference in total healthcare cost of $124.91 per patient (95%CI $53.54 - $196.29) translating to an increased cost attributable to anemia of 2.08% (95%CI 0.89% - 3.28%, p<0.001). In a subgroup analysis of patients undergoing hysterectomy (N=9041), the cost was also significantly higher for anemic patients (mean difference per patient of $117.67, 95%CI $41.58 - $193.75). For those undergoing myomectomy (N=1062) the difference in cost was not statistically significant (mean difference $186.61, 95%CI -$17.42 - $390.65). CONCLUSION: Pre-operative anemia was associated with significantly increased healthcare resource utilization and costs for patients undergoing elective gynecologic surgery. Although the cost difference per case was modest, when extrapolated to the population level, this difference could result in substantially significant cost to the healthcare system, attributable to pre-operative anemia.

Incidence of Total Knee Arthroplasty After Arthroscopic Surgery for Knee Osteoarthritis: A Secondary Analysis of a Randomized Clinical Trial.

Importance: It is unclear whether arthroscopic resection of degenerative knee tissues among patients with osteoarthritis (OA) of the knee delays or hastens total knee arthroplasty (TKA); opposite findings have been reported. Objective: To compare the long-term incidence of TKA in patients with OA of the knee after nonoperative management with or without additional arthroscopic surgery. Design, Setting, and Participants: In this ad hoc secondary analysis of a single-center, assessor-blinded randomized clinical trial performed from January 1, 1999, to August 31, 2007, 178 patients were followed up through March 31, 2019. Participants included adults diagnosed with OA of the knee referred for potential arthroscopic surgery in a tertiary care center specializing in orthopedics in London, Ontario, Canada. All participants from the original randomized clinical trial were included. Data were analyzed from June 1, 2021, to October 20, 2022. Exposures: Arthroscopic surgery (resection or debridement of degenerative tears of the menisci, fragments of articular cartilage, or chondral flaps and osteophytes that prevented full extension) plus nonoperative management (physical therapy plus medications as required) compared with nonoperative management only (control). Main Outcomes and Measures: Total knee arthroplasty was identified by linking the randomized trial data with prospectively collected Canadian health administrative datasets where participants were followed up for a maximum of 20 years. Multivariable Cox proportional hazards regression models were used to compare the incidence of TKA between intervention groups. Results: A total of 178 of 277 eligible patients (64.3%; 112 [62.9%] female; mean [SD] age, 59.0 [10.0] years) were included. The mean (SD) body mass index was 31.0 (6.5). With a median follow-up of 13.8 (IQR, 8.4-16.8) years, 31 of 92 patients (33.7%) in the arthroscopic surgery group vs 36 of 86 (41.9%) in the control group underwent TKA (adjusted hazard ratio [HR], 0.85 [95% CI, 0.52-1.40]). Results were similar when accounting for crossovers to arthroscopic surgery (13 of 86 [15.1%]) during follow-up (HR, 0.88 [95% CI, 0.53-1.44]). Within 5 years, the cumulative incidence was 10.2% vs 9.3% in the arthroscopic surgery group and control group, respectively (time-stratified HR for 0-5 years, 1.06 [95% CI, 0.41-2.75]); within 10 years, the cumulative incidence was 23.3% vs 21.4%, respectively (time-stratified HR for 5-10 years, 1.06 [95% CI, 0.45-2.51]). Sensitivity analyses yielded consistent results. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial of arthroscopic surgery for patients with OA of the knee, a statistically significant association with delaying or hastening TKA was not identified. Approximately 80% of patients did not undergo TKA within 10 years of nonoperative management with or without additional knee arthroscopic surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT00158431.

Treatment and Mortality Following Cancer Diagnosis Among People With Non-affective Psychotic Disorders in Ontario, Canada: A Retrospective Cohort Study.

BACKGROUND AND HYPOTHESIS: People with psychotic disorders have a higher risk of mortality following cancer diagnosis, compared to people without psychosis. The extent to which this disparity is influenced by differences in cancer-related treatment is currently unknown. We hypothesized that, following a cancer diagnosis, people with psychotic disorders were less likely to receive treatment and were at higher risk of death than those without psychosis. STUDY DESIGN: We constructed a retrospective cohort of cases of non-affective psychotic disorder (NAPD) and a general population comparison group, using Ontario Health (OH) administrative data. We identified cases of all cancers diagnosed between 1995 and 2019 and obtained information on cancer-related treatment and mortality. Cox proportional hazards models were used to compare the probability of having a consultation with an oncologist and receiving cancer-related treatment, adjusting for tumor site and stage. We also compared the rate of all-cause and cancer-related mortality between the two groups, adjusting for tumor site. STUDY RESULTS: Our analytic sample included 24 944 people diagnosed with any cancer. People with NAPD were less likely to receive treatment than people without psychosis (HR = 0.87, 95% CI = 0.82, 0.91). In addition, people with NAPD had a greater risk of death from any cause (HR = 1.68, 95% CI = 1.60, 1.76), compared to people without NAPD. CONCLUSIONS: The lower likelihood of receiving cancer treatment reflects disparities in accessing cancer care for people with psychotic disorders, which may partially explain the higher mortality risk following cancer diagnosis. Future research should explore mediating factors in this relationship to identify targets for reducing health disparities.

Epidemiology of paediatric out-of-hospital cardiac arrest in Ontario, Canada.

Background: There are no Canadian epidemiological studies of Paediatric Out-of-Hospital Cardiac Arrest (POHCA) for ≥20 years. Understanding the epidemiology of POHCA is key to prevention, education, and management strategies. Methods: We applied a validated algorithm to hospital administrative databases to describe paediatric (age 1 day to ≤18 years) atraumatic OHCA in Ontario from 2004-2020. Results: The cohort included 1,839 paediatric patients with atraumatic POHCA occurring at a median (IQR) age of 2 (0-12) years with 721 (39.2%) POHCA events in <1-year-olds. Males accounted for 71.1% (n = 1123) of the cohort. Crude incidence of children with POHCA who were transported to an Emergency Department was 4.2/100,000 with an increase annually over the study period (p = 0.0065). Thirty percent (n = 560) lived in a neighbourhood with the lowest income quintile, while 13.6% (n = 251) lived in a neighbourhood with the highest income quintile, 78.6% (n = 1444) presented to a non-academic hospital, and the majority (n = 1533, 83.4%) did not have significant comorbidities. Survival to hospital discharge was achieved in 167 (9.1%). Less than 6 (<3.6%) patients had a repeat POHCA in the year following the index event. Conclusions: This is the largest Canadian POHCA cohort and the first to describe its incidence, comorbidities, and sociodemographic characteristics. We found an increase in annual crude incidence, POHCA mostly occurred in healthy children, and survival was similar to other cohorts. There were more than double the number of POHCA events in children living in the lowest income quintile neighborhoods compared to the highest. Most children presented to non-academic hospitals first.

The burden of psychiatric disorders associated with orofacial cleft pathology among children in Ontario, Canada.

BACKGROUND: Individuals with orofacial cleft (OFC) may be at a higher risk of developing psychiatric disorders (PD) than the general population. We determined the risk of psychiatric diagnoses in children with OFC in Canada. METHODS: This population-based retrospective cohort study used health administrative data from the province of Ontario, Canada. Children with OFC who were born between April 1, 1994, and March 31, 2017, in Ontario were matched to five non-OFC children based on sex, date of birth, and mother's age. We determined the rate of events and time-to-event for first diagnosis of PD in children aged ≥ 3 years (y), and for intellectual developmental delay (IDD) from birth. Risk factors for PD and IDD were assessed using 1-way ANOVA for means, Kruskal-Wallis for medians, and the χ2 test for categorical variables. OUTCOMES: There were 3051 children with OFC (matched to 15,255 controls), of whom 2515 patients with OFC (12,575 controls) had a complete follow-up to the third birthday. Children with OFC were more likely to have PD than controls (54.90 vs. 43.28 per 1000 patient-years, P < .001), with a mean age to first diagnosis of 8.6 ± 4.2 y. The cleft palate group had the highest risk (HR 1.33, 95% CI 1.18-1.49). Children with OFC also had a higher risk of IDD than non-OFC children (27.78 vs. 3.46 per 1000 patient-years, p < .001). INTERPRETATION: Children born with OFC in Ontario had a higher risk of psychiatric diagnosis and IDD compared to controls. Further research is also required to better understand the predictors of variation in risk, including geographic location and the presence of congenital abnormalities, and identify potential areas for intervention. EVIDENCE RATING SCALE FOR PROGNOSTIC/RISK STUDIES: Level II.

Early mortality in patients with cancer treated with immune checkpoint inhibitors in routine practice.

BACKGROUND: We sought to estimate the proportion of patients with cancer treated with immune checkpoint inhibitors (ICI) who die soon after starting ICI in the real world and examine factors associated with early mortality (EM). METHODS: We conducted a retrospective cohort study using linked health administrative data from Ontario, Canada. EM was defined as death from any cause within 60 days of ICI initiation. Patients with melanoma, lung, bladder, head and neck, or kidney cancer treated with ICI between 2012 and 2020 were included. RESULTS: A total of 7126 patients treated with ICI were evaluated. Fifteen percent (1075 of 7126) died within 60 days of initiating ICI. The highest mortality was observed in patients with bladder and head and neck tumors (approximately 21% each). In multivariable analysis, previous hospital admission or emergency department visit, prior chemotherapy or radiation therapy, stage 4 disease at diagnosis, lower hemoglobin, higher white blood cell count, and higher symptom burden were associated with higher risk of EM. Conversely, patients with lung and kidney cancer (compared with melanoma), lower neutrophil to lymphocytes ratio, and with higher body mass index were less likely to die within 60 days post ICI initiation. In a sensitivity analysis, 30-day and 90-day mortality were 7% (519 of 7126) and 22% (1582 of 7126), respectively, with comparable clinical factors associated with EM identified. CONCLUSIONS: EM is common among patients treated with ICI in the real-world setting and is associated with several patient and tumor characteristics. Development of a validated tool to predict EM may facilitate better patient selection for treatment with ICI in routine practice.

Evaluation of a modernized supported housing intervention for individuals who experience severe and persistent mental illness in Ontario, Canada.

WHAT IS KNOWN ON THE SUBJECT: Supported housing approaches that include case management and increased opportunities for independence and personal autonomy for people who are living with severe and persistent mental illness (SPMI) have been found to help reduce hospitalizations and use of the emergency department. What is not fully clear is if these types of supported housing arrangements also influence the use of primary health care and other specialist services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: This study uncovered that individuals experiencing SPMI who lived in supported housing used more primary health care and specialist physician services, in the year following transition to this housing arrangement. WHAT ARE THE IMPLICATIONS FOR PRACTICE: The findings of this study suggest that supported housing arrangements for people experiencing SPMI may help in improving the personalization of health services for individual residents, including increasing access to both primary health care and specialist services. This is important for nursing practice, as the findings of the study show that supported housing arrangements for people experiencing SPMI may assist in better supporting their complex health care needs. ABSTRACT: INTRODUCTION: Supported housing for people who are living with severe and persistent mental illness (SPMI) has been found to help reduce hospitalizations and use of the emergency department. What is not fully clear is if these types of supported housing arrangements also influence the use of primary health care and other specialist services. AIM/QUESTION: The aim of this study was to compare the use of health services use of individuals with SPMI, before and after transition to the new supported housing program. METHOD: Using health care administrative databases, a pre-post cohort study was conducted examining the health system use of residents who transitioned from custodial to supported housing arrangements between 2017 and 2019. RESULTS: Individuals with SPMI used more primary health care and specialist physician services after transition to the supported housing model. DISCUSSION: The results suggest that a supported housing model may be associated with increased usage of outpatient person-centred health services in people experiencing SPMI. IMPLICATIONS FOR PRACTICE: The findings of this study suggest that supported housing arrangements for people experiencing SPMI may help in improving the personalization of health services for individual. This is important for nursing practice, as the findings of the study show that supported housing arrangements may assist in better supporting complex health care needs of individuals.

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.

Pitfalls and Solutions in Mass Spectrometry-Based Identification of Protein Glycation.

Emerging evidence suggests that advanced glycation end-products (AGEs) such as Nε-(carboxymethyl)lysine (CML) and Nε-(carboxymethyl)lysine (CEL) may play important roles in certain human diseases. Reliable analytical methods are needed for their characterizations and measurements. Pitfalls have been reported for applications of LC-MS/MS to identify various types of post-translational modifications, but not yet for the case of AGEs. Here, we showed that in the absence of manual inspection, cysteine alkylation with 2-iodoacetamide (IAA) can result in false-positive/ambiguous identifications of CML >20%. They were attributed to offsite alkylation together with incorrect monoisotopic peak assignment (pitfall 1) or together with deamidation (pitfall 2). For pitfall 1, false-positive identifications can be alleviated using a peptide mass error tolerance ≤5 ppm during the database search. Pitfall 2 results in ambiguous modification assignments, which may be overcome by using other alkylation reagents. According to calculations of theoretical mass shifts, the use of other common alkylation reagents (iodoacetic acid, 2-chloroacetamide, and acrylamide) should face similar pitfalls. The use of acrylamide can result in false-positive identifications of CEL instead of CML. Subsequently, we showed that compared to IAA, the use of N-isopropylacrylamide (NIPAM) as an alkylation reagent achieved similar levels of proteome coverage, while reducing the offsite alkylation reactions at lysine by more than five times. Furthermore, false-positive/ambiguous identifications of CML due to the two types of pitfalls were absent when using NIPAM. NIPAM alkylation results in a unique mass shift that allows reliable identifications of CML and most likely other AGEs, such as CEL.

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.

Bariatric Center Designation and Outcomes Following Repeat Abdominal Surgery in Bariatric Patients.

INTRODUCTION: Repeat abdominal surgery in the bariatric surgery patient population may be challenging for non-bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery. METHODS: This is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay. RESULTS: Among the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers. CONCLUSIONS: Our study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.

Utilization of Immunotherapy in Patients with Cancer Treated in Routine Care Settings: A Population-Based Study Using Health Administrative Data.

INTRODUCTION: The introduction of immunotherapy (IO) in the treatment of patients with cancer has significantly improved clinical outcomes. Population level information on actual IO utilization is limited. METHODS: We conducted a retrospective cohort study using provincial health administrative data from Ontario, Canada to: (1) assess the extent of IO use from 2011 (pre-IO funding) to 2019; and (2) identify factors associated with IO use in patients with advanced cancers for which IO is reimbursed including melanoma, bladder, lung, head and neck, and kidney tumors. The datasets were linked using a unique encoded identifier. A Fine and Gray regression model with death as a competing risk was used to identify factors associated with IO use. RESULTS: Among 59 510 patients assessed, 8771 (14.7%) received IO between 2011 and 2019. Use of IO increased annually from 2011 (3.3%) to 2019 (39.2%) and was highest in melanoma (52%) and lowest in head and neck cancer (6.6%). In adjusted analysis, factors associated with lower IO use included older age (hazard ratio (HR) 0.91 (95% CI, 0.89-0.93)), female sex (HR 0.85 (95% CI, 0.81-0.89)), lower-income quintile, hospital admission (HR 0.78 (95% CI, 0.75-0.82)), high Charlson score and de novo stage 4 cancer. IO use was heterogeneous across cancer centers and regions. CONCLUSION: IO utilization for advanced cancers rose substantially since initial approval albeit use is associated with patient characteristics and system-level factors even in a universal healthcare setting. To optimize IO utilization in routine practice, survival estimates and potential inequity in access should be further investigated and addressed.

Outcomes After Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis.

OBJECTIVES: To compare health service use and clinical outcomes for patients with and without direct discharge to home (DDH) from ICUs in Ontario. DESIGN: Population-based, observational, cohort study using propensity scoring to match patients who were DDH to those not DDH and a preference-based instrumental variable (IV) analysis using ICU-level DDH rate as the IV. SETTING: ICUs in Ontario. PATIENTS: Patients discharged home from a hospitalization either directly or within 48 hours of care in an ICU between April 1, 2015, and March 31, 2017. INTERVENTION: DDH from ICU. MEASUREMENTS AND MAIN RESULTS: Among 76,737 patients in our cohort, 46,859 (61%) were DDH from the ICU. In the propensity matched cohort, the odds for our primary outcome of hospital readmission or emergency department (ED) visit within 30 days were not significantly different for patients DDH (odds ratio [OR], 1.00; 95% CI, 0.96-1.04), and there was no difference in mortality at 90 days for patients DDH (OR, 1.08; 95% CI, 0.97-1.21). The effect on hospital readmission or ED visits was similar in the subgroup of patients discharged from level 2 (OR, 0.98; 95% CI, 0.92-1.04) and level 3 ICUs (OR, 1.02; 95% CI, 0.96-1.09) and in the subgroups with cardiac conditions (OR, 1.03; 95% CI, 0.96-1.12) and noncardiac conditions (OR, 0.98; 95% CI, 0.94-1.03). Similar results were obtained in the IV analysis (coefficient for hospital readmission or ED visit within 30 d = -0.03 ± 0.03 ( se ); p = 0.3). CONCLUSIONS: There was no difference in outcomes for patients DDH compared with ward transfer prior to discharge when two approaches were used to minimize confounding within a large health systemwide observational cohort. We did not evaluate how patients are selected for DDH. Our results suggest that with careful patient selection, this practice might be feasible for routine implementation to ensure efficient and safe use of limited healthcare resources.

Risk factors for abdominal reoperations in bariatric patients.

BACKGROUND: With a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop reliable benchmarking targets. OBJECTIVES: To investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients. SETTING: This is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016. METHODS: A multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery. RESULTS: Among a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR [odds ratio] .85, 95% CI [confidence interval] .70-1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26-4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02-1.62), and previously higher health care users (OR 1.30, 95% CI 1.15-1.46) were most significantly associated with reoperations. CONCLUSION: Reoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.

Trends in basal insulin prescribing in older adults with chronic kidney disease in Ontario, Canada: A population-based analysis from 2010 to 2020.

AIM: To examine trends in basal insulin prescribing in older adults with chronic kidney disease (CKD). MATERIALS AND METHODS: We conducted a population-based study of adults aged 66 years or older with treated diabetes from 1 January 2010 to 30 September 2020 in Ontario, Canada. We examined prevalent and incident prescriptions for human NPH, Levemir, glargine-100, Basaglar, glargine-300, and degludec insulin over 43 study intervals. We present trends in those with CKD, and in a subgroup, by estimated glomerular filtration rate (eGFR). To provide context for prescribing, we provide demographics, co-morbidities, and the healthcare utilization of included patients. RESULTS: In CKD, use of basal insulin was about 2-fold higher than in the general treated diabetes cohort. Prescriptions for NPH declined over time, while prescriptions for Levemir and glargine-100 increased until 2018 then decreased. Following drug formulary approval (September 2018), prescriptions for glargine-300 and degludec increased substantially. Incident prescriptions for basal insulin in CKD declined over time; however, in those with an eGFR of less than 30 ml/min/1.73m2 , rates remained stable. In recent years, rates of degludec and glargine-300 have rivalled glargine-100. CONCLUSIONS: In an era of new oral and injectable diabetes medications, the use of basal insulin has declined in older adults with CKD. However, in those with more advanced CKD, basal insulin, particularly newer analogues, remain a mainstay treatment.

The association between endocrine therapy use and osteoporotic fracture among post-menopausal women treated for early-stage breast cancer in Ontario, Canada.

BACKGROUND: The use of endocrine therapy for early-stage breast cancer, particularly aromatase inhibitor therapy has been associated with an increased risk of osteoporosis and fracture in clinical trials. We sought to validate this observation in real-world practice. METHODS: We used health administrative data collected from post-menopausal women (aged ≥66 years) who were diagnosed with breast cancer and started on adjuvant endocrine therapy from 2005 to 2012. Patients were classified by use of either an aromatase inhibitor or tamoxifen and followed until 2017 for a new diagnosis of an osteoporotic fracture. A multivariable analysis using a Cox proportional hazards model was adjusting for age, medical co-morbidities, medication use and duration of endocrine therapy. RESULTS: We identified 12,077 patients of whom 73% were treated with an aromatase inhibitor as compared to 27% with tamoxifen. Our multivariable analysis did not demonstrate any significant difference in the rate of osteoporotic fracture between patients treated with an aromatase inhibitor when compared with tamoxifen [Hazard ratio (HR) = 1.09; 95% confidence interval (CI) = 0.96-1.23, p-value = 0.18]. The 5-year rate of osteoporotic fracture for patients treated with either an aromatase inhibitor or tamoxifen was 7.5% and 6.9%, respectively. A completed sensitivity analysis did observe a decreased risk of fracture associated with tamoxifen usage over time. CONCLUSION: We could not detect a significant difference in the rate of osteoporotic fracture among patients treated with an aromatase inhibitor versus tamoxifen. Nonetheless, the risk with tamoxifen was numerically lower and significantly decreased when accounting for total duration of endocrine therapy.

Neighbourhood material deprivation and severe maternal morbidity: a population-based cohort study in Ontario, Canada.

OBJECTIVES: Rates of age-associated severe maternal morbidity (SMM) have increased in Canada, and an association with neighbourhood income is well established. Our aim was to examine SMM trends according to neighbourhood material deprivation quintile, and to assess whether neighbourhood deprivation effects are moderated by maternal age. DESIGN, SETTING AND PARTICIPANTS: A population-based retrospective cohort study using linked administrative databases in Ontario, Canada. We included primiparous women with a live birth or stillbirth at ≥20 weeks' gestational age. PRIMARY OUTCOME: SMM from pregnancy onset to 42 days postpartum. We calculated SMM rate differences (RD) and rate ratios (RR) by neighbourhood material deprivation quintile for each of four 4-year cohorts from 1 April 2002 to 31 March 2018. Log-binomial multivariable regression adjusted for maternal age, demographic and pregnancy-related variables. RESULTS: There were 1 048 845 primiparous births during the study period. The overall rate of SMM was 18.0 per 1000 births. SMM rates were elevated for women living in areas with high material deprivation. In the final 4-year cohort, the RD between women living in high vs low deprivation neighbourhoods was 3.91 SMM cases per 1000 births (95% CI: 2.12 to 5.70). This was higher than the difference observed during the first 4-year cohort (RD 2.09, 95% CI: 0.62 to 3.56). SMM remained associated with neighbourhood material deprivation following multivariable adjustment in the pooled sample (RR 1.16, 95% CI: 1.11 to 1.21). There was no evidence of interaction with maternal age. CONCLUSION: SMM rate increases were more pronounced for primiparous women living in neighbourhoods with high material deprivation compared with those living in low deprivation areas. This raises concerns of a widening social gap in maternal health disparities and highlights an opportunity to focus risk reduction efforts toward disadvantaged women during pregnancy and postpartum.

Effects of removing a fee-for-service incentive on specialist chronic disease services: a time-series analysis. / Effets de la suppression des mesures incitatives s'ajoutant à la rémunération à l'acte sur les services spécialisés liés aux maladies chroniques : une analyse des séries chronologiques.

INTRODUCTION: Physician payment models are known to affect the nature and volume of services provided. Our objective was to study the effects of removing a financial incentive, the fee-for-service premium, on the provision of chronic disease follow-up services by internal medicine, cardiology, nephrology and gastroenterology specialists. METHODS: We collected linked administrative health care data for the period 1 April 2013 to 31 March 2017 from databases held at the Institute for Clinical Evaluative Sciences (ICES) in Ontario, Canada. We conducted a time-series analysis before and after the removal of the fee-for-service premium on 1 April 2015. The primary outcome was total monthly visits for chronic disease follow-up services. Secondary outcomes were monthly visits for total follow-up services and new patient consultations. We compared internal medicine, cardiology, nephrology and gastroenterology specialists practising during the study timeframe with respirology, hematology, endocrinology, rheumatology and infectious diseases specialists who remained eligible to claim the premium. We chose this comparison group as these are all subspecialties of internal medicine, providing similar services. RESULTS: The number of chronic disease follow-up visits decreased significantly after removal of the premium, but there was no decrease in total follow-up visits. There was also a significant downward trend in new patient consultations. No changes were observed in the comparison group. CONCLUSION: The decrease in volume of chronic disease follow-up visits can be explained by diagnostic criteria being met less often, rather than an actual reduction in services provided. Potential effects on patient outcomes require further exploration.