Characterizing the Impact of Procedure Funding on the Covid-19 Generated Procedure Gap in Ontario: A Population-Based Analysis.

BACKGROUND: Surgical procedures in Canada were historically funded through global hospital budgets. Activity-based funding models were developed to improve access, equity, timeliness, and value of care for priority areas. COVID-19 upended health priorities and resulted in unprecedented disruptions to surgical care, which created a significant procedure gap. We hypothesized that activity-based funding models influenced the magnitude and trajectory of this procedure gap. METHODS: Population-based analysis of procedure rates comparing the pandemic (March 1, 2020-December 31, 2021) to a prepandemic baseline (January 1, 2017-February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates in the pandemic based on the prepandemic baseline. Analyses were stratified by procedure type (outpatient, inpatient), body region, and funding category (activity-based funding programs vs. global budget). RESULTS: In all, 281,328 fewer scheduled procedures were performed during the COVID-19 period compared with the prepandemic baseline (Rate Ratio 0.78; 95% CI 0.77-0.80). Inpatient procedures saw a larger reduction (24.8%) in volume compared with outpatient procedures (20.5%). An increase in the proportion of procedures funded through activity-based programs was seen during the pandemic (52%) relative to the prepandemic baseline (50%). Body systems funded predominantly through global hospital budgets (eg, gynecology, otologic surgery) saw the least months at or above baseline volumes, whereas those with multiple activity-based funding options (eg, musculoskeletal, abdominal) saw the most months at or above baseline volumes. CONCLUSIONS: Those needing procedures funded through global hospital budgets may have been disproportionately disadvantaged by pandemic-related health care disruptions.

Declining Comprehensiveness of Services Delivered by Canadian Family Physicians Is Not Driven by Early-Career Physicians.

We describe changes in the comprehensiveness of services delivered by family physicians in 4 Canadian provinces (British Columbia, Manitoba, Ontario, Nova Scotia) during the periods 1999-2000 and 2017-2018 and explore if changes differ by years in practice. We measured comprehensiveness using province-wide billing data across 7 settings (home, long-term care, emergency department, hospital, obstetrics, surgical assistance, anesthesiology) and 7 service areas (pre/postnatal care, Papanicolaou [Pap] testing, mental health, substance use, cancer care, minor surgery, palliative home visits). Comprehensiveness declined in all provinces, with greater changes in number of service settings than service areas. Decreases were no greater among new-to-practice physicians.

Changes in comprehensiveness of services delivered by Canadian family physicians: Analysis of population-based linked data in 4 provinces.

OBJECTIVE: To describe changes in the comprehensiveness of services delivered by family physicians across service settings and service areas in 4 Canadian provinces, to identify which settings and areas have changed the most, and to compare the magnitude of changes by physician characteristics. DESIGN: Descriptive analysis of province-wide, population-based billing data linked to population and physician registries. SETTING: British Columbia, Manitoba, Ontario, and Nova Scotia. PARTICIPANTS: Family physicians registered to practise in the 1999-2000 and 2017-2018 fiscal years. MAIN OUTCOME MEASURES: Comprehensiveness was measured across 7 service settings (home care, long-term care, emergency departments, hospitals, obstetric care, surgical assistance, anesthesiology) and in 7 service areas consistent with office-based practice (prenatal and postnatal care, Papanicolaou testing, mental health, substance use, cancer care, minor surgery, palliative home visits). The proportion of physicians with activity in each setting and area are reported and the average number of service settings and areas by physician characteristics is described (years in practice, sex, urban or rural practice setting, and location of medical degree training). RESULTS: Declines in comprehensiveness were observed across all provinces studied. Declines were greater for comprehensiveness of settings than for areas consistent with office-based practice. Changes were observed across all physician characteristics. On average across provinces, declines in the number of service settings and service areas were highest among physicians in practice 20 years or longer, male physicians, and physicians practising in urban areas. CONCLUSION: Declining comprehensiveness was observed across all physician characteristics, pointing to changes in the practice and policy contexts in which all family physicians work.

A Population-based Analysis of the COVID-19 Generated Surgical Backlog and Associated Emergency Department Presentations for Inguinal Hernias and Gallstone Disease.

OBJECTIVE: To evaluate the downstream effects of the COVID-19 generated surgical backlog. BACKGROUND: Delayed elective surgeries may result in emergency department (ED) presentations and the need for urgent interventions. METHODS: Population-based repeated cross-sectional study utilizing administrative data. We quantified rates of elective cholecystectomy and inguinal hernia repair and rates of ED presentations, urgent interventions, and outcomes during the first and second waves of COVID-19 (March 1, 2020- February 28, 2021) as compared to a 3-year pre-COVID-19 period (January 1, 2017-February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates during COVID-19 based on the pre-COVID-19 period. The ratio of observed (actual events) to expected rates was generated for surgical procedures (SRRs) and ED visits (ED-RRs). RESULTS: We identified 74,709 elective cholecystectomies and 60,038 elective inguinal hernia repairs. During the COVID-19 period, elective inguinal hernia repairs decreased by 21% (SRR 0.791; 0.760-0.824) whereas elective cholecystectomies decreased by 23% (SRR 0.773; 0.732-0.816). ED visits for inguinal hernia decreased by 17% (ED-RR 0.829; 0.786 - 0.874) whereas ED visits for gallstones decreased by 8% (ED-RR 0.922; 0.878 - 0.967). A higher population rate of urgent cholecystectomy was observed, particularly after the first wave (SRR 1.076; 1.000-1.158). No difference was seen in inguinal hernias. CONCLUSIONS: An over 20% reduction in elective surgeries and an increase in urgent cholecystectomies was observed during the COVID-19 period suggesting a rebound effect secondary to the surgical backlog. The COVID-19 generated surgical backlog will have a heterogeneous downstream effect with significant implications for surgical recovery planning.

Asthma Severity and Control and Their Association With Perinatal Mental Illness.

OBJECTIVE: Growing evidence suggests asthma increases perinatal mental illness risk, but few studies have explored the impact of asthma severity and control. Our objective was to explore the association between asthma severity and control and perinatal mental illness risk and the impact of asthma exacerbations during pregnancy on postpartum mental illness risk. METHODS: This was a population-based retrospective cohort study of all women in Ontario, Canada, from 2005 to 2015 with a singleton live birth who used public drug insurance, excluding women with recent history of mental illness. We constructed modified Poisson regression models to assess the risk of perinatal mental illness, defined as a mood or anxiety, psychotic or substance use disorder, self-harm or other mental illness diagnosed from conception to 365 days postnatally. Models controlled for socio-demographic factors and medical history. RESULTS: There were 62,583 women in the cohort (46.7% between 15 - 24 years), of whom 22.7% had asthma (94.3% mild, 5.7% moderate/severe; 86.5% controlled and 13.5% uncontrolled). After adjustment, there was increased risk of perinatal mental illness with mild asthma (adjusted relative risk [RR]: 1.12; 95% confidence interval [CI], 1.09 to 1.16) and moderate/severe asthma (aRR: 1.16; 95% CI, 1.04 to 1.30) compared to no asthma. Controlled asthma (aRR: 1.11; 95% CI, 1.08 to 1.15) and uncontrolled asthma (aRR: 1.19; 95% CI, 1.11 to 1.27) were also associated with increased perinatal mental illness risk compared to no asthma. Women with worsened asthma during pregnancy had the highest risk of postpartum mental illness compared to no change in asthma status (by severity: aRR: 1.57; 95% CI, 1.36 to 1.80; by control: aRR: 1.37; 95% CI, 1.22 to 1.54). CONCLUSION: Asthma is associated with increased risk of perinatal mental illness, particularly in the presence of asthma exacerbations in pregnancy. The results support multidisciplinary collaborative care programmes throughout the perinatal period, especially among women with asthma exacerbations during pregnancy.

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits.

BACKGROUND: Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients. METHODS: We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes. RESULTS: Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions. INTERPRETATION: Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Ethnic and Immigrant Variations in the Time Trends of Dementia and Parkinsonism.

OBJECTIVE: We assessed long-term incidence and prevalence trends of dementia and parkinsonism across major ethnic and immigrant groups in Ontario. METHODS: Linking administrative databases, we established two cohorts (dementia 2001-2014 and parkinsonism 2001-2015) of all residents aged 20 to 100 years with incident diagnosis of dementia (N = 387,937) or parkinsonism (N = 59,617). We calculated age- and sex-standardized incidence and prevalence of dementia and parkinsonism by immigrant status and ethnic groups (Chinese, South Asian, and the General Population). We assessed incidence and prevalence trends using Poisson regression and Cochran-Armitage trend tests. RESULTS: Across selected ethnic groups, dementia incidence and prevalence were higher in long-term residents than recent or longer-term immigrants from 2001 to 2014. During this period, age- and sex-standardized incidence of dementia in Chinese, South Asian, and the General Population increased, respectively, among longer-term immigrants (by 41%, 58%, and 42%) and long-term residents (28%, 7%, and 4%), and to a lesser degree among recent immigrants. The small number of cases precluded us from assessing parkinsonism incidence trends. For Chinese, South Asian, and the General Population, respectively, prevalence of dementia and parkinsonism modestly increased over time among recent immigrants but significantly increased among longer-term immigrants (dementia: 134%, 217%, and 117%; parkinsonism: 55%, 54%, and 43%) and long-term residents (dementia: 97%, 132%, and 71%; parkinsonism: 18%, 30%, and 29%). Adjustment for pre-existing conditions did not appear to explain incidence trends, except for stroke and coronary artery disease as potential drivers of dementia incidence. CONCLUSION: Recent immigrants across major ethnic groups in Ontario had considerably lower rates of dementia and parkinsonism than long-term residents, but this difference diminished with longer-term immigrants.

Morbidity and mortality reduction associated with polysomnography testing in idiopathic pulmonary fibrosis: a population-based cohort study.

BACKGROUND: It is not well-known if diagnosing and treating sleep breathing disorders among individuals with idiopathic pulmonary fibrosis (IPF) improves health outcomes. We evaluated the association between receipt of laboratory-based polysomnography (which is the first step in the diagnosis and treatment of sleep breathing disorders in Ontario, Canada) and respiratory-related hospitalization and all-cause mortality among individuals with IPF. METHODS: We used a retrospective, population-based, cohort study design, analyzing health administrative data from Ontario, Canada, from 2007 to 2019. Individuals with IPF were identified using an algorithm based on health administrative codes previously developed by IPF experts. Propensity score matching was used to account for potential differences in 41 relevant covariates between individuals that underwent polysomnography (exposed) and individuals that did not undergo polysomnography (controls), in order minimize potential confounding. Respiratory-related hospitalization and all-cause mortality were evaluated up to 12 months after the index date. RESULTS: Out of 5044 individuals with IPF identified, 201 (4.0%) received polysomnography, and 189 (94.0%) were matched to an equal number of controls. Compared to controls, exposed individuals had significantly reduced rates of respiratory-related hospitalization (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.24-0.75), p = 0.003) and all-cause mortality (HR 0.49, 95% CI 0.30-0.80), p = 0.004). Significantly reduced rate of respiratory-related hospitalization (but not all-cause mortality) was also observed among those with > = 1 respiratory-related hospitalization (HR 0.38, 95% CI 0.15-0.99) and systemic corticosteroid receipt (HR 0.37, 95% CI 0.19-0.94) in the year prior to the index date, which reflect sicker subgroups of persons. CONCLUSIONS: Undergoing polysomnography was associated with significantly improved clinically-important health outcomes among individuals with IPF, highlighting the potential importance of incorporating this testing in IPF disease management.

Development and validation of a simple algorithm to estimate common gestational age categories using standard administrative birth record data in Ontario, Canada.

Gestational age is often incompletely recorded in administrative records, despite being critical to paediatric and maternal health research. Several algorithms exist to estimate gestational age using administrative databases; however, many have not been validated or use complicated methods that are not readily adaptable. We developed a simple algorithm to estimate common gestational age categories from routine administrative data. We leveraged a population-based registry of all hospital births occurring in Ontario, Canada over 2002-2016 including 1.8 million birth records. In this sample, this simple algorithm had excellent performance compared to a verified measure of gestational age; 87.61% agreement (95% CI: 87.49, 87.74). The accuracy of the algorithm exceeded 98% for all of the gestational age categories. Agreement notably increased over time and was greatest among singleton births and infants born at 2500-2999 g. This study provides a straight-forward algorithm for accurately estimating common gestational age categories that is easily adaptable for use in other countries.Impact StatementWhat is already known on this subject? Gestational age is often incompletely or inaccurately recorded in administrative health databases, despite being critical to the study of many paediatric and maternal health outcomes. Consequently, researchers must rely on various methods to estimate gestational age, many of these methods are either overly simple (i.e. assuming a uniform duration) or analytically complicated and difficult to adapt for new populations (e.g. regression-based approaches).What the results of this study add? This study, based on a population-based registry of all 1.8 million births occurring in Ontario, Canada 2003-2016, found that a simple, sex-specific algorithm using three commonly recorded birth record characteristics performs almost perfectly compared to a clinical estimate recorded near birth.What the implications are of these findings for clinical practice and/or further research? This study suggests that a straight-forward, sex-specific algorithm based on routinely collected birth record data is able to accurately estimate common gestational age categories (i.e. extreme preterm, <28 weeks; very preterm, 28-32 weeks; moderate-to-late preterm, 33-26 weeks; and term, 37 weeks of completed gestational age). This work will be of greatest interest to perinatal researchers using routinely collected health administrative data.

Prepregnancy Diabetes and Perinatal Mental Illness: A Population-Based Latent Class Analysis.

We examined the risk of any perinatal mental illness associated with prepregnancy diabetes and identified how diabetes duration, complexity, and intensity of care affect this risk. We performed a population-based study of women aged 15-49 years with (n = 14,186) and without (n = 843,818) prepregnancy diabetes who had a singleton livebirth (Ontario, Canada, 2005-2015) and no recent mental illness. Modified Poisson regression estimated perinatal mental illness risk between conception and 1 year postpartum in women with versus without diabetes and in diabetes groups, defined by a latent class analysis of diabetes duration, complexity, and intensity-of-care variables, versus women without diabetes. Women with diabetes were more likely than those without to develop perinatal mental illness (18.1% vs. 16.0%; adjusted relative risk = 1.11, 95% confidence interval: 1.07, 1.15). Latent classes of women with diabetes were: uncomplicated and not receiving regular care (59.7%); complicated, with longstanding diabetes, and receiving regular care (16.4%); and recently diagnosed, with comorbidities, and receiving regular care (23.9%). Perinatal mental illness risk was elevated in all classes versus women without diabetes (adjusted relative risks: 1.09-1.12), but results for class 2 were nonsignificant after adjustment. Women with diabetes could benefit from preconception and perinatal strategies to reduce their mental illness risk.

Health Service Use among Individuals with Depression and Psychological Distress: A Population-Based Cohort Study in Ontario, Canada: Utilisation des services de santé par les personnes souffrant de dépression et de détresse psychologique : une étude de cohorte dans la population de l'Ontario, Canada.

OBJECTIVES: Relatively little is known about how health-care utilization differs among individuals with psychological distress compared to those with major depressive disorder (MDD). METHODS: Ontario participants of the Canadian Community Health Survey Cycle 1.2 (2002) were linked to health administrative data to follow their health-care utilization patterns for up to 15 years. Based on their survey responses, we classified individuals hierarchically into Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria MDD, psychological distress (Kessler-6: 8 to 24), or an unexposed group with neither condition. We compared the rates of outpatient and acute care mental and nonmental health-related visits across the 3 groups over time using Poisson regression. RESULTS: Among the 430 individuals with MDD, 668 with psychological distress, and 9,089 in the unexposed group, individuals with MDD and psychological distress had higher rates of health-care utilization than the unexposed overall and across time. The rates of psychiatrist visits for the MDD group were significantly higher than the other groups initially but declined over the follow-up. Conversely, the rates of psychiatrist visits among the psychological distress group increased over time and converged with that of the MDD group by the end of follow-up (rate ratioMDD vs. psychological distress at 1 year: 4.20 [1.97 to 11.40]; at 15 years: 1.53 [0.54 to 4.08]). Acute care visits were similar between the MDD and psychological distress groups at all time points. CONCLUSIONS: Individuals with psychological distress required mental health care rivalling that of individuals with MDD over time, suggesting that even a cross-sectional assessment of significant psychological distress is a serious clinical concern.

Smoking patterns based on birth-cohort-specific histories from 1965 to 2013, with projections to 2041.

BACKGROUND: Characterizing smoking patterns over time is essential for evaluating the impact of tobacco control interventions and predicting smoking-related mortality. Beginning with a 1920s birth cohort, smoking histories (i.e., estimates of smoking initiation and cessation, and prevalence of current and former smokers) were generated. DATA: The Ontario sample (n = 238,411) of the 2003 to 2013 cycles of the Canadian Community Health Survey, which is conducted biennially, was used to obtain cross-sectional information on current smoking behaviour. METHODS: Age at smoking initiation and age at smoking cessation were used to construct smoking histories for each respondent, up to the survey date. An age-period-cohort model was generated and used to examine survival differences by smoking status. Using the model, and adjusting for survival differences in smoking status, the prevalence of current, former and never smokers was estimated in cohorts from 1920 to 1985. Smoking initiation, cessation and intensity were then estimated for age-specific distributions of each birth cohort. These rates were projected forward through to 2041. Smoking patterns by highest level of education were generated using education-stratified models. RESULTS: Smoking histories show clear trends over time by sex, cohort and age. If current patterns persist, smoking prevalence is projected to decline to single digits (below 10%) by 2023 for women and 2040 for men. DISCUSSION: Birth-cohort-specific smoking histories can be generated using cross-sectional health surveys. These cohort histories can describe smoking patterns over time and into the future. In turn, these histories can be used in micro-simulation models to evaluate historic or planned tobacco control interventions, and to project smoking prevalence.

Chronic physical conditions and risk for perinatal mental illness: A population-based retrospective cohort study.

BACKGROUND: One in 5 women experience mental illness in pregnancy or post partum. Universal preventive interventions have not lowered the incidence of perinatal mental illness, perhaps because those at highest risk were not targeted. Outside of pregnancy, chronic physical conditions are known to confer increased risk for mental illness. Our objective was to examine the association between chronic physical conditions and risk of perinatal mental illness. METHODS AND FINDINGS: We conducted a population-based retrospective cohort study using linked health administrative data sets in Ontario, Canada, in 2005 to 2015. We compared 77,385 women with chronic physical conditions to 780,619 women without such conditions, all of whom had a singleton live birth. Excluded were women with a mental illness diagnosis within 2 years before pregnancy. Chronic physical conditions were captured using the Agency for Healthcare Research and Quality Chronic Condition Indicator, applied to acute healthcare encounters in the 2 years before pregnancy. The outcome was perinatal mental illness, defined by a mental illness or addiction diagnosis arising between conception and 365 days post partum. The outcome was further defined by timing (prenatal or post partum) and specific diagnosis (psychotic disorder, mood or anxiety disorder, substance use disorder, self-harm, or other). Modified Poisson regression generated relative risks and 95% confidence intervals (CIs), adjusted for age, parity, rural residence, income quintile, and remote history of mental health care. Women in the cohort had an average age of 29.6 years (standard deviation 5.4), 44.2% were primiparous, 11.0% lived in a rural area, 40.1% were in the lowest 2 income quintiles, and 47.9% had a remote history of mental health care. More women with (20.4%) than without (15.6%) a chronic physical condition experienced perinatal mental illness-an adjusted relative risk (aRR) of 1.20 (95% CI 1.18-1.22, p < 0.0001). The aRRs were statistically significant for mental illness in pregnancy (1.12, 95% CI 1.10-1.15, p < 0.0001) and post partum (1.25, 95% CI 1.23-1.28, p < 0.0001). Psychotic disorders (aRR 1.50, 95% CI 1.36-1.65, p < 0.0001), mood or anxiety disorders (aRR 1.19, 95% CI 1.17-1.21, p < 0.0001), substance use disorders (aRR 1.47, 95% CI 1.34-1.62, p < 0.0001), and other mental illness (aRR 1.68, 95% CI 1.50-1.87, p < 0.0001) were more likely in women with than without chronic physical conditions, but not self-harm (aRR 1.14, 95% CI 0.87-1.48, p = 0.34). The study was limited by reliance on acute health care encounters to measure chronic physical conditions and the inability to capture undiagnosed mental health problems. CONCLUSIONS: Findings from this study suggest that women with a chronic physical condition predating pregnancy may be at heightened risk of developing mental illness in the perinatal period. These women may require targeted efforts to lower the severity of their condition and improve their coping strategies and supports in pregnancy and thereafter.

Comparing prescribing and dispensing databases to study antibiotic use: a validation study of the Electronic Medical Record Administrative data Linked Database (EMRALD).

BACKGROUND: Monitoring and studying community antibiotic use is a critical component in combating rising antimicrobial resistance. OBJECTIVES: To validate an electronic medical record dataset containing antibiotic prescriptions and to quantify some important differences between prescribing and dispensing databases. METHODS: We evaluated antibiotics prescribed and dispensed to patients ≥65 years of age during 2011-15. We compared the EMRALD prescribing database with the validated Ontario Drug Benefit (ODB) dispensing database. Using ODB as the gold standard and limiting to EMRALD physicians, we calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% CIs. We also compared the relative change in antibiotic use prescribed by all physicians to this population over time between the databases using Poisson regression models. RESULTS: In this population, 74% of all antibiotics dispensed were from non-EMRALD physicians. Trends in use were discordant over time. When we limited ODB to EMRALD prescribers only to assess the validity of EMRALD data, we observed good sensitivity and excellent specificity for correctly identifying antibiotics at 85% (95% CI 84%-85%) and 98% (95% CI 98%-98%), respectively. The PPV was 78% (95% CI 78%-78%) and the NPV was 99% (95% CI 99%-99%). All performance measures were higher among the highest prescribing physicians. CONCLUSIONS: We demonstrated EMRALD is well suited for studying antibiotic prescribing by EMRALD physicians. However, due to the frequency with which patients receive antibiotic prescriptions from their non-primary care physicians, we caution against the use of non-population-based prescribing databases to infer antibiotic use rates or trends over time.

Time Trends of the Incidence, Prevalence, and Mortality of Parkinsonism.

OBJECTIVES: We assessed trends in the incidence, prevalence, and post-diagnosis mortality of parkinsonism in Ontario, Canada over 18 years. We also explored the influence of a range of risk factors for brain health on the trend of incident parkinsonism. METHODS: We established an open cohort by linking population-based health administrative databases from 1996 to 2014 in Ontario. The study population comprised residents aged 20-100 years with an incident diagnosis of parkinsonism ascertained using a validated algorithm. We calculated age- and sex-standardized incidence, prevalence, and mortality of parkinsonism, stratified by young onset (20-39 years) and mid/late onset (≥40 years). We assessed trends in incidence using Poisson regression, mortality using negative binomial regression, and prevalence of parkinsonism and pre-existing conditions (e.g., head injury) using the Cochran-Armitage trend test. To better understand trends in the incidence of mid/late-onset parkinsonism, we adjusted for various pre-existing conditions in the Poisson regression model. RESULTS: From 1996 to 2014, we identified 73,129 incident cases of parkinsonism (source population of ∼10.5 million), of whom 56% were male, mean age at diagnosis was 72.6 years, and 99% had mid/late-onset parkinsonism. Over 18 years, the age- and sex-standardized incidence decreased by 13.0% for mid/late-onset parkinsonism but remained unchanged for young-onset parkinsonism. The age- and sex-standardized prevalence increased by 22.8%, while post-diagnosis mortality decreased by 5.5%. Adjustment for pre-existing conditions did not appreciably explain the declining incidence of mid/late-onset parkinsonism. CONCLUSION: Young-onset and mid/late-onset parkinsonism exhibited differing trends in incidence over 18 years in Ontario. Further research to identify other factors that may appreciably explain trends in incident parkinsonism is warranted.

Recent trends in child and youth emergency department visits because of pedestrian motor vehicle collisions by socioeconomic status in Ontario, Canada.

BACKGROUND: Children in lower-income households have higher injury rates. Trends in emergency department (ED) visits by children 0-19 years because of pedestrian motor vehicle collisions (PMVCs) in Ontario, Canada (2008-2015) by socioeconomic status were examined. METHODS: PMVC ED data were obtained from the Institute for Clinical Evaluative Sciences for children age 0-19 years over the period 2008-2015. Age-adjusted rates were calculated using Ontario census data. Household income quintiles were determined from the Registered Persons Database. Poisson regression was used to model ED visit rates by year, age and income quintile. RESULTS: The frequency of child PMVC ED visits in Ontario decreased from 1562 in 2008 to 1281 in 2015. Age-adjusted rates were unchanged over time (IRR 1.00, 95% CI 0.99 to 1.00); however, rate disparities by income status persisted with an IRR of 0.52 (0.50 to 0.55) comparing the highest with the lowest income level. CONCLUSIONS: Exposure to traffic may play a role in rate disparities by income status in child PMVC; however, less safe traffic environments in lower income areas may also be strong contributors. These findings highlight the potential impact of roadway safety modifications in lower income areas to mitigate disparities in injury rates by socioeconomic status.

Living near major roads and the incidence of dementia, Parkinson's disease, and multiple sclerosis: a population-based cohort study.

BACKGROUND: Emerging evidence suggests that living near major roads might adversely affect cognition. However, little is known about its relationship with the incidence of dementia, Parkinson's disease, and multiple sclerosis. We aimed to investigate the association between residential proximity to major roadways and the incidence of these three neurological diseases in Ontario, Canada. METHODS: In this population-based cohort study, we assembled two population-based cohorts including all adults aged 20-50 years (about 4·4 million; multiple sclerosis cohort) and all adults aged 55-85 years (about 2·2 million; dementia or Parkinson's disease cohort) who resided in Ontario, Canada on April 1, 2001. Eligible patients were free of these neurological diseases, Ontario residents for 5 years or longer, and Canadian-born. We ascertained the individual's proximity to major roadways based on their residential postal-code address in 1996, 5 years before cohort inception. Incident diagnoses of dementia, Parkinson's disease, and multiple sclerosis were ascertained from provincial health administrative databases with validated algorithms. We assessed the associations between traffic proximity and incident dementia, Parkinson's disease, and multiple sclerosis using Cox proportional hazards models, adjusting for individual and contextual factors such as diabetes, brain injury, and neighbourhood income. We did various sensitivity analyses, such as adjusting for access to neurologists and exposure to selected air pollutants, and restricting to never movers and urban dwellers. FINDINGS: Between 2001, and 2012, we identified 243 611 incident cases of dementia, 31 577 cases of Parkinson's disease, and 9247 cases of multiple sclerosis. The adjusted hazard ratio (HR) of incident dementia was 1·07 for people living less than 50 m from a major traffic road (95% CI 1·06-1·08), 1·04 (1·02-1·05) for 50-100 m, 1·02 (1·01-1·03) for 101-200 m, and 1·00 (0·99-1·01) for 201-300 m versus further than 300 m (p for trend=0·0349). The associations were robust to sensitivity analyses and seemed stronger among urban residents, especially those who lived in major cities (HR 1·12, 95% CI 1·10-1·14 for people living <50 m from a major traffic road), and who never moved (1·12, 1·10-1·14 for people living <50 m from a major traffic road). No association was found with Parkinson's disease or multiple sclerosis. INTERPRETATION: In this large population-based cohort, living close to heavy traffic was associated with a higher incidence of dementia, but not with Parkinson's disease or multiple sclerosis. FUNDING: Health Canada (MOA-4500314182).

Introduction of surgical safety checklists in Ontario, Canada.

BACKGROUND: Evidence from observational studies that the use of surgical safety checklists results in striking improvements in surgical outcomes led to the rapid adoption of such checklists worldwide. However, the effect of mandatory adoption of surgical safety checklists is unclear. A policy encouraging the universal adoption of checklists by hospitals in Ontario, Canada, provided a natural experiment to assess the effectiveness of checklists in typical practice settings. METHODS: We surveyed all acute care hospitals in Ontario to determine when surgical safety checklists were adopted. Using administrative health data, we compared operative mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department visits within 30 days after discharge among patients undergoing a variety of surgical procedures before and after adoption of a checklist. RESULTS: During 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29). CONCLUSIONS: Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications. (Funded by the Canadian Institutes of Health Research.).

Perinatal suicide in Ontario, Canada: a 15-year population-based study.

BACKGROUND: Death by suicide during the perinatal period has been understudied in Canada. We examined the epidemiology of and health service use related to suicides during pregnancy and the first postpartum year. METHODS: In this retrospective, population-based cohort study, we linked health administrative databases with coroner death records (1994-2008) for Ontario, Canada. We compared sociodemographic characteristics, clinical features and health service use in the 30 days and 1 year before death between women who died by suicide perinatally, women who died by suicide outside of the perinatal period and living perinatal women. RESULTS: The perinatal suicide rate was 2.58 per 100 000 live births, with suicide accounting for 51 (5.3%) of 966 perinatal deaths. Most suicides occurred during the final quarter of the first postpartum year, with highest rates in rural and remote regions. Perinatal women were more likely to die from hanging (33.3% [17/51]) or jumping or falling (19.6% [10/51]) than women who died by suicide non-perinatally (p = 0.04). Only 39.2% (20/51) had mental health contact within the 30 days before death, similar to the rate among those who died by suicide non-perinatally (47.7% [762/1597]; odds ratio [OR] 0.71, 95% confidence interval [CI] 0.40-1.25). Compared with living perinatal women matched by pregnancy or postpartum status at date of suicide, perinatal women who died by suicide had similar likelihood of non-mental health primary care and obstetric care before the index date but had a lower likelihood of pediatric contact (64.5% [20/31] v. 88.4% [137/155] at 30 days; OR 0.24, 95% CI 0.10-0.58). INTERPRETATION: The perinatal suicide rate for Ontario during the period 1994-2008 was comparable to international estimates and represents a substantial component of Canadian perinatal mortality. Given that deaths by suicide occur throughout the perinatal period, all health care providers must be collectively vigilant in assessing risk.