Coronavirus Disease 2019 Vaccination Is Associated With Reduced Outpatient Antibiotic Prescribing in Older Adults With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2: A Population-Wide Cohort Study.

BACKGROUND: Antibiotics are frequently prescribed unnecessarily in outpatients with coronavirus disease 2019 (COVID-19). We sought to evaluate factors associated with antibiotic prescribing in outpatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: We performed a population-wide cohort study of outpatients aged ≥66 years with polymerase chain reaction-confirmed SARS-CoV-2 from 1 January 2020 to 31 December 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1 week before (prediagnosis) and 1 week after (postdiagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary-series COVID-19 vaccination, in univariate and multivariable analyses. RESULTS: We identified 13 529 eligible nursing home residents and 50 885 eligible community-dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3020 (22%) and 6372 (13%), respectively, received at least 1 antibiotic prescription within 1 week of a SARS-CoV-2 positive result. Antibiotic prescribing in nursing home and community residents occurred, respectively, at 15.0 and 10.5 prescriptions per 1000 person-days prediagnosis and 20.9 and 9.8 per 1000 person-days postdiagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted postdiagnosis incidence rate ratios (95% confidence interval) of 0.7 (0.4-1) and 0.3 (0.3-0.4), respectively. CONCLUSIONS: Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis but was reduced in COVID-19-vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.

Risk of Cardiovascular Events and Mortality Among Elderly Patients With Reduced GFR Receiving Direct Oral Anticoagulants.

RATIONALE & OBJECTIVE: Evidence for the efficacy of direct oral anticoagulants (DOACs) to prevent cardiovascular (CV) events and mortality in older individuals with a low estimated glomerular filtration rate (eGFR) is lacking. We sought to characterize the association of oral anticoagulant use with CV morbidity in elderly patients with or without reductions in eGFRs, comparing DOACs with vitamin K antagonists (VKAs). STUDY DESIGN: Population-based retrospective cohort study. SETTINGS & PARTICIPANTS: All individuals 66 years or older with an initial prescription for oral anticoagulants dispensed in Ontario, Canada, from 2009 to 2016. EXPOSURE: DOACs (apixaban, dabigatran, and rivaroxaban) compared with VKAs by eGFR group (≥60, 30-59, and<30mL/min/1.73m2). OUTCOMES: The primary outcome was a composite of a CV event (myocardial infarction, revascularization, or ischemic stroke) or mortality. Secondary outcomes were CV events alone, mortality, and hemorrhage requiring hospitalization. ANALYTICAL APPROACH: High-dimensional propensity score matching of DOAC to VKA users and Cox proportional hazards regression. RESULTS: 27,552 new DOAC users were matched to 27,552 new VKA users (median age, 78 years; 49% women). There was significantly lower risk for CV events or mortality among DOAC users compared with VKA users (event rates of 79.78 vs 99.77 per 1,000 person-years, respectively; HR, 0.82 [95% CI, 0.75-0.90]) and lower risk for hemorrhage (event rates of 10.35 vs 16.77 per 1,000 person-years, respectively; HR, 0.73 [95% CI, 0.58-0.91]). There was an interaction between eGFR and the association of anticoagulant class with the primary composite outcome (P<0.02): HRs of 1.01 [95% CI, 0.92-1.12], 0.83 [95% CI, 0.75-0.93], and 0.75 [95% CI, 0.51-1.10] for eGFRs of≥60, 30 to 59, and<30mL/min/1.73m2. No interaction was detected for the outcome of hemorrhage. LIMITATIONS: Retrospective observational study design limits causal inference; dosages of DOACs and international normalized ratio values were not available; low event rates in some subgroups limited statistical power. CONCLUSIONS: DOACs compared with VKAs were associated with lower risk for the composite of CV events or mortality, an association for which the strength was most apparent among those with reduced eGFRs. The therapeutic implications of these findings await further study.

Evaluation of a preoperative personalized risk communication tool: a prospective before-and-after study.

PURPOSE: Patients want personalized information before surgery; most do not receive personalized risk estimates. Inadequate information contributes to poor experience and medicolegal complaints. We hypothesized that exposure to the Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment (PREDICT) app, a personalized risk communication tool, would improve patient knowledge and satisfaction after anesthesiology consultations compared with standard care. METHODS: We conducted a prospective clinical study (before-after design) and used patient-reported data to calculate personalized risks of morbidity, mortality, and expected length of stay using a locally calibrated National Surgical Quality Improvement Program risk calculator embedded in the PREDICT app. In the standard care (before) phase, the application's materials and output were not available to participants; in the PREDICT app (after) phase, personalized risks were communicated. Our primary outcome was knowledge score after the anesthesiology consultation. Secondary outcomes included patient satisfaction, anxiety, feasibility, and acceptability. RESULTS: We included 183 participants (90 before; 93 after). Compared with standard care phase, the PREDICT app phase had higher post-consultation: knowledge of risks (14.3% higher; 95% confidence interval [CI], 6.5 to 22.0; P < 0.001) and satisfaction (0.8 points; 95% CI, 0.1 to 1.4; P = 0.03). Anxiety was unchanged (- 1.9%; 95% CI, - 4.2 to 0.5; P = 0.13). Acceptability was high for patients and anesthesiologists. CONCLUSION: Exposure to a patient-facing, personalized risk communication app improved knowledge of personalized risk and increased satisfaction for adults before elective inpatient surgery. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03422133); registered 5 February 2018.

RéSUMé: OBJECTIF: Les patients veulent disposer d'informations personnalisées avant leur chirurgie, mais la plupart d'entre eux ne reçoivent pas d'estimations de leur risque personnalisées. Des informations inadéquates contribuent à une mauvaise expérience et à des plaintes médicolégales. Nous avons émis l'hypothèse qu'une exposition à l'application PREDICT (Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment), un outil de communication du risque personnalisé, améliorerait les connaissances et la satisfaction des patients après leurs consultations en anesthésiologie comparativement à des soins standard. MéTHODE: Nous avons réalisé une étude clinique prospective (de type avant-après) et utilisé les données rapportées par les patients afin de calculer leur risque personnalisé de morbidité et de mortalité, ainsi que la durée de séjour anticipée à l'aide d'un calculateur de risque tiré du Programme national d'amélioration de la qualité chirurgicale que nous avons calibré localement et intégré à l'application PREDICT. Dans la phase de soins standard (avant), le contenu et les résultats de l'application n'étaient pas divulgués aux participants; dans la phase comportant l'application PREDICT (après), les risques personnalisés étaient communiqués. Notre critère d'évaluation principal était le score des connaissances des patients après la consultation en anesthésiologie. Les critères d'évaluation secondaires comprenaient la satisfaction des patients et leur niveau d'anxiété ainsi que la faisabilité et l'acceptabilité d'une telle approche. RéSULTATS: Nous avons inclus 183 participants (90 avant; 93 après). Comparativement à la phase de soins standard, la phase avec l'application PREDICT a démontré un niveau plus élevé de connaissances des risques post consultation (14,3 % plus élevé; intervalle de confiance [IC] 95 %, 6,5 à 22,0; P < 0,001) et de satisfaction (0,8 point; IC 95 %, 0,1 à 1,4; P = 0,03). L'anxiété est demeurée inchangée (− 1,9 %; IC 95 %, − 4,2 à 0,5; P = 0,13). L'acceptabilité était élevée, tant chez les patients que chez les anesthésiologistes. CONCLUSION: L'exposition des patients à une application de communication du risque personnalisé a amélioré leurs connaissances de leur risque personnalisé et augmenté la satisfaction des adultes avant une chirurgie non urgente et non ambulatoire. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03422133); enregistrée le 5 février 2018.

Association Between Immigrant Status and End-of-Life Care in Ontario, Canada.

Importance: People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care. Objective: To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life. Design, Setting, and Participants: This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts. Exposures: All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care. Main Outcomes and Measures: Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities. Results: Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia. Conclusions and Relevance: Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.

Describing the linkages of the immigration, refugees and citizenship Canada permanent resident data and vital statistics death registry to Ontario's administrative health database.

BACKGROUND: Ontario, the most populous province in Canada, has a universal healthcare system that routinely collects health administrative data on its 13 million legal residents that is used for health research. Record linkage has become a vital tool for this research by enriching this data with the Immigration, Refugees and Citizenship Canada Permanent Resident (IRCC-PR) database and the Office of the Registrar General's Vital Statistics-Death (ORG-VSD) registry. Our objectives were to estimate linkage rates and compare characteristics of individuals in the linked versus unlinked files. METHODS: We used both deterministic and probabilistic linkage methods to link the IRCC-PR database (1985-2012) and ORG-VSD registry (1990-2012) to the Ontario's Registered Persons Database. Linkage rates were estimated and standardized differences were used to assess differences in socio-demographic and other characteristics between the linked and unlinked records. RESULTS: The overall linkage rates for the IRCC-PR database and ORG-VSD registry were 86.4 and 96.2 %, respectively. The majority (68.2 %) of the record linkages in IRCC-PR were achieved after three deterministic passes, 18.2 % were linked probabilistically, and 13.6 % were unlinked. Similarly the majority (79.8 %) of the record linkages in the ORG-VSD were linked using deterministic record linkage, 16.3 % were linked after probabilistic and manual review, and 3.9 % were unlinked. Unlinked and linked files were similar for most characteristics, such as age and marital status for IRCC-PR and sex and most causes of death for ORG-VSD. However, lower linkage rates were observed among people born in East Asia (78 %) in the IRCC-PR database and certain causes of death in the ORG-VSD registry, namely perinatal conditions (61.3 %) and congenital anomalies (81.3 %). CONCLUSIONS: The linkages of immigration and vital statistics data to existing population-based healthcare data in Ontario, Canada will enable many novel cross-sectional and longitudinal studies to be conducted. Analytic techniques to account for sub-optimal linkage rates may be required in studies of certain ethnic groups or certain causes of death among children and infants.

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.

Quality of diabetes care in the Canadian forces.

BACKGROUND: Published data on quality of care indicators from various countries indicate the challenges of providing high-quality diabetes care. The objective of this study was to evaluate the quality of care provided to members of the Canadian Forces (CF) who have diabetes, by determining the extent to which healthcare providers adhere to recommendations outlined in the 2008 Canadian Diabetes Association (CDA) clinical practice guidelines. METHODS: All 14 CF bases meeting eligibility criteria were included in the evaluation. Cases of diabetes were ascertained based on laboratory criteria. Adherence to 21 CDA guideline recommendations was evaluated following a review of patient medical records. RESULTS: The CF demonstrated high adherence (>75%) with 9 recommendations, moderate adherence (50% to 75%) with 7 recommendations and low adherence (<50%) with 5 recommendations. Most notably, there were 4 recommendations for which adherence was greater than 90%. The mean rate of adherence with all applicable recommendations per patient was 60.3% (95% Confidence Interval [CI], 59.0% to 61.6%). CF adherence rates were generally similar to or better than comparable rates in the civilian population within Canada and other industrialized countries. CONCLUSIONS: It is unclear what accounts for the favourable quality of diabetes care in the CF Health Services, but this highly structured practice setting has a number of features that distinguish it from provincial healthcare systems. Several strategies can be considered to improve diabetes care even further, including providing feedback to physicians about their performance, promoting the use of diabetes care flow sheets and creating a diabetes registry.

Use of acute care hospital services by immigrant seniors in Ontario: A linkage study.

BACKGROUND: Seniors constitute the largest group of hospital users. The increasing share of immigrants in Canada's senior population can affect the demand for hospital care. DATA AND METHODS: This study used the linked 2006 Census-Hospital Discharge Abstract Database to examine hospitalization during the 2004-to-2006 period, by immigrant status, of Ontario seniors living in the community. Hospitalization was assessed with logistic regressions; cumulative length of stay, with zero-truncated negative binomial regressions. All-cause hospitalization and hospitalizations specific to circulatory and digestive diseases were examined. RESULTS: Immigrant seniors had significantly low age-/sex-adjusted odds of hospitalization, compared with Canadian-born seniors (OR = 0.81). The odds varied from 0.4 among East Asians to 0.89 among Europeans, and rose with length of time since arrival from 0.54 for recent (1994 to 2003) to 0.86 for long-term (before 1984) immigrants. Adjustment for demographic and socio-economic characteristics did not change the overall patterns. Immigrants' cumulated length of hospital stay tended to be shorter than or similar to that of Canadian-born seniors. INTERPRETATION: Immigrant seniors, especially recent arrivals, had lower odds of hospitalization and similar time in hospital, compared with Canadian-born seniors. These patterns likely reflect differences in health status. Variations by world region and disease reflect the diverse health care needs of immigrant seniors.

Assessment of the quality and content of clinical practice guidelines for vitamin D and for immigrants using the AGREE II instrument: global systematic review.

BACKGROUND: Worldwide, more immigrants experience vitamin D (vitD) deficiency than non-immigrants. Recommendations in current clinical practice guidelines (CPGs) concerning vitD are inadequate to address vitD deficiency among immigrants, and there are concerns regarding the quality of guidance in these CPGs. OBJECTIVES: This study aimed to identify and evaluate the quality of published CPGs addressing vitD and immigrants' health using the Appraisal of Guidelines for Research and Evaluation-II (AGREE II) tool and clarify the recommendations pertaining to vitD and immigrant populations in these CPGs. METHODS: We performed a systematic search to identify the most recent CPGs across various databases (Ovid MEDLINE ALL, Embase and Turning Research Into Practice), guideline repositories and grey literature. Two reviewers independently conducted study selection and data abstraction and evaluated the quality of the included guidelines using the AGREE II tool. RESULTS: We identified 25 relevant CPGs; 21 focused on vitD and 4 covered immigrants' health. Around one-quarter of the included CPGs were high quality (≥60% in at least four of the six domains, including 'rigour of development'). The highest mean scores among the six AGREE II domains were for 'clarity of presentation' and 'scope and purpose'. About 4.8% (1/21) of the CPGs on vitD had immigrant-related recommendations. VitD recommendations were emphasised in one out of the four immigrant health CPGs (25%). CPGs covering immigrants' health and vitD were inadequately systematically appraised. Moreover, recommendations regarding vitD were insufficient to address the growing epidemic of vitD deficiency among immigrant populations. CONCLUSION: The insufficient recommendations for vitD fail to address the rising vitD deficiency among immigrants, highlighting a critical gap in healthcare provisions. Urgent national and international efforts are needed to develop comprehensive CPGs, bridging research, policy and practice disparities. Future guidelines must prioritise routine vitD screening, supplementation protocols for vulnerable immigrant groups, and culturally appropriate interventions to improve health outcomes for immigrants globally. PROSPERO REGISTRATION NUMBER: CRD42021240562.

End-of-Life Care Among Patients With Kidney Failure on Maintenance Dialysis: A Retrospective Population-Based Study.

Background: Nephrologists routinely provide end-of-life care for patients with kidney failure (KF) on maintenance dialysis. Involvement of primary care and palliative care physicians may enhance this experience. Objective: The objective was to describe outpatient care patterns in the last year of life and the end-of-life acute care utilization for patients with KF on maintenance dialysis. Design: Retrospective cohort study using population-level health administrative data. Setting & Participants: Outpatient and inpatient care during the last year of life among patients who died between 2017 and 2019, receiving maintenance dialysis in Ontario, Canada. Measurements: The primary exposure is patterns of physician specialties providing outpatient care in the last year of life. Outcomes include outpatient encounters in the last year of life, acute care visitation in the last month of life, and place of death. Methods: We reported the count and percentage of categorical outcomes and the median (interquartile range) for numeric outcomes. We produced time series plots of the mean monthly percentage of encounters to different specialties stratified by physician specialty patterns. We evaluated differences in outcomes by physician specialty patterns using analysis of variance (ANOVA) and Pearson's chi-square tests (P < .05, two-tailed). Results: Among 6866 patients, the median age at death was 73, 36.1% were female, and 87.8% resided in urban regions. Three patterns emerged: a primary care, nephrology, and palliative care triad (25.5%); a primary care and nephrology dyad (59.3%); and a non-primary care pattern (15.2%). Palliative care involvement is concentrated near death. Of all, 81.4% spent at least 1 day in hospital or emergency department in the last month, but those with primary care, palliative care, and nephrology involvement had the fewest acute care deaths (65.8%). Limitations: Outpatient care patterns were defined using physician billing codes, potentially missing care from other providers. Conclusions: Nephrology and primary care predominantly manage outpatient care in the last year of life for patients with KF on maintenance dialysis, with consistent acute care use across care patterns except for the place of death. Future research should explore associations between patterns of care and end-of-life outcomes to identify the most optimal model of care for patients with KF on maintenance dialysis.

Contexte: Il est courant pour les néphrologues de prodiguer des soins de fin de vie aux patients souffrant d'insuffisance rénale (IR) sous dialyse d'entretien. Cette expérience pourrait être enrichie par la participation des médecins des unités de soins primaires et de soins palliatifs. Objectif: Cette étude visait à décrire les modèles de soins ambulatoires prodigués au cours de la dernière année de vie et l'utilisation des soins aigus en fin de vie chez les patients atteints d'IR sous dialyse d'entretien. Conception: Étude de cohorte populationnelle rétrospective réalisée à partir des données administratives du système de santé. Cadre et sujets de l'étude: Les soins ambulatoires et hospitaliers au cours de la dernière année de vie chez les patients décédés sous dialyse d'entretien entre 2017 et 2019 en Ontario (Canada). Mesures: La principale mesure est le profil des spécialités médicales qui fournissent des soins ambulatoires dans la dernière année de vie. Les données recueillies comprennent les consultations externes au cours de la dernière année de vie, les visites en soins aigus au cours du dernier mois de vie et le lieu du décès. Méthodologie: Nous avons rapporté le nombre et le pourcentage de résultats catégoriels, ainsi que la médiane (écart interquartile) des résultats numériques. Nous avons produit des graphiques chronologiques du pourcentage mensuel moyen de consultations avec différentes spécialités, stratifiées selon les spécialités médicales. Nous avons évalué les différences dans les résultats selon les profils de spécialités médicales en utilisant les tests ANOVA et Chi-Square de Pearson (P <,05; bilatéral). Résultats: Des 6 866 patients inclus (âge médian au décès: 73 ans), 36,1% étaient des femmes et 87,8% vivaient en région urbaine. Trois modèles sont apparus: une triade soins primaires, néphrologie et soins palliatifs (25,5%); une dyade soins primaires et néphrologie (59,3%); et un modèle de soins non primaires (15,2%). La participation des soins palliatifs est concentrée autour du moment du décès. Une grande majorité des patients (81,4%) avait passé au moins une journée à l'hôpital ou aux urgences au cours du dernier mois, mais les personnes qui avaient bénéficié d'une triade de soins (primaires, néphrologie et soins palliatifs) présentaient une moins grande proportion de décès en soins aigus (65,8%). Limites: Les modèles de soins ambulatoires ont été définis à l'aide des codes de facturation des médecins, ce qui pourrait avoir exclu les soins dispensés par d'autres prestataires. Conclusion: Les soins ambulatoires au cours de la dernière année de vie des patients atteints d'IR sous dialyse d'entretien sont principalement prodigués par la néphrologie et les soins primaires, avec une utilisation constante des soins aigus dans tous les modèles de soins, sauf pour le lieu du décès. Les futures recherches devraient explorer les liens entre les modèles de soins et les résultats en fin de vie afin d'identifier le modèle de soins le plus optimal pour les patients atteints d'IR sous dialyse d'entretien.

Development of a population-based microsimulation mode of physical activity in Canada.

BACKGROUND: Computer simulation modeling makes it possible to project physical activity levels and the prevalence of related health outcomes. Such projections can help to inform programs that aim to increase physical activity levels and improve population health. DATA AND METHODS: The Population Health Model (POHEM) platform was used to develop a dynamic microsimulation model of physical activity among Canadian adults. Key parameters were derived from the National Population Health Survey (1994/1995 to 2006/2007) and the 2000/2001 Canadian Community Health Survey. To assess the validity of the physical activity module (POHEM-PA), estimates from the simulation projections were compared with results from nationally representative surveys. RESULTS: Trends over time in physical activity levels, chronic disease prevalence, and Health Utilities Index based on POHEM-PA projections were similar to those based on data from subsequent cycles of the Canadian Community Health Survey. INTERPRETATION: The addition of a physical activity module to POHEM provides a tool that can improve understanding of the complex dynamics underlying the relationship between physical activity and health outcomes as a population ages.

End-of-life interventions in patients with cancer.

OBJECTIVES: To describe variations in the receipt of potentially inappropriate interventions in the last 100 days of life of patients with cancer according to patient characteristics and cancer site. METHODS: We conducted a population-based retrospective cohort study of cancer decedents in Ontario, Canada who died between 1 January 2013 and 31 December 2018. Potentially inappropriate interventions, including chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy, were captured via hospital discharge records. We used Poisson regression to examine associations between interventions and decedent age, sex, rurality, income and cancer site. RESULTS: Among 151 618 decedents, 81.3% received at least one intervention, and 21.4% received 3+ different interventions. Older patients (age 95-105 years vs 19-44 years, rate ratio (RR) 0.36, 95% CI 0.34 to 0.38) and women (RR 0.94, 95% CI 0.93 to 0.94) had lower intervention rates. Rural patients (RR 1.09, 95% CI 1.08 to 1.10), individuals in the highest area-level income quintile (vs lowest income quintile RR 1.02, 95% CI 1.01 to 1.04), and patients with pancreatic cancer (vs colorectal cancer RR 1.10, 95% CI 1.07 to 1.12) had higher intervention rates. CONCLUSIONS: Potentially inappropriate interventions were common in the last 100 days of life of cancer decedents. Variations in interventions may reflect differences in prognostic awareness, healthcare access, and care preferences and quality. Earlier identification of patients' palliative care needs and involvement of palliative care specialists may help reduce the use of these interventions at the end of life.

Physician continuity of care in the last year of life in community-dwelling adults: retrospective population-based study.

OBJECTIVE: To describe the timing of involvement of various physician specialties over the last year of life across different levels of primary care physician continuity for differing causes of death. METHODS: We conducted a retrospective cohort study of adults who died in Ontario, Canada, between 1 January 2013 and 31 December 2018, using linked population level health administrative data. Outcomes were median days between death and first and last outpatient palliative care specialist encounter, last outpatient encounter with other specialists and with the usual primary care physician. These were calculated by tertile of score on the Usual Provider Continuity Index, defined as the proportion of outpatient physician encounters with the patient's primary care physician. RESULTS: Patients' (n=395 839) mean age at death was 76 years. With increasing category of usual primary care physician continuity, a larger proportion were palliative care generalists, palliative care specialist involvement decreased in duration and was concentrated closer to death, the primary care physician was involved closer to death, and other specialist physicians ceased involvement earlier. For patients with cancer, palliative care specialist involvement was longer than for other patients. CONCLUSIONS: Compared with patients with lower continuity, those with higher usual provider continuity were more likely to have a primary care physician involved closer to death providing generalist palliative care.

Describing settings of care in the last 100 days of life for cancer decedents: a population-based descriptive study.

BACKGROUND: Few studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death. METHODS: A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada. RESULTS: Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home. CONCLUSIONS: In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience.

Detection of Covid-19 Outbreaks Using Built Environment Testing for SARS-CoV-2.

BACKGROUND: Environmental surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through wastewater has become a useful tool for population-level surveillance. Built environment sampling may provide a more spatially refined approach for surveillance in congregate living settings. METHODS: We conducted a prospective study in 10 long-term care homes (LTCHs) between September 2021 and November 2022. Floor surfaces were sampled weekly at multiple locations within each building and analyzed for the presence of SARS-CoV-2 using quantitative reverse transcriptase polymerase chain reaction. The primary outcome was the presence of a coronavirus disease 2019 (Covid-19) outbreak in the week that floor sampling was performed. RESULTS: Over the 14-month study period, we collected 4895 swabs at 10 LTCHs. During the study period, 23 Covid-19 outbreaks occurred with 119 cumulative weeks under outbreak. During outbreak periods, the proportion of floor swabs that were positive for SARS-CoV-2 was 54.3% (95% confidence interval [CI], 52 to 56.6), and during non-outbreak periods it was 22.3% (95% CI, 20.9 to 23.8). Using the proportion of floor swabs positive for SARS-CoV-2 to predict Covid-19 outbreak status in a given week, the area under the receiver-operating characteristic curve was 0.84 (95% CI, 0.78 to 0.9). Among 10 LTCHs with an outbreak and swabs performed in the prior week, eight had positive floor swabs exceeding 10% at least 5 days before outbreak identification. For seven of these eight LTCHs, positivity of floor swabs exceeded 10% more than 10 days before the outbreak was identified. CONCLUSIONS: Detection of SARS-CoV-2 on floors is strongly associated with Covid-19 outbreaks in LTCHs. These data suggest a potential role for floor sampling in improving early outbreak identification.

The influence of measurement error on calibration, discrimination, and overall estimation of a risk prediction model.

BACKGROUND: Self-reported height and weight are commonly collected at the population level; however, they can be subject to measurement error. The impact of this error on predicted risk, discrimination, and calibration of a model that uses body mass index (BMI) to predict risk of diabetes incidence is not known. The objective of this study is to use simulation to quantify and describe the effect of random and systematic error in self-reported height and weight on the performance of a model for predicting diabetes. METHODS: Two general categories of error were examined: random (nondirectional) error and systematic (directional) error on an algorithm relating BMI in kg/m2 to probability of developing diabetes. The cohort used to develop the risk algorithm was derived from 23,403 Ontario residents that responded to the 1996/1997 National Population Health Survey linked to a population-based diabetes registry. The data and algorithm were then simulated to allow for estimation of the impact of these errors on predicted risk using the Hosmer-Lemeshow goodness-of-fit χ2 and C-statistic. Simulations were done 500 times with sample sizes of 9,177 for males and 10,618 for females. RESULTS: Simulation data successfully reproduced discrimination and calibration generated from population data. Increasing levels of random error in height and weight reduced the calibration and discrimination of the model. Random error biased the predicted risk upwards whereas systematic error biased predicted risk in the direction of the bias and reduced calibration; however, it did not affect discrimination. CONCLUSION: This study demonstrates that random and systematic errors in self-reported health data have the potential to influence the performance of risk algorithms. Further research that quantifies the amount and direction of error can improve model performance by allowing for adjustments in exposure measurements.

Screening Large Population Health Databases for Potential Coronavirus Disease 2019 Therapeutics: A Pharmacopeia-Wide Association Study of Commonly Prescribed Medications.

Background: For both the current and future pandemics, there is a need for high-throughput drug screening methods to identify existing drugs with potential preventive and/or therapeutic activity. Epidemiologic studies could complement laboratory-focused efforts to identify possible therapeutic agents. Methods: We performed a pharmacopeia-wide association study (PWAS) to identify commonly prescribed medications and medication classes that are associated with the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in older individuals (≥65 years) in long-term care homes (LTCHs) and the community, between 15 January 2020 and 31 December 2020, across the province of Ontario, Canada. Results: A total of 26 121 cases and 2 369 020 controls from LTCHs and the community were included in this analysis. Many of the drugs and drug classes evaluated did not yield significant associations with SARS-CoV-2 detection. However, some drugs and drug classes appeared to be significantly associated with reduced SARS-CoV-2 detection, including cardioprotective drug classes such as statins (weighted odds ratio [OR], 0.91; standard P < .01, adjusted P < .01) and ß-blockers (weighted OR, 0.87; standard P < .01, adjusted P = .01), along with individual agents ranging from levetiracetam (weighted OR, 0.70; standard P < .01, adjusted P < .01) to fluoxetine (weighted OR, 0.86; standard P = .013, adjusted P = .198) to digoxin (weighted OR, 0.89; standard P < .01, adjusted P = .02). Conclusions: Using this epidemiologic approach, which can be applied to current and future pandemics, we have identified a variety of target drugs and drug classes that could offer therapeutic benefit in coronavirus disease 2019 (COVID-19) and may warrant further validation. Some of these agents (eg, fluoxetine) have already been identified for their therapeutic potential.

Continuity of physician care over the last year of life for different cause-of-death categories: a retrospective population-based study.

BACKGROUND: The mix of care provided by family physicians, specialists and palliative care physicians can vary by the illnesses leading to death, which may result in disruptions of continuity of care at the end of life. We measured continuity of outpatient physician care in the last year of life across differing causes of death and assessed factors associated with higher continuity. METHODS: We conducted a retrospective descriptive study of adults who died in Ontario between 2013 and 2018, using linked provincial health administrative data. We calculated 3 measures of continuity (usual provider, Bice-Boxerman and sequential continuity), which range from 0 to 1, from outpatient physician visits over the last year of life for terminal illness, organ failure, frailty, sudden death and other causes of death. We used multivariable logistic regression models to evaluate associations between characteristics and a continuity score of 0.5 or greater. RESULTS: Among the 417 628 decedents, we found that mean usual provider, Bice-Boxerman and sequential continuity indices were 0.37, 0.30 and 0.37, respectively, with continuity being the lowest for those with terminal illness (0.27, 0.23 and 0.33, respectively). Higher number of comorbidities, higher neighbourhood income quintile and all non-sudden death categories were associated with lower continuity. INTERPRETATION: We found that continuity of physician care in the last year of life was low, especially in those with cancer. Further research is needed to validate measures of continuity against end-of-life health care outcomes.

Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada.

BACKGROUND: The majority of immigrants to Canada originate from the developing world, where the most rapid increase in prevalence of diabetes mellitus is occurring. We undertook a population-based study involving immigrants to Ontario, Canada, to evaluate the distribution of risk for diabetes in this population. METHODS: We used linked administrative health and immigration records to calculate age-specific and age-adjusted prevalence rates among men and women aged 20 years or older in 2005. We compared rates among 1,122,771 immigrants to Ontario by country and region of birth to rates among long-term residents of the province. We used logistic regression to identify and quantify risk factors for diabetes in the immigrant population. RESULTS: After controlling for age, immigration category, level of education, level of income and time since arrival, we found that, as compared with immigrants from western Europe and North America, risk for diabetes was elevated among immigrants from South Asia (odds ratio [OR] for men 4.01, 95% CI 3.82-4.21; OR for women 3.22, 95% CI 3.07-3.37), Latin America and the Caribbean (OR for men 2.18, 95% CI 2.08-2.30; OR for women 2.40, 95% CI: 2.29-2.52), and sub-Saharan Africa (OR for men 2.31, 95% CI 2.17-2.45; OR for women 1.83, 95% CI 1.72-1.95). Increased risk became evident at an early age (35-49 years) and was equally high or higher among women as compared with men. Lower socio-economic status and greater time living in Canada were also associated with increased risk for diabetes. INTERPRETATION: Recent immigrants, particularly women and immigrants of South Asian and African origin, are at high risk for diabetes compared with long-term residents of Ontario. This risk becomes evident at an early age, suggesting that effective programs for prevention of diabetes should be developed and targeted to immigrants in all age groups.

Wait times for women with abnormal uterine bleeding in South-Western Ontario.

OBJECTIVE: Women referred to an obstetrician-gynaecologist because of abnormal uterine bleeding (AUB) should be seen within 12 weeks, according to the benchmarks recommended for medically acceptable wait times established by the Society of Obstetricians and Gynaecologists of Canada. Our study aimed to determine the proportion of patients having wait times that meet this recommendation, and to understand patient-level sources of variation in these waits. METHODS: We performed a secondary analysis of data from the Delivering Primary Healthcare Information (DELPHI) project database. Electronic medical record data from 10 family practices across south-western Ontario were used to study AUB wait times. RESULTS: Over a 30-month period, 223 referrals were made to obstetrician-gynaecologists because of AUB. The mean wait time for initial assessment was 70.4 days (median = 51 days); the range among referring practices varied from 36 to 111 days. Seventy-one percent of women were seen by the obstetrician-gynaecologist within the recommended time of 12 weeks or less. Multi-level regression analysis indicated that older patients were more likely to have shorter waits. The intraclass correlation was 0.256, indicating that nearly a quarter of the variation in wait time was explained at the practice level. CONCLUSION: Nearly 30% of women referred to specialists because of AUB wait longer than the period of time recommended by the SOGC, with younger women more likely to wait longer. This difference may be due to the perception of an increased risk of malignancy in older women. Future research on correlates of AUB wait times should take factors such as severity and prior family physician work up into account.