Multimorbidity and Complexity Among Patients with Cancer in Ontario: A Retrospective Cohort Study Exploring the Clustering of 17 Chronic Conditions with Cancer.

BACKGROUND: Multimorbidity is a concern for people living with cancer, as over 90% have at least one other condition. Multimorbidity complicates care coming from multiple providers who work within separate, siloed systems. Information describing high-risk and high-cost disease combinations has potential to improve the experience, outcome, and overall cost of care by informing comprehensive care management frameworks. This study aimed to identify disease combinations among people with cancer and other conditions, and to assess the health burden associated with those combinations to help healthcare providers more effectively prioritize and coordinate care. METHODS: We used a population-based retrospective cohort design including adults with a cancer diagnosis between March-2003 and April-2013, followed-up until March 2018. We used observed disease combinations defined by level of multimorbidity and partitive (k-means) clusters, ie groupings of similar diseases based on the prevalence of each condition. We assessed disease combination-associated health burden through health service utilization, including emergency department visits, primary care visits and hospital admissions during the follow-up period. RESULTS: 549,248 adults were included in the study. Anxiety, diabetes mellitus, hypertension, and osteoarthritis co-occurred with cancer 1.1 to 5.3 times more often than expected by chance. Disease combinations varied by cancer type and age but were similar between sexes. The largest partitive cluster included cancer and anxiety, with at least 25% of individuals also having osteoarthritis. Cancer also tended to co-occur with hypertension (8.0%) or osteoarthritis (6.2%). There were differences between clusters in healthcare utilization, regardless of the number of disease combinations or clustering approach used. CONCLUSION: Researchers, clinicians, policymakers, and other stakeholders can use the clustering information presented here to improve the healthcare system for people with cancer multimorbidity by developing cluster-specific care management and clinical guidelines for common disease combinations.

Prevalence of multimorbidity in adults with cancer, and associated health service utilization in Ontario, Canada: a population-based retrospective cohort study.

BACKGROUND: The majority of people with cancer have at least one other chronic health condition. With each additional chronic disease, the complexity of their care increases, as does the potential for negative outcomes including premature death. In this paper, we describe cancer patients' clinical complexity (i.e., multimorbidity; MMB) in order to inform strategic efforts to improve care and outcomes for people with cancer of all types and commonly occurring chronic diseases. METHODS: We conducted a population-based, retrospective cohort study of adults diagnosed with cancer between 2003 and 2013 (N = 601,331) identified in Ontario, Canada healthcare administrative data. During a five to 15-year follow-up period (through March 2018), we identified up to 16 co-occurring conditions and patient outcomes for the cohort, including health service utilization and death. RESULTS: MMB was extremely common, affecting more than 91% of people with cancer. Nearly one quarter (23%) of the population had five or more co-occurring conditions. While we saw no differences in MMB between sexes, MMB prevalence and level increased with age. MMB prevalence and type of co-occurring conditions also varied by cancer type. Overall, MMB was associated with higher rates of health service utilization and mortality, regardless of other patient characteristics, and specific conditions differentially impacted these rates. CONCLUSIONS: People with cancer are likely to have at least one other chronic medical condition and the presence of MMB negatively affects health service utilization and risk of premature death. These findings can help motivate and inform health system advances to improve care quality and outcomes for people with cancer and MMB.

Do graphic health warning labels on cigarette packages deter purchases at point-of-sale? An experiment with adult smokers.

This experiment tested whether the presence of graphic health warning labels on cigarette packages deterred adult smokers from purchasing cigarettes at retail point-of-sale (POS), and whether individual difference variables moderated this relationship. The study was conducted in the RAND StoreLab (RSL), a life-sized replica of a convenience store that was developed to evaluate how changing POS tobacco advertising influences tobacco use outcomes during simulated shopping experiences. Adult smokers (n = 294; 65% female; 59% African-American; 35% White) were assigned randomly to shop in the RSL under one of two experimental conditions: graphic health warning labels present on cigarette packages versus absent on cigarette packages. Cigarette packages in both conditions were displayed on a tobacco power wall, which was located behind the RSL cashier counter. Results revealed that the presence of graphic health warning labels did not influence participants' purchase of cigarettes as a main effect. However, nicotine dependence acted as a significant moderator of experimental condition. Graphic health warning labels reduced the chances of cigarette purchases for smokers lower in nicotine dependence but had no effect on smokers higher in dependence.

One size fits all? Disentangling the effects of tobacco taxes, laws, and control spending on adult subgroups in the United States.

Background: To determine the relative impact of each of the 3 state-level tobacco control policies (cigarette taxation, tobacco control spending, and smoke-free air [SFA] laws) on adult smoking rate overall and separately for adult subgroups in the United States. Methods: A difference-in-differences analysis was conducted with generalized propensity scores. State-level policies were merged with the individual-level Behavioral Risk Factor Surveillance System in 1995-2009. Results: State cigarette taxation was the only policy that significantly impacted smoking among the general adult population, with a 1-standard deviation increase in taxes (i.e., $0.68 in constant 2014 dollars) lowering the adult smoking rate by about a quarter of a percentage point. The taxation impact was consistent, regardless of the presence of, or interactions with, other policies. Taxation was also the only policy that significantly reduced smoking for some adult subgroups, including females, non-Hispanic whites, adults aged 51 or older, and adults with more than a high school education. However, other adult subgroups responded to the other 2 types of policies, either by mediating the taxation effect or by reducing smoking independently. Specifically, tobacco control spending reduced smoking among young adults (ages 18-25 years) and Hispanics. SFA laws affected smoking among men, young adults, non-Hispanic blacks, and Hispanics. Conclusions: State cigarette taxation is the single most important policy for reducing smoking among the general adult population. However, adult subgroups' reactions to taxes are diverse and mediated by tobacco control spending and SFA laws.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care.

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Perceptions of e-cigarettes: a comparison of adult smokers and non-smokers in a Mechanical Turk sample.

BACKGROUND: Given plans to extend its regulatory authority to e-cigarettes, the Food and Drug Administration (FDA) urgently needs to understand how e-cigarettes are perceived by the public. OBJECTIVES: To examine how smoking status impacts adult perceptions and expectations of e-cigarettes. METHODS: We used Mechanical Turk (MTurk), a "crowdsourcing" platform, to rapidly survey a large (n = 796; female = 381; male = 415), diverse sample of adult ever (44%) and never smokers (56%), including ever (28%) and never (72%) users of e-cigarettes. RESULTS: Smokers and non-smokers learned about e-cigarettes primarily through the internet and conversations with others. Ever smokers were more likely than never smokers, and female current smokers were more likely than female former smokers, to have learned about e-cigarettes from point of sale advertising (p's < 0.05) and to believe that e-cigarettes help smokers quit (ps < 0.05). Among never users of e-cigarettes, current smokers were more likely than never smokers and former smokers to report that they would try e-cigarettes in the future (ps < 0.01). Current smokers' top reason for wanting to try e-cigarettes was to quit or reduce smoking (56%), while never and former smokers listed curiosity. In contrast, female current smokers' top reason for not trying e-cigarettes was health and safety concerns (44%) while males were deterred by expense (44%). CONCLUSIONS: Adult smokers and non-smokers have different perceptions and expectations of e-cigarettes. Public health messages regarding e-cigarettes may need to be tailored separately for persons with and without a history of using conventional cigarettes. Tailoring messages by gender within smoker groups may also improve their impact.

Hiding the tobacco power wall reduces cigarette smoking risk in adolescents: using an experimental convenience store to assess tobacco regulatory options at retail point-of-sale.

OBJECTIVES: This experiment tested whether changing the location or visibility of the tobacco power wall in a life sized replica of a convenience store had any effect on adolescents' susceptibility to future cigarette smoking. METHODS: The study was conducted in the RAND StoreLab (RSL), a life sized replica of a convenience store that was developed to experimentally evaluate how changing aspects of tobacco advertising displays in retail point-of-sale environments influences tobacco use risk and behaviour. A randomised, between-subjects experimental design with three conditions that varied the location or visibility of the tobacco power wall within the RSL was used. The conditions were: cashier (the tobacco power wall was located in its typical position behind the cash register counter); sidewall (the tobacco power wall was located on a sidewall away from the cash register); or hidden (the tobacco power wall was located behind the cashier but was hidden behind an opaque wall). The sample included 241 adolescents. RESULTS: Hiding the tobacco power wall significantly reduced adolescents' susceptibility to future cigarette smoking compared to leaving it exposed (ie, the cashier condition; p=0.02). Locating the tobacco power wall on a sidewall away from the cashier had no effect on future cigarette smoking susceptibility compared to the cashier condition (p=0.80). CONCLUSIONS: Hiding the tobacco power wall at retail point-of-sale locations is a strong regulatory option for reducing the impact of the retail environment on cigarette smoking risk in adolescents.

Matching Mobile Crisis Models to Communities: An Example from Northwestern Ontario.

Police are often the first to encounter individuals when they are experiencing a mental health crisis. Other professionals with different skill sets, however, may be needed to optimize crisis response. Increasingly, police and mental health agencies are creating co-responder teams (CRTs) in which police and mental health professionals co-respond to crisis calls. While past evaluations of CRTs have shown promising results (e.g. hospital diversions; cost-effectiveness), most studies occurred in larger urban contexts. How CRTs function in smaller jurisdictions, with fewer complementary resources and other unique contextual features, is unknown. This paper describes the evaluation of a CRT operating in a geographically isolated and northern mid-sized city in Ontario, Canada. Data from program documents, interviews with frontline and leadership staff, and ride-along site visits were analyzed according to an extended Donabedian framework. Through thematic analysis, 12 themes and 11 subthemes emerged. Overall, data showed that the program was generally operating and supporting the community as intended through crisis de-escalation and improved quality of care, but it illuminated potential areas for improvement, including complementary community-based services. Data suggested specific structures and processes of the embedded CRT model for optimal function in a northern context, and it demonstrated the transferability of the CRT model beyond large urban centres. This research has implications for how communities can make informed choices about what crisis models are best for them based on their resources and context, thus potentially improving crisis response and alleviating strain on emergency departments and systems.

Advancing Measurement-Informed Care in Outpatient Community Behavioral Health.

Measurement-informed care (MIC), also known as measurement-based care or patient-reported outcomes, for behavioral health conditions has had low uptake in the United States. To advance MIC in the near term, the authors reviewed nationally endorsed behavioral health measures and worked with national experts to recommend a core set of outpatient measures to prioritize for use. The resulting set of measures is for common behavioral and comorbid conditions and is outcomes based, low burden, and suitable for value-based payment. The panel of national experts also recommended developing a consensus on quality-of-life measures and functional measures for use across diagnostic categories of the core set.

Cannabis advertising impacts on youth cannabis use intentions following recreational legalization in Canada: An Ecological Momentary Assessment (EMA) study.

OBJECTIVE: In 2018, Canada's Cannabis Act legalized adult recreational cannabis use and limited cannabis product advertising to adults. Cannabis product advertising to youth remains illegal. The extent to which adult-targeted, or illicit youth-targeted cannabis advertisements is reaching and impacting Canadian youth is unknown. We used Ecological Momentary Assessment (EMA) to describe how often and how much exposures to cannabis advertising influence Canadian youths' real-world, real-time intentions to use cannabis. METHODS: 120 Ontario, Canada youths ages 14-18, took photos of cannabis advertising that they encountered in their natural environments over a period of nine consecutive days. Following each exposure and twice daily device-issued random prompts, they also rated their intentions to use cannabis. RESULTS: Many participating youth (n = 85; 70.83 %) reported at least one cannabis advertising exposure during the study (range 1-30, M = 4.02). Exposures occurred through a range of advertising channels (e.g., internet ads, billboards). Multilevel modeling showed that youth advertising exposure increased cannabis use intentions in vivo (ß = 0.06,SE = 0.03;t = 1.98;p =.04;n = 1,348). CONCLUSION: Data from this study shows that cannabis advertisements are regularly reaching Canadian youth and increasing their intentions to use cannabis. This suggests that current Canadian prohibitions on cannabis advertising to youth are ineffective and/or ineffectively enforced, and that the Canadian government needs additional or enhanced prohibitions on cannabis promotion to protect youth from harms associated with increased advertisement exposure, such as increased cannabis use.

Technology for advancing behavioral health integration: implications for behavioral health practice and policy.

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

Behavioral health integration (BHI) combines physical, mental, and substance use care to enhance overall well-being. While BHI offers benefits, it faces challenges. Researchers developed the Continuum-Based Framework to aid primary healthcare centers in implementing BHI. Technology is key to supporting BHI effectiveness. Researchers examined how technology can assist with BHI by interviewing experts and analyzing real-world examples. They found that technology helps healthcare centers address BHI challenges by ensuring comprehensive and equitable care delivery, promoting patient engagement, and supporting healthcare providers. Technology can improve BHI practices over time, but policy, investment, and privacy changes are necessary for optimal integration.

Exposure to pro-smoking media in college students: does type of media channel differentially contribute to smoking risk?

BACKGROUND: There are almost no data on whether the different channels through which pro-smoking media appear (i.e., point-of-sale advertising, movie smoking) differently influence smoking. PURPOSE: This study used ecological momentary assessment to examine whether differences in smoking risk were observed for exposures to different pro-smoking media channels. METHODS: College students (n = 134) carried smartphones for 21 days, recording their exposures to pro-smoking media and the media channels for that exposure and responding to three randomly issued control prompts per day. Participants answered questions about their future smoking risk after each pro-smoking media exposure and random prompt. RESULTS: Participants had elevated future smoking risk following exposure to pro-smoking media at point of sale (p < 0.001); smoking risk at times of exposure to smoking in movies did not differ from risk measured during control prompts (p = 0.78). CONCLUSIONS: There is merit to examining the relative contribution of different pro-smoking media channels to smoking behavior.

The impact of multimorbidity on severe COVID-19 outcomes in community and congregate settings.

Purpose: This study examined the impact of multimorbidity on severe COVID-19 outcomes in community and long-term care (LTC) settings, alone and in interaction with age and sex. Methods: We conducted a retrospective cohort study of all Ontarians who tested positive for COVID-19 between January-2020 and May-2021 with follow-up until June 2021. We used cox regression to evaluate the adjusted impact of multimorbidity, individual characteristics, and interactions on time to hospitalization and death (any cause). Results: 24.5% of the cohort had 2 or more pre-existing conditions. Multimorbidity was associated with 28% to 170% shorter time to hospitalization and death, respectively. However, predictors of hospitalization and death differed for people living in community and LTC. In community, increasing multimorbidity and age predicted shortened time to hospitalization and death. In LTC, we found none of the predictors examined were associated with time to hospitalization, except for increasing age that predicted reduced time to death up to 40.6 times. Sex was a predictor across all settings and outcomes: among male the risk of hospitalization or death was higher shortly after infection (e.g. HR for males at 14 days = 30.3) while among female risk was higher for both outcome in the longer term (e.g. HR for males at 150 days = 0.16). Age and sex modified the impact of multimorbidity in the community. Conclusion: Community-focused public health measures should be targeted and consider sociodemographic and clinical characteristics such as multimorbidity. In LTC settings, further research is needed to identify factors that may contribute to improved outcomes.

The effects of Arkansas master settlement spending on disparities in smoking.

OBJECTIVES: We assessed the effect of Master Settlement Agreement (MSA) spending on smoking disparities in Arkansas, which distinguished itself from other states by investing all of its MSA funds in health-related programs. METHODS: In 1996-2009 data from the Behavioral Risk Factor Surveillance System, we specified multivariate logistic models to examine gender and racial/ethnic disparities in smoking rates within Arkansas (a pre-post analysis) and between Arkansas and its 6 neighboring states. RESULTS: Before the MSA programs started in 2001, male Arkansans smoked more than did female Arkansans (P < .05). After the programs, smoking declined significantly among men (but not women), eliminating the gender disparity by 2009. Smoking among men in Arkansas also declined more than it did in neighboring states (P < .05). Hispanics showed a greater decline in smoking than did non-Hispanic Whites in Arkansas (but not in neighboring states). In 2001, Hispanic Arkansans smoked more than did non-Hispanic Whites (P < .05); by 2009, Hispanic Arkansans smoked significantly less than did non-Hispanic Whites (P < .05). CONCLUSIONS: MSA-funded programs were more effective in some segments of the Arkansas population than in others. Policymakers should consider targeting future MSA tobacco control programs to populations most resistant to change.

Measuring exposure to protobacco marketing and media: a field study using ecological momentary assessment.

INTRODUCTION: The aims of this study were to validate ecological momentary assessment (EMA) as a method for measuring exposure to tobacco-related marketing and media and to use this method to provide detailed descriptive data on college students' exposure to protobacco marketing and media. METHODS: College students (n = 134; ages 18-24 years) recorded their exposures to protobacco marketing and media on handheld devices for 21 consecutive days. Participants also recalled exposures to various types of protobacco marketing and media at the end of the study period. RESULTS: Retrospectively recalled and EMA-based estimates of protobacco marketing exposure captured different information. The correlation between retrospectively recalled and EMA-logged exposures to tobacco marketing and media was moderate (r = .37, p < .001), and EMA-logged exposures were marginally associated with the intention to smoke at the end of the study, whereas retrospective recall of exposure was not. EMA data showed that college students were exposed to protobacco marketing through multiple channels in a relatively short period: Exposures (M = 8.24, SD = 7.85) occurred primarily in the afternoon (42%), on weekends (35%), and at point-of-purchase locations (68%) or in movies/TV (20%), and exposures to Marlboro, Newport, and Camel represented 56% of all exposures combined and 70% of branded exposures. CONCLUSIONS: Findings support the validity of EMA as a method for capturing detailed information about youth exposure to protobacco marketing and media that are not captured through other existing methods. Such data have the potential to highlight areas for policy change and prevention in order to reduce the impact of tobacco marketing on youth.

Structural Components of Integrated Behavioral Health Care: A Comparison of National Programs.

Initiatives that support and incentivize the integration of behavioral health and general medical care have become a focus of government strategies to achieve the triple aim of improved health, better patient experience, and reduced costs. The authors describe the components of four large-scale national initiatives aimed at integrating care for a wide range of behavioral health needs. Commonalities across these national initiatives highlight health care and social services needs that must be addressed to improve care for people with co-occurring behavioral health and general medical conditions. These findings can inform how to design, test, select, and align the most promising strategies for integrated care in a variety of settings.

Experiences, impacts and service needs of injured and ill workers in the WSIB process: evidence from Thunder Bay and District (Ontario, Canada). / Expériences, besoins en services et répercussions des processus de la Commission de la sécurité professionnelle et de l'assurance contre les accidents du travail (WSIB) chez les travailleurs blessés et malades : données probantes de la ville et du district de Thunder Bay (Ontario, Canada).

INTRODUCTION: Individuals experience negative physical, social and psychological ramifications when they are hurt or become ill at work. Ontario's Workplace Safety and Insurance Board (WSIB) is intended to mitigate these effects, yet the WSIB process can be difficult. Supports for injured workers can be fragmented and scarce, especially in underserved areas. We describe the experiences and mental health needs of injured and ill Northwestern Ontario workers in the WSIB process, in order to promote system improvements. METHODS: Community-recruited injured and ill workers (n = 40) from Thunder Bay and District completed an online survey about their mental health, social service and legal system needs while involved with WSIB. Additional Northwestern Ontario injured and ill workers (n = 16) and community service providers experienced with WSIB processes (n = 8) completed interviews addressing similar themes. RESULTS: Northwestern Ontario workers described the impacts of workplace injury and illness on their professional, family, financial and social functioning, and on their physical and mental health. Many also reported incremental negative impacts of the WSIB processes themselves, including regional issues such as "small town" privacy concerns and the cost burden of travel required by the WSIB, especially during COVID-19. Workers and service providers suggested streamlining and explicating WSIB processes, increasing WSIB continuity of care, and region-specific actions such as improving access to regional support services through arm's-length navigators. CONCLUSION: Northwestern Ontario workers experienced negative effects from workplace injuries and illness and the WSIB process itself. Stakeholders can use these findings to improve processes and outcomes for injured and ill workers, with special considerations for the North.

Nicotine replacement prescribing trends in a large psychiatric hospital, before and after implementation of a hospital-wide smoking ban.

OBJECTIVE: We examined prescribing patterns for nicotine replacement therapies (NRTs) in a large psychiatric hospital, before and after the implementation of a smoking ban. METHOD: We extracted 5 years of NRT utilization data from hospital pharmacy records. The ban went into effect on January 1, 2007. Data reflect NRT prescriptions from 2 years before and 3 years after the ban, and N = 30,908 total inpatient hospital admissions. RESULTS: The monthly rate of total NRT prescriptions increased after the ban from M = 254.25 (SD = 126.60) doses per month to M = 4,467.52 (SD = 1,785.87) doses per month (>1,700% increase, p < .0001). After the smoking ban, clinicians prescribed higher doses of transdermal (but not oral) NRT (Tukey, p < .0001). Comparisons of NRT prescribing across hospital units tentatively suggested that patients being treated on the substance use disorders unit were prescribed more doses of NRT, as well as higher doses of NRT compared with patients on other units. Analysis of trends over time showed no apparent downward trend for NRT usage during the 3 years following the smoking ban, suggesting that clinicians continued to treat nicotine dependence after smoking was restricted. CONCLUSIONS: Clinicians are more likely to identify and treat symptoms of nicotine withdrawal when smoking is restricted. Hospitals should consider monitoring prescriptions for NRT as part of their ongoing quality assurance practices so that patients receive aggressive treatment of nicotine withdrawal symptoms--an essential component of high-quality patient care.