Cost Evaluation of the Ontario Virtual Urgent Care Pilot Program: Population-Based, Matched Cohort Study.

BACKGROUND: In 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns. OBJECTIVE: This study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective. METHODS: Using administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD $1=US $0.76 is applicable). RESULTS: We matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral ($2805 vs $2299; difference of $506, 95% CI $139-$885) and significantly lower for the VUC cohort of patients who did not require ED referral ($907 vs $1270; difference of $362, 95% CI 284-$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were $18.9 million (ie, $6.0 million + $12.9 million) versus $22.9 million ($4.9 million + $18.0 million) for the 2 in-person ED cohorts. CONCLUSIONS: This costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions.

Health care utilization and outcomes of patients seen by virtual urgent care versus in-person emergency department care.

BACKGROUND: Virtual urgent care (VUC) is intended to support diversion of patients with low-acuity complaints and reduce the need for in-person emergency department visits. We aimed to describe subsequent health care utilization and outcomes of patients who used VUC compared with similar patients who had an in-person emergency department visit. METHODS: We used patient-level encounter data that were prospectively collected for patients using VUC services provided by 14 pilot programs in Ontario, Canada. We linked the data to provincial administrative databases to identify subsequent 30-day health care utilization and outcomes. We defined 2 subgroups of VUC users; those with a documented prompt referral to an emergency department by a VUC provider, and those without. We matched patients in each cohort to an equal number of patients presenting to an emergency department in person, based on encounter date, medical concern and the logit of a propensity score. For the subgroup of patients not promptly referred to an emergency department, we matched patients to those who were seen in an emergency department and then discharged home. RESULTS: Of the 19 595 patient VUC visits linked to administrative data, we matched 2129 patients promptly referred to the emergency department by a VUC provider to patients presenting to the emergency department in person. Index visit hospital admissions (9.4% v. 8.7%), 30-day emergency department visits (17.0% v. 17.5%), and hospital admissions (12.9% v. 11.0%) were similar between the groups. We matched 14 179 patients who were seen by a VUC provider with no documented referral to the emergency department. Patients seen by VUC were more likely to have a subsequent in-person emergency department visit within 72 hours (13.7% v. 7.0%), 7 days (16.5% v. 10.3%) and 30 days (21.9% v. 17.9%), but hospital admissions were similar within 72 hours (1.1% v. 1.3%), and higher within 30 days for patients who were discharged home from the emergency department (2.6% v. 3.4%). INTERPRETATION: The impact of the provincial VUC pilot program on subsequent health care utilization was limited. There is a need to better understand the inherent limitations of virtual care and ensure future virtual providers have timely access to in-person outpatient resources, to prevent subsequent emergency department visits.

Household Transmission of Carbapenemase-producing Enterobacterales in Ontario, Canada.

BACKGROUND: Data on household transmission of carbapenemase-producing Enterobacterales (CPE) remain limited. We studied risk of CPE household co-colonization and transmission in Ontario, Canada. METHODS: We enrolled CPE index cases (identified via population-based surveillance from January 2015 to October 2018) and their household contacts. At months 0, 3, 6, 9, and 12, participants provided rectal and groin swabs. Swabs were cultured for CPE until September 2017, when direct polymerase chain reaction (PCR; with culture of specimens if a carbapenemase gene was detected) replaced culture. CPE risk factor data were collected by interview and combined with isolate whole-genome sequencing to determine likelihood of household transmission. Risk factors for household contact colonization were explored using a multivariable logistic regression model with generalized estimating equations. RESULTS: Ninety-five households with 177 household contacts participated. Sixteen (9%) household contacts in 16 (17%) households were CPE-colonized. Household transmission was confirmed in 3/177 (2%) cases, probable in 2/177 (1%), possible in 9/177 (5%), and unlikely in 2/177 (1%). Household contacts were more likely to be colonized if they were the index case's spouse (odds ratio [OR], 6.17; 95% confidence interval [CI], 1.05-36.35), if their index case remained CPE-colonized at household enrollment (OR, 7.00; 95% CI, 1.92-25.49), or if they had at least 1 set of specimens processed after direct PCR was introduced (OR, 6.46; 95% CI, 1.52-27.40). CONCLUSIONS: Nine percent of household contacts were CPE-colonized; 3% were a result of household transmission. Hospitals may consider admission screening for patients known to have CPE-colonized household contacts.

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti.

OBJECTIVES: To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-)eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes. METHODS: We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services. RESULTS: A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55-6.55) and low birthweight (OR 1.40; 95% CI 1.05-1.86) for women with complicated pregnancies. CONCLUSION: To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended.

Emergence of Carbapenemase-Producing Enterobacteriaceae, South-Central Ontario, Canada1.

We analyzed population-based surveillance data from the Toronto Invasive Bacterial Diseases Network to describe carbapenemase-producing Enterobacteriaceae (CPE) infections during 2007-2015 in south-central Ontario, Canada. We reviewed patients' medical records and travel histories, analyzed microbiologic and clinical characteristics of CPE infections, and calculated incidence. Among 291 cases identified, New Delhi metallo-ß-lactamase was the predominant carbapenemase (51%). The proportion of CPE-positive patients with prior admission to a hospital in Canada who had not received healthcare abroad or traveled to high-risk areas was 13% for patients with oxacillinase-48, 24% for patients with New Delhi metallo-ß-lactamase, 55% for patients with Klebsiella pneumoniae carbapenemase, and 67% for patients with Verona integron-encoded metallo-ß-lactamase. Incidence of CPE infection increased, reaching 0.33 cases/100,000 population in 2015. For a substantial proportion of patients, no healthcare abroad or high-risk travel could be established, suggesting CPE acquisition in Canada. Policy and practice changes are needed to mitigate nosocomial CPE transmission in hospitals in Canada.

Virtual care use prior to emergency department admissions during a stable COVID-19 period in Ontario, Canada.

BACKGROUND: The increased use of telemedicine to provide virtual outpatient visits during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of virtual visits use prior to ED admissions and characterized the patients with prior virtual visit use and the physicians who provided these outpatient visits. METHODS: We conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization. RESULTS: There were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%). INTERPRETATION: The net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seemed to be able to appropriately triage patients to the ED and virtual visits replaced in-person visits ahead of ED admissions, as opposed to being additive.

Metabolic Impact of Intermittent Fasting in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis of Interventional Studies.

CONTEXT: Intermittent fasting (IF) has been proposed as a weight-loss strategy with additional cardiometabolic benefits in individuals with obesity. Despite its growing popularity, the effect of IF in patients with type 2 diabetes (T2DM) remains unclear. OBJECTIVE: We conducted a systematic review and meta-analysis to evaluate the metabolic impact of IF compared to standard diet in patients with T2DM. METHODS: Embase, PubMed, and clinicaltrials.gov between 1950 and August 12, 2020 were searched for randomized, diet-controlled studies evaluating any IF intervention in adults with T2DM. We examined the impact of IF on weight loss and glucose-lowering by calculating pooled estimates of the absolute differences in body weight and glycated hemoglobin A1c (HbA1c) compared to a control group using a random-effects model. RESULTS: Seven studies (n = 338 participants; mean body mass index [BMI] 35.65, mean baseline HbA1c 8.8%) met our inclusion criteria. IF induced a greater decrease in body weight by -1.89 kg (95% CI, -2.91 to -0.86 kg) compared to a regular diet, with no significant between-study heterogeneity (I2 21.0%, P = .28). The additional weight loss induced by IF was greater in studies with a heavier population (BMI > 36) (-3.43 kg [95% CI, -5.72 to -1.15 kg]) and in studies of shorter duration (≤ 4 months) (-3.73 kg [95% CI, -7.11 to -0.36 kg]). IF was not associated with further reduction in HbA1c compared to a standard diet (HbA1c -0.11% [95% CI, -0.38% to 0.17%]). CONCLUSION: Current evidence suggests that IF is associated with greater weight loss in patients with T2DM compared with a standard diet, with a similar impact on glycemic control.

Rectal screening displays high negative predictive value for bloodstream infection with (ESBL-producing) Gram-negative bacteria in neonates with suspected sepsis in a low-resource setting neonatal care unit.

OBJECTIVES: We analysed the concordance of rectal swab isolates and blood culture for Gram-negative bacteria (GNB) isolates in neonates with a suspicion of neonatal sepsis admitted to a neonatal care unit in Haiti. METHODS: We matched pairs of blood and rectal samples taken on the date of suspected sepsis onset in the same neonate. We calculated the proportion of rectal isolates in concordance with the blood isolates by species and genus. We calculated the negative predictive value (NPV) for GNB and extended-spectrum ß-lactamase (ESBL)-producing GNB for all rectal and blood isolate pairs in neonates with suspected sepsis. RESULTS: We identified 238 blood and rectal samples pairs, with 238 blood isolate results and 309 rectal isolate results. The overall concordance in genus and species between blood and rectal isolates was 22.3% [95% confidence interval (CI) 17.4-28.0%] and 20.6% (95% CI 16.0-26.2%), respectively. The highest concordance between blood and rectal isolates was observed for samples with no bacterial growth (65%), followed byKlebsiella pneumoniae (18%) and Klebsiella oxytoca (12%). The NPV of detecting GNB bacterial isolates in rectal samples compared with those in blood samples was 81.6% and the NPV for ESBL-positive GNB was 92.6%. CONCLUSIONS: The NPV of rectal swab GNB isolates was high in all patient groups and was even higher for ESBL-positive GNB. Clinicians can use the results from rectal swabs when taken simultaneously with blood samples during outbreaks to inform the (de-)escalation of antibiotic therapy in those neonates that have an ongoing sepsis profile.

Evidence of transmission of Clostridium difficile in asymptomatic patients following admission screening in a tertiary care hospital.

BACKGROUND: Clostridium difficile (CD) is the leading cause of infectious health-care associated diarrhea. However, little is known regarding CD carriage and transmission amongst asymptomatic colonizers. We evaluated carriage, characterized strains and examined epidemiologic linkages in asymptomatic colonized CD patients. METHODS: Rectal swabs from asymptomatic patients admitted to the general medicine ward from April 1-June 30 2012 were collected. PCR-confirmed CD colonies were ribotyped and characterized by Modified-Multi Locus Variable Number Tandem Repeat Analysis (MMLVA). RESULTS: 1549-swabs were collected from 474-patients. Overall, 50/474(10.6%) were CD PCR-positive, 24/50 were colonized at admission, while 26/50 were first identified > = 72 hours after admission. Amongst the 50 CD PCR-positive patients, 90% were asymptomatically colonized and 80% of individuals carried toxigenic CD-strains, including ribotype-027 (5/45:11%). MMLVA revealed five-clusters involving 15-patients harboring toxigenic (4/5) and non-toxigenic CD strains (1/5). In two clusters, patients were CD positive on admission while in the other three clusters involving 10 patients, we observed CD transmission from asymptomatically colonized patients to 8 previously CD-negative patients. CONCLUSIONS: We identified increasing rates of colonization during admission to medical wards. MMLVA typing effectively discriminated between strains and suggests that 20% of patients with CD colonization acquired their strain(s) from asymptomatically colonized individuals in hospital.

Correction: Evidence of transmission of Clostridium difficile in asymptomatic patients following admission screening in a tertiary care hospital.

[This corrects the article DOI: 10.1371/journal.pone.0207138.].

Objectively Measured Physical Activity and Mortality Risk Among American Adults.

INTRODUCTION: One major limitation of prior studies examining the influence of physical activity on mortality is use of self-reported measures. This study examined the association between objectively measured light physical activity (LPA) and moderate to vigorous physical activity (MVPA) and all-cause mortality. METHODS: This study included 5,562 adults from the 2003-2006 National Health and Nutrition Examination Survey. LPA and MVPA were measured over 4-7 days using Actigraph AM-7164 accelerometers. For both activity intensities, the first quintile defined low participation and the remaining quintiles defined modest to high participation. Information on age, sex, race, SES, diet, smoking, and alcohol were collected and controlled for. Survival status through December 31, 2011, was determined. Average follow-up was 6.7 years. Data were analyzed in 2015. RESULTS: In women, the all-cause mortality hazard ratio (HR) was 0.58 (95% CI=0.38, 0.88) for modest to high LPA and 0.34 (95% CI=0.20, 0.57) for modest to high MVPA. Corresponding HRs in men were 1.02 (95% CI=0.64, 1.61) and 0.39 (95% CI=0.27, 0.56). Compared with women with a low LPA/low MVPA combination, mortality risk was reduced in the modest to high LPA/low MVPA (HR=0.42, 95% CI=0.26, 0.70), low LPA/modest to high MVPA (HR=0.16, 95% CI=0.07, 0.34), and modest to high LPA/modest to high MVPA (HR=0.17, 95% CI=0.09, 0.36) combinations. In men, mortality risk was not reduced with modest to high LPA/low MVPA. CONCLUSIONS: MVPA was associated with a substantially lower mortality risk. LPA was associated with lower mortality risk, but only within women with low MVPA.

Imputing Accelerometer Nonwear Time When Assessing Moderate to Vigorous Physical Activity in Children.

BACKGROUND: A limitation of accelerometer measures of moderate to vigorous physical activity (MVPA) is nonwear time. Nonwear-time data is typically deleted prior to estimating MVPA. In this study, we used an approach that used sociodemographic, health, and time data to guide the imputation of nonwear-time data. We determined whether imputing nonwear-time data influences estimates of MVPA and the association between MVPA, body mass index, and blood pressure. METHODS: Seven days of accelerometer data were collected on 332 children aged 10-13 years. MVPA was estimated in a "nonimputed dataset," wherein nonwear-time data were deleted prior to estimating MVPA, and in an "imputed dataset," wherein nonwear-time data were imputed using sociodemographic and health characteristics of participants and time characteristics of the nonwear period prior to estimating MVPA. RESULTS: Nonwear time represented 7% of waking hours. Average MVPA estimates did not differ in the nonimputed and imputed datasets (56.8 vs 58.4 min/d). The strength of the relationship between MVPA and the 2 health outcomes did not differ in the nonimputed and imputed datasets. CONCLUSIONS: Studies achieving high accelerometer wear-time compliance can obtain MVPA estimates without substantial bias if they use the traditional approach of deleting nonwear-time data.

Unit-Specific Rates of Hand Hygiene Opportunities in an Acute-Care Hospital.

OBJECTIVE To explore the frequency of hand hygiene opportunities (HHOs) in multiple units of an acute-care hospital. DESIGN Prospective observational study. SETTING The adult intensive care unit (ICU), medical and surgical step-down units, medical and surgical units, and the postpartum mother-baby unit (MBU) of an academic acute-care hospital during May-August 2013, May-July 2014, and June-August 2015. PARTICIPANTS Healthcare workers (HCWs). METHODS HHOs were recorded using direct observation in 1-hour intervals following Public Health Ontario guidelines. The frequency and distribution of HHOs per patient hour were determined for each unit according to time of day, indication, and profession. RESULTS In total, 3,422 HHOs were identified during 586 hours of observation. The mean numbers of HHOs per patient hour in the ICU were similar to those in the medical and surgical step-down units during the day and night, which were higher than the rates observed in medical and surgical units and the MBU. The rate of HHOs during the night significantly decreased compared with day (P92% of HHOs on medical and surgical units, compared to 67% of HHOs on the MBU. CONCLUSIONS Assessment of hand hygiene compliance using product utilization data requires knowledge of the appropriate opportunities for hand hygiene. We have provided a detailed characterization of these estimates across a wide range of inpatient settings as well as an examination of temporal variations in HHOs. Infect Control Hosp Epidemiol 2017;38:411-416.

Rate of healthcare worker-patient interaction and hand hygiene opportunities in an acute care setting.

OBJECTIVE: Identify factors affecting the rate of hand hygiene opportunities in an acute care hospital. DESIGN: Prospective observational study. SETTING: Medical and surgical in-patient units, medical-surgical intensive care unit (MSICU), neonatal intensive care unit (NICU), and emergency department (ED) of an academic acute care hospital from May to August, 2012. PARTICIPANTS: Healthcare workers. METHODS: One-hour patient-based observations measured patient interactions and hand hygiene opportunities as defined by the "Four Moments for Hand Hygiene." Rates of patient interactions and hand hygiene opportunities per patient-hour were calculated, examining variation by room type, healthcare worker type, and time of day. RESULTS: During 257 hours of observation, 948 healthcare worker-patient interactions and 1,605 hand hygiene opportunities were identified. Moments 1, 2, 3, and 4 comprised 42%, 10%, 9%, and 39% of hand hygiene opportunities. Nurses contributed 77% of opportunities, physicians contributed 8%, other healthcare workers contributed 11%, and housekeeping contributed 4%. The mean rate of hand hygiene opportunities per patient-hour was 4.2 for surgical units, 4.5 for medical units, 5.2 for ED, 10.4 for NICU, and 13.2 for MSICU (P < .001). In non-ICU settings, rates of hand hygiene opportunities decreased over the course of the day. Patients with transmission-based precautions had approximately half as many interactions (rate ratio [RR], 0.55 [95% confidence interval (CI), 0.37-0.80]) and hand hygiene opportunities per hour (RR, 0.47 [95% CI, 0.29-0.77]) as did patients without precautions. CONCLUSIONS: Measuring hand hygiene opportunities across clinical settings lays the groundwork for product use-based hand hygiene measurement. Additional work is needed to assess factors affecting rates in other hospitals and health care settings.