COVID-19 Policy Response Analysis: A Canadian Perspective.

The COVID-19 pandemic highlighted the challenges that go into effective policymaking. Facing a public health crisis of epic proportion, government bodies across the world sought to manage the spread of infectious disease and healthcare-system overwhelm in the face of historic economic instability and social unrest. Recognizing that COVID-19 debates and research are still actively ongoing, this paper aims to objectively compare COVID-19 responses from countries across the world that exhibit similar economic and political models to Canada, identify notable failures, successes, and key takeaways to inform future-state pandemic preparedness.

A forecasting tool for a hospital to plan inbound transfers of COVID-19 patients from other regions.

BACKGROUND: In April 2021, the province of Ontario, Canada, was at the peak of its third wave of the COVID-19 pandemic. Intensive Care Unit (ICU) capacity in the Toronto metropolitan area was insufficient to handle local COVID patients. As a result, some patients from the Toronto metropolitan area were transferred to other regions. METHODS: A spreadsheet-based Monte Carlo simulation tool was built to help a large tertiary hospital plan and make informed decisions about the number of transfer patients it could accept from other hospitals. The model was implemented in Microsoft Excel to enable it to be widely distributed and easily used. The model estimates the probability that each ward will be overcapacity and percentiles of utilization daily for a one-week planning horizon. RESULTS: The model was used from May 2021 to February 2022 to support decisions about the ability to accept transfers from other hospitals. The model was also used to ensure adequate inpatient bed capacity and human resources in response to various COVID-related scenarios, such as changes in hospital admission rates, managing the impact of intra-hospital outbreaks and balancing the COVID response with planned hospital activity. CONCLUSIONS: Coordination between hospitals was necessary due to the high stress on the health care system. A simple planning tool can help to understand the impact of patient transfers on capacity utilization and improve the confidence of hospital leaders when making transfer decisions. The model was also helpful in investigating other operational scenarios and may be helpful when preparing for future outbreaks or public health emergencies.

A Spatio-Temporal Analysis of OECD Member Countries' Health Care Systems: Effects of Data Missingness and Geographically and Temporally Weighted Regression on Inference.

Determinants of health care quality and efficiency are of importance to researchers, policy-makers, and public health officials as they allow for improved human capital and resource allocation as well as long-term fiscal planning. Statistical analyses used to understand determinants have neglected to explicitly discuss how missing data are handled, and consequently, previous research has been limited in inferential capability. We study OECD health care data and highlight the importance of transparency in the assumptions grounding the treatment of data missingness. Attention is drawn to the variation in ordinary least squares coefficient estimates and performance resulting from different imputation methods, and how this variation can undermine statistical inference. We also suggest that parametric regression models used previously are limited and potentially ill-suited for analysis of OECD data due to the inability to deal with both spatial and temporal autocorrelation. We propose the use of an alternative method in geographically and temporally weighted regression. A spatio-temporal analysis of health care system efficiency and quality of care across OECD member countries is performed using four proxy variables. Through a forward selection procedure, medical imaging equipment in a country is identified as a key determinant of quality of care and health outcomes, while government and compulsory health insurance expenditure per capita is identified as a key determinant of health care system efficiency.

LncRNAs in Osteoarthritis.

Osteoarthritis (OA) is a progressive joint disease that affects millions of older adults around the world. With increasing rates of incidence and prevalence worldwide, OA has become an enormous global socioeconomic burden on healthcare systems. Long non-coding ribonucleic acids (lncRNAs), essential functional molecules in many biological processes, are a group of non-coding RNAs that are greater than approximately 200 nucleotides in length. Fast-growing and recent developments in lncRNA research are captivating and represent a novel and promising field in understanding the complexity of OA pathogenesis. The involvement of lncRNAs in OA's pathological processes and their altered expressions in joint tissues, blood and synovial fluid make them attractive candidates for the diagnosis and treatment of OA. We focus on the recent advances in major regulator mechanisms of lncRNAs in the pathophysiology of OA and discuss potential diagnostic and therapeutic uses of lncRNAs for OA. We investigate how upregulation or downregulation of lncRNAs influences the pathogenesis of OA and how we can use lncRNAs to elucidate the molecular mechanism of OA. Furthermore, we evaluate how we can use lncRNAs as a diagnostic marker or therapeutic target for OA. Our study not only provides a comprehensive review of lncRNAs regarding OA's pathogenesis but also contributes to the elucidation of its molecular mechanisms and to the development of diagnostic and therapeutic approaches for OA.

Relative Efficiency of Radiation Treatment Centers: An Application of Data Envelopment Analysis.

This study determines the relative efficiencies of a number of cancer treatment centers in Ontario, taking into account the differences among them so that their performances can be compared against the provincial targets. These differences can be in physical and financial resources, and patient demographics. An analytical framework is developed based on a three-step data envelopment analysis (DEA) model to build efficiency metrics for planning, delivery, and quality of treatment at each center. Regression analysis is used to explain the efficiency metrics and demonstrates how these findings can inform continuous improvement efforts.

Working from home during the COVID-19 pandemic, its effects on health, and recommendations: The pandemic and beyond.

PURPOSE: We provide an overview of how to work from home during the coronavirus disease 2019 (COVID-19) pandemic and what measures should be taken to minimize the negative effects of working from during this time. CONCLUSIONS: The COVID-19 pandemic has forced an adaptation process for the whole world and working life. One of the most adaptation measures is working from home. Working from home comes with challenges and concerns but it also has favorable aspects. PRACTICE IMPLICATIONS: It is crucial to develop and implement best practices for working from home to maintain a good level of productivity, achieve the right level of work and life balance and maintain a good level of physical and mental health.

Association of serum lncRNA H19 expression with inflammatory and oxidative stress markers and routine biochemical parameters in chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is a disorder that affects millions worldwide, and current treatment options aiming at inhibiting the progression of kidney damage are limited. Long noncoding RNA (lncRNA) H19 is one of the first explored lncRNAs and its deregulation is associated with renal pathologies, such as renal cell injury and nephrotic syndrome. However, there is still no research investigating the connection between serum lncRNA H19 expressions and clinical outcomes in CKD patients. Therefore, we investigated the relation of serum lncRNA H19 expressions with routine biochemical parameters, inflammatory cytokines, oxidative stress and mineralization markers in advanced CKD patients. METHODS: lncRNA H19 serum levels from 56 CKD patients and 20 healthy controls were analyzed with reverse-transcription quantitative polymerase chain reaction method. Serum tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), and osteocalcin (OC) levels were measured with enzyme linked-immunosorbent assay. Total antioxidant status (TAS) and total oxidative status (TOS) levels were evaluated by the routine measurement method. RESULTS: We found that lncRNA H19 expressions were upregulated in patients with CKD compared to the controls. Furthermore, lncRNA H19 relative expression levels showed a negative relationship with glomerular filtration rate (GFR) while it was positively correlated with ferritin, phosphorus, parathyroid hormone, TNF-α, IL-6, OC, TAS and TOS levels. CONCLUSION: lncRNA H19 expressions were increased in CKD stage 3-5 and HD patients, and elevated lncRNA H19 expressions were associated with decreased glomerular filtration rate, inflammation, and mineralization markers in these patients.

miRNAs as attractive diagnostic and therapeutic targets for Familial Mediterranean Fever.

Familial Mediterranean Fever (FMF) is a hereditary early-onset disease that causes periodical fever attack, excessive release of IL-1ß, serositis, arthritis and peritonitis. Genetic analyses conducted on FMF patients (mutated and non-mutated) have highlighted that additional contributing factors such as epigenetics and environment play a role in clinical manifestations of FMF. Recently researchers report that microRNAs (miRNAs), implicated in epigenetic mechanisms, may contribute to the pathogenesis of FMF. miRNAs, a member of the captivating noncoding RNA family, are the single-strand transcripts that work in physiological and pathophysiological processes by regulating target gene expression. Recent studies have shown that miRNAs are associated with various mechanisms involved in the pathogenesis of FMF, such as apoptosis, inflammation and autophagy. Moreover, these miRNAs molecules might have potential use in treatment, therapeutic response monitoring and the diagnosis of subtypes of the disease in the future. Motivated by these potential benefits (diagnostic and therapeutic) of miRNAs, we focus on recent advances of clinical significances and potential action mechanisms of miRNAs in FMF pathogenesis and discuss their potential use for FMF.

Evaluating multiple living kidney donor candidates simultaneously is more cost-effective than sequentially.

When multiple living donor candidates come forward to donate a kidney to the same recipient, some living donor programs evaluate one candidate at a time to avoid unnecessary evaluations. Evaluating multiple candidates concurrently rather than sequentially may be cost-effective from a societal perspective if it reduces the time recipients spend on dialysis. We used a simple decision tree to estimate the cost-effectiveness of evaluating two to four candidates simultaneously rather than sequentially as potential kidney donors for the same intended recipient. Evaluating two donor candidates simultaneously cost $1,266 (CAD) more than if they were evaluated sequentially, but living donation occurred one month earlier. This translated into $6,931 in averted dialysis costs and a total cost-savings of $5,665 per intended recipient. Simultaneous evaluations also resulted in one percent more living donor transplants and overall gains in quality-of-life as recipients spent less time on dialysis. If recipients were free from dialysis at the start of donor candidate evaluations, simultaneous evaluations also reduced the rate of dialysis initiation by two percent. Benefits were also observed in the three- and four-candidate scenarios. Thus, living donor programs should consider evaluating up to four living donor candidates simultaneously when they come forward for the same recipient as health care system costs incurred are more than offset by avoided dialysis costs.

Healthcare Costs for the Evaluation, Surgery, and Follow-Up Care of Living Kidney Donors.

BACKGROUND: The healthcare costs to evaluate, perform surgery, and follow a living kidney donor for the year after donation are poorly described. METHODS: We obtained information on the healthcare costs of 1099 living kidney donors between April 1, 2004, and March 31, 2014, from Ontario, Canada, using comprehensive healthcare administrative databases. We estimated the cost of 3 periods of the living donation process: the predonation evaluation period (start of evaluation until the day before donation), perioperative period (day of donation until 30-days postdonation), and 1 year of follow-up period (after perioperative period until 1 year postdonation). We analyzed data for donors and healthy matched nondonor controls using regression-based methods to estimate the incremental cost of living donation. Costs are presented from the perspective of the Canadian healthcare payer (2017 CAD $). RESULTS: The incremental healthcare costs (compared with controls) for the evaluation, perioperative, and follow-up periods were CAD $3596 (95% confidence interval [CI], CAD $3350-$3842), CAD $11 694 (95% CI, CAD $11 415-CAD $11 973), and $1011 (95% CI, CAD $793-CAD $1230), respectively, totalling CAD $16 290 (95% CI, CAD $15 814-CAD $16 767). The evaluation cost was higher if the intended recipient started dialysis partway through the donor evaluation (CAD $886; 95% CI, CAD $19, CAD $1752). The perioperative cost varied across transplant centers (P < 0.0001). CONCLUSIONS: Although substantial costs of living donor care are related to the nephrectomy procedure, comprehensive assessment of costs must also include the evaluation and follow-up periods. These estimates are informative for planning future work to support and expand living donation and transplantation, and directing efforts to improve the cost efficiency of living donor care.

Variability of waiting times for the 4 most prevalent cancer types in Ontario: a retrospective population-based analysis.

BACKGROUND: Longer waiting times in cancer care are associated with lower care quality and wait-related patient dissatisfaction. We analyzed the variability and median of waiting times from when a patient seeks care to first treatment for the 4 most prevalent cancer types in Ontario. METHODS: Using retrospective health administrative data, we identified patients with a new diagnosis of prostate, breast, lung or colorectal cancer in Ontario between 2002 and 2012. Treatment interventions were categorized as chemotherapy, radiotherapy or surgery. We used regression analyses to calculate trends for the coefficient of variation, the Gini coefficient and the median waiting time for each cancer type-treatment type pair over the study period. RESULTS: During the study period, 95 501 new cases of prostate cancer, 89 244 breast cancer cases, 82 604 lung cancer cases and 80 761 colorectal cancer cases were registered. The coefficient of variation and the Gini coefficient of waiting times decreased for all cancer type-treatment type pairs (except for the Gini coefficient for breast cancer-radiotherapy) over the study period. However, both decreasing and increasing trends in median waiting times were observed across cancer type-treatment type pairs. INTERPRETATION: The variability of waiting time to first treatment for patients with prostate, breast, lung or colorectal cancer decreased between 2002 and 2012, which indicates improvements in equity in access to cancer care. This trend aligns with provincial efforts to improve access to and the efficiency of cancer care treatment in Ontario. The lack of consistent decreases in median waiting time highlights the need to identify improvement opportunities for cancer type-treatment type pairs with increasing median waiting times.

Initiating Maintenance Dialysis Before Living Kidney Donor Transplantation When a Donor Candidate Evaluation Is Well Underway.

BACKGROUND: Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis before living kidney donor transplantation when their donor candidate evaluation is well underway. METHODS: Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004 to 2014 across 5 transplant centers in Ontario, Canada, where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant. RESULTS: A total of 167 (35%) of 478 persons with kidney failure initiated dialysis in a median of 9.7 months (25th-75th percentile, 5.4-18.7 months) after their donor candidate began their evaluation and received dialysis for a median of 8.8 months (3.6-16.9 months) before kidney transplantation. The total cohort's dialysis cost was CAD $8.1 million, and 44 (26%) of 167 recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 months (6.4-21.6 months) for preemptive transplants and 22.4 months (13.1-38.7 months) for donors whose recipients started dialysis before transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-income neighborhood, and if the transplant center received the recipient referral later. CONCLUSION: One third of persons initiated dialysis before receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs.

Potential implications of a more timely living kidney donor evaluation.

Living donor kidney transplantation is the most promising way to avoid or minimize the amount of time a recipient spends on dialysis before transplantation. We studied 887 living kidney donors at 5 transplant centers in Ontario, Canada, who started their evaluation and donated between April 2006 and March 2014. Using a series of hypothetical scenarios, we estimated the impact of an earlier living donor evaluation completion and donation on the number pre-emptive transplants, the time spent on dialysis, healthcare cost savings from averted dialysis costs (CAD $2016), and the number of additional transplants. During the study period, if the donor transplants occurred 3 months earlier, the healthcare system would save on average $12 055 (standard deviation [SD] $13 594) per recipient; 21 recipients could have avoided dialysis altogether, and 57 additional transplants (a 26% increase) could have occurred each year. For the 220 living kidney donor transplants performed in Ontario, Canada, each year, this translates to a total annual cost savings of $2.7M. In conclusion, a more timely evaluation of living donor candidates and their intended recipients may increase the supply of kidneys for transplantation. Improved evaluation efficiency may also yield more pre-emptive transplants and substantial healthcare cost savings through averted dialysis costs.

Duration of Living Kidney Transplant Donor Evaluations: Findings From 2 Multicenter Cohort Studies.

BACKGROUND: A prolonged living kidney donor evaluation may result in worse outcomes for transplant recipients. Better knowledge of the duration of this process may help inform future donors and identify opportunities for improvement. STUDY DESIGN: 1 prospective and 1 retrospective cohort study. SETTING & PARTICIPANTS: At 16 Canadian and Australian transplantation centers (prospective cohort) and 5 Ontario transplantation centers (retrospective cohort), we assessed the duration of living kidney donor evaluation and explored donor, recipient, and transplantation factors associated with longer evaluation times. Data were obtained from 2 sources: donor medical records using chart abstraction and health care administrative databases. PREDICTORS: Donor and recipient demographics, direct versus paired donation, center-level variables. OUTCOMES: Duration of living donor evaluation. RESULTS: The median total duration of transplantation evaluation (time from when the candidate started the evaluation until donation) was 10.3 (IQR, 6.5-16.7) months. The median duration from evaluation start until approval to donate was 7.9 (IQR, 4.6-14.1) months, and from approval until donation was 0.7 (IQR, 0.3-2.4) months, respectively. The median time between the first and last consultation among donors who completed a nephrology, surgery, and psychosocial assessment in the prospective cohort was 3.0 (IQR, 1.0-6.3) months, and between computed tomography angiography and donation was 4.8 (IQR, 2.6-9.2) months. After adjustment, the total duration of transplantation evaluation was longer if the donor participated in paired donation (6.6 [95% CI, 1.6-9.7] months) and if the recipient was referred later relative to the donor's evaluation start date (0.9 [95% CI, 0.8-1.0] months [per month of delayed referral]). Results depended on whether the recipient was receiving dialysis. LIMITATIONS: Living donor candidates who did not donate were not included and proxy measures were used for some dates in the donor evaluation process. CONCLUSIONS: The duration of kidney transplant donor evaluation is variable and can be lengthy. Better understanding of the reasons for a prolonged evaluation may inform quality improvement initiatives to reduce unnecessary delays.