Did Emergency Department Visits in Infants and Young Children Increase in the Last Decade?: An Ontario, Canada Study.

OBJECTIVES: The aims of the study were to measure overall trends and to identify leading causes for pediatric emergency department (ED) visits among children aged 0 to 4 years. METHODS: We conducted an 11-year population-based open cohort study using health administrative data from 2008 to 2018 in Ontario, Canada. All ED visits were extracted from the National Ambulatory Care Reporting System, along with the most responsible cause of each visit. Annual ED visit rates were calculated per 100 children in each year. Overall and disease-specific rates for all children were calculated and then stratified by sex and age groups. Relative percentage change in rates between 2008 and 2018 were calculated and compared using standardized differences (SDIFs). Statistical significance of time trends was tested using Poisson regression. RESULTS: This study included an average of 911,566 children from 2008 to 2018. All-cause ED visit rates increased by 28.2% from 2008 to 2018 (43.24-55.42 per 100, SDIF >0.1). Respiratory diseases were consistently the top cause of ED visits, and contributed to 1 in 3 ED visits in 2018. These respiratory conditions include asthma, asthma-related diseases (bronchiolitis, bronchitis, influenza, and pneumonia), and other respiratory diseases. Respiratory ED visit rates increased by 32.8% from 2008 to 2018 (11.51-15.28 per 100, SDIF <0.1), driven by a 46.4% (14.58-21.35 per 100, SDIF >0.1) increase among children younger than 1 year. There was a 78.0% increase in ED visits for bronchiolitis in infants (1.45-2.58 per 100, SDIF <0.1). CONCLUSIONS: Respiratory diseases like bronchiolitis among infants were the consistent leading cause for ED visits. All-cause ED visit rates among young children increased by 28.17% from 2008 to 2018.

Effect of smoke-free legislation on respiratory health services use in children with asthma: a population-based open cohort study in Ontario, Canada.

OBJECTIVE: This study will add to existing literature by examining the impact of smoke-free legislation in outdoor areas among children with asthma. We aimed to examine the effect of the 2015 Smoke-Free Ontario Act (SFOA) amendment, which prohibited smoking on patios, playgrounds and sports fields, on health services use (HSU) rates in children with asthma. METHODS: We conducted a population-based open cohort study using health administrative data from the province of Ontario, Canada. Each year, all Ontario residents aged 0-18 years with physician diagnosed asthma were included in the study. Annual rates of HSU (emergency department (ED) visits, hospitalisations and physician office visits) for asthma and asthma-related conditions (eg, bronchitis, allergic rhinitis, influenza and pneumonia) were calculated. Interrupted time-series analysis, accounting for seasonality, was used to estimate changes in HSU following the 2015 SFOA. RESULTS: The study population ranged from 618 957 individuals in 2010 to 498 812 in 2018. An estimated average increase in ED visits for asthma in infants aged 0-1 years of 0.42 per 100 individuals (95% CI: 0.09 to 0.75) and a 57% relative increase corresponding to the 2015 SFOA was observed. A significant decrease in ED visits for asthma-related conditions of 0.19 per 100 individuals (95% CI: -0.37 to -0.01) and a 22% relative decrease corresponding to the 2015 SFOA was observed. CONCLUSION: Based on the observed positive effect of restricting smoking on patios, playgrounds and sports fields on respiratory morbidity in children with asthma, other jurisdictions globally should consider implementing similar smoke-free policies.

Medication Discontinuation in Adults With COPD Discharged From the Hospital: A Population-Based Cohort Study.

BACKGROUND: Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation. RESEARCH QUESTION: What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD? STUDY DESIGN AND METHODS: A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort. RESULTS: Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P < .001] and 1.62 [95% CI, 1.39, 1.90; P < .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group. INTERPRETATION: In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.

Does an mHealth system reduce health service use for asthma?

BACKGROUND: Breathe is a mobile health (mHealth) application developed for the self-management of asthma in adults. There is evidence to suggest that mHealth interventions can be used for asthma control; however, their effects on the use of health services remain poorly understood. We sought to determine whether Breathe reduces health services use amongst asthma patients who used the app compared to controls who did not. METHODS: The impact of Breathe on health services use was estimated using a quasi-experimental approach. Two groups of subjects who had participated in a previous randomised clinical trial were included: an intervention group of asthma patients who used the app for 12 months, and a group of controls who did not use the app but received equivalent quality asthma care. A third, external control group of asthma patients were matched to the intervention participants. Generalised linear mixed models were used to determine relative changes in rates of asthma hospitalisations, emergency department (ED) visits, outpatient physician visits and completion of pulmonary function tests (PFTs) over time. RESULTS: A total of 677 individuals with asthma were included in the study: 132 in the intervention group, and 149 and 396 in the internal and external control groups, respectively. There were no statistically significant differences in the change of asthma hospitalisations, ED visits, physician office visits or completion of PFTs between the intervention group and either control group. CONCLUSIONS: Use of the Breathe app is not associated with changes in health services use in adults with asthma.

Longitudinal associations between number of cigarettes per day and depressive symptoms in adult smokers with type 2 diabetes: A path analysis approach.

OBJECTIVE: Three theoretical models describe the direction of the association between depressive symptoms and cigarettes per day (CPD) in smokers: 1) CPD predicts subsequent depressive symptoms, 2) depressive symptoms predict CPD, and 3) there is a bidirectional relation between CPD and depressive symptoms. The objective of the study was to compare the fit of these three theoretical models to data from a community-based sample of adults with type 2 diabetes (T2D) who smoke cigarettes. METHODS: Data were from adults with T2D who participated in the Evaluation of Diabetes Treatment Study. At baseline, 296 participants reported being a current smoker and were included in the analyses. Measures of CPD and depressive symptoms were collected annually over four years. Path models corresponding to the three directionality hypotheses were estimated. Model fit was compared, and the best fitting model was selected on the basis of Akaike's Information Criterion (AIC). RESULTS: The path model depicting a unidirectional association from CPD to subsequent depressive symptoms had the lowest AIC value (7110.94) and was thus identified as the best fitting model. Although some paths within the model did not meet conventional levels of statistical significance, in general, more CPD predicted higher levels of depressive symptoms at subsequent follow-up points. CONCLUSION: Amongst smokers with T2D, a primary smoking model, in which smoking precedes depressive symptoms, may best explain the longitudinal association between CPD and depressive symptoms. These findings further justify the need for early smoking cessation in diabetes care.

Patterns of health care use related to respiratory conditions in early life: A birth cohort study with linked administrative data.

OBJECTIVES: To identify distinctive patterns of respiratory-related health services use (HSU) between birth and 3 years of age, and to examine associated symptom and risk profiles. METHODS: This study included 729 mother and child pairs enrolled in the Toronto site of the Canadian Healthy Infant Longitudinal Development study in 2009-2012; they were linked to Ontario health administrative databases (2009-2016). A model-based cluster analysis was performed to identify distinct groups of children who followed a similar pattern of respiratory-related HSU between birth and 3 years of age, regarding hospitalization, emergency department (ED) and physician office visits for respiratory conditions and total health care costs (2016 Canadian dollars). RESULTS: The majority (estimated cluster weight = 0.905) showed a pattern of low and stable respiratory care use (low HSU) while the remainder (weight = 0.095) showed a pattern of high use (high HSU). From 0 to 3 years of age, the low- and high-HSU groups differed in mean trajectories of total health care costs ($783 per 6 months decreased to $114, vs $1796 to $177, respectively). Compared to low-HSU, the high-HSU group was associated with a constant risk of hospitalizations, early high ED utilization and physician visits for respiratory problems. The two groups differed significantly in the timing of wheezing (late onset in low-HSU vs early in high-HSU) and future total costs (stable vs increased). CONCLUSIONS: One in ten children had high respiratory care use in early life. Such information can help identify high-risk young children in a large population, monitor their long-term health, and inform resource allocation.

Cross-sectoral integration in youth-focused health and social services in Canada: a social network analysis.

BACKGROUND: Youth with concurrent substance use and mental health concerns have diverse psychosocial needs and may present to a multitude of clinical and social service sectors. By integrating service sectors at a system level, the diversity of needs of youth with concurrent disorders can be addressed in a more holistic way. The objective of the present study was to quantify the level of cross-sectoral integration in youth-focused services in Canada. METHODS: Social network analysis (SNA) was used to examine the relationships between eight sectors: addictions, child welfare, education, physical health, housing, mental health, youth justice, and other social services. A total of 597 participants representing twelve networks of youth-serving agencies across Canada provided information on their cross-sectoral contacts and referrals. RESULTS: Overall, results suggested a moderate level of integration between sectors. The mental health and the addictions sectors demonstrated only moderate integration, while the addictions sector was strongly connected with the youth justice sector. CONCLUSIONS: Despite evidence of moderate integration, increased integration is called for to better meet the needs of youth with concurrent mental health and substance use concerns across youth-serving sectors. Ongoing efforts to enhance the integration between youth-serving sectors should be a primary focus in organizing networks serving youth with concurrent mental health and substance use needs.