Severe Respiratory Disease Among Children With and Without Medical Complexity During the COVID-19 Pandemic.

Importance: Severe respiratory disease declined during the COVID-19 pandemic, partially due to decreased circulation of respiratory pathogens. However, the outcomes of children with higher risk have not been described using population-based data. Objective: To compare respiratory-related hospitalizations, intensive care unit (ICU) admissions, and mortality during the pandemic vs prepandemic, among children with medical complexity (CMC) and without medical complexity (non-CMC). Design, Setting, and Participants: This population-based repeated cross-sectional study used Canadian health administrative data of children aged younger than 18 years in community and pediatric hospitals during a pandemic period (April 1, 2020, to February 28, 2022) compared with a 3-year prepandemic period (April 1, 2017, to March 31, 2020). The pandemic period was analyzed separately for year 1 (April 1, 2020, to March 31, 2021) and year 2 (April 1, 2021, to February 28, 2022). Statistical analysis was performed from October 2022 to April 2023. Main Outcomes and Measures: Respiratory-related hospitalizations, ICU admissions, and mortality before and during the pandemic among CMC and non-CMC. Results: A total of 139 078 respiratory hospitalizations (29 461 respiratory hospitalizations for CMC and 109 617 for non-CMC) occurred during the study period. Among CMC, there were fewer respiratory hospitalizations in both 2020 (rate ratio [RR], 0.44 [95% CI, 0.42-0.46]) and 2021 (RR, 0.55 [95% CI, 0.51-0.62]) compared with the prepandemic period. Among non-CMC, there was an even larger relative reduction in respiratory hospitalizations in 2020 (RR, 0.18 [95% CI, 0.17-0.19]) and a similar reduction in 2021 (RR, 0.55 [95% CI, 0.54-0.56]), compared with the prepandemic period. Reductions in ICU admissions for respiratory illness followed a similar pattern for CMC (2020: RR, 0.56 [95% CI, 0.53-0.59]; 2021: RR, 0.66 [95% CI, 0.63-0.70]) and non-CMC (2020: RR, 0.22 [95% CI, 0.20-0.24]; RR, 0.65 [95% CI, 0.61-0.69]). In-hospital mortality for these conditions decreased among CMC in both 2020 (RR, 0.63 [95% CI, 0.51-0.77]) and 2021 (RR, 0.72 [95% CI, 0.59-0.87]). Conclusions and Relevance: This cross-sectional study found a substantial decrease in severe respiratory disease resulting in hospitalizations, ICU admissions, and mortality during the first 2 years of the pandemic compared with the 3 prepandemic years. These findings suggest that future evaluations of the effect of public health interventions aimed at reducing circulating respiratory pathogens during nonpandemic periods of increased respiratory illness may be warranted.

Acute presentations of eating disorders among adolescents and adults before and during the COVID-19 pandemic in Ontario, Canada.

BACKGROUND: Increased rates of pediatric eating disorders have been observed during the COVID-19 pandemic, but little is known about trends among adults. We aimed to evaluate rates of emergency department visits and hospital admissions for eating disorders among adolescents and adults during the pandemic. METHODS: We conducted a population-based, repeated cross-sectional study using linked health administrative data for Ontario residents aged 10-105 years during the prepandemic (Jan. 1, 2017, to Feb. 29, 2020) and pandemic (Mar. 1, 2020, to Aug. 31, 2022) periods. We evaluated monthly rates of emergency department visits and hospital admissions for eating disorders, stratified by age. RESULTS: Compared with expected rates derived from the prepandemic period, emergency department visits for eating disorders increased during the pandemic among adolescents aged 10-17 years (7.38 v. 3.33 per 100 000; incidence rate ratio [IRR] 2.21, 95% confidence interval [CI] 2.17-2.26), young adults aged 18-26 years (2.79 v. 2.46 per 100 000; IRR 1.13, 95% CI 1.10-1.16) and older adults aged 41-105 years (0.14 v. 0.11 per 100 000; IRR 1.15, 95% CI 1.07-1.24). Hospital admissions for eating disorders increased during the pandemic for adolescents (8.82 v. 5.74 per 100 000; IRR 1.54, 95% CI 1.54-1.54) but decreased for all adult age groups, especially older adults aged 41-105 years (0.21 v. 0.30 per 100 000; IRR 0.72, 95% CI 0.64-0.80). INTERPRETATION: Emergency department visits for eating disorders increased among adolescents, young adults and older adults during the pandemic, but hospital admissions increased only for adolescents and decreased for all adult groups. Differential rates of acute care use for eating disorders by age have important implications for allocation of inpatient mental health resources.

Self-harm among youth during the first 28 months of the COVID-19 pandemic in Ontario, Canada: a population-based study.

BACKGROUND: Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use. METHODS: We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10-17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10-13 yr and 14-17 yr), sex and mental health service use (new and continuing). RESULTS: In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19-1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46-2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10-13 years and those aged 14-17 years, as well as for both those new to the mental health system and those already engaged in care. INTERPRETATION: Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population.

Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada.

Importance: Reasons for elevated suicide risks among autistic people are unclear, with insufficient population-based research on sex-specific patterns to inform tailored prevention and intervention. Objectives: To examine sex-stratified rates of self-harm events and suicide death among autistic individuals compared with nonautistic individuals, as well as the associated sociodemographic and clinical risk factors. Design, Setting, and Participants: This population-based matched-cohort study using linked health administrative databases in Ontario, Canada included all individuals with physician-recorded autism diagnoses from April 1, 1988, to March 31, 2018, each matched on age and sex to 4 nonautistic individuals from the general population. Self-harm events resulting in emergency health care from April 1, 2005, to December 31, 2020, were examined for one cohort, and death by suicide and other causes from April 1, 1993, to December 31, 2018, were examined for another cohort. Statistical analyses were conducted between October 2021 and June 2023. Exposure: Physician-recorded autism diagnoses from 1988 to 2018 from health administrative databases. Main Outcomes and Measures: Autistic and nonautistic individuals who were sex stratified a priori were compared using Andersen-Gill recurrent event models on self-harm events, and cause-specific competing risk models on death by suicide or other causes. Neighborhood-level income and rurality indices, and individual-level broad diagnostic categories of intellectual disabilities, mood and anxiety disorders, schizophrenia spectrum disorders, substance use disorders, and personality disorders were covariates. Results: For self-harm events (cohort, 379 630 individuals; median age at maximum follow-up, 20 years [IQR, 15-28 years]; median age of first autism diagnosis claim for autistic individuals, 9 years [IQR, 4-15 years]; 19 800 autistic females, 56 126 autistic males 79 200 nonautistic females, and 224 504 nonautistic males), among both sexes, autism diagnoses had independent associations with self-harm events (females: relative rate, 1.83; 95% CI, 1.61-2.08; males: relative rate, 1.47; 95% CI, 1.28-1.69) after accounting for income, rurality, intellectual disabilities, and psychiatric diagnoses. For suicide death (cohort, 334 690 individuals; median age at maximum follow-up, 19 years [IQR, 14-27 years]; median age of first autism diagnosis claim for autistic individuals, 10 years [IQR, 5-16 years]; 17 982 autistic females, 48 956 autistic males, 71 928 nonautistic females, 195 824 nonautistic males), there was a significantly higher crude hazard ratio among autistic females (1.98; 95% CI, 1.11-3.56) and a nonsignificantly higher crude hazard ratio among autistic males (1.34; 95% CI, 0.99-1.82); the increased risks were associated with psychiatric diagnoses. Conclusions and Relevance: This cohort study suggests that autistic individuals experienced increased risks of self-harm events and suicide death. Psychiatric diagnoses were significantly associated with the increased risks among both sexes, especially for suicide death, and in partially sex-unique ways. Autism-tailored and autism-informed clinical and social support to reduce suicide risks should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses.

Primary health care utilization in the first year after arrival by refugee sponsorship model in Ontario, Canada: A population-based cohort study.

BACKGROUND: Canada's approach to refugee resettlement includes government sponsorship, a pioneering private sponsorship model and a third blended approach. Refugees are selected and supported differently in each approach including healthcare navigation. Little is known about how well private sponsors facilitate primary care navigation and whether this changed during the large-scale 2015 Syrian resettlement initiative characterized by civic and healthcare systems engagement. METHODS AND FINDINGS: Population-based cohort study of resettled refugees arriving in Ontario between April 1, 2008 and March 31, 2017, with one-year follow-up, using linked health and demographic administrative databases. We evaluated associations of resettlement model (GARs, Privately Sponsored Refugees [PSRs], and Blended-Visa Office Referred [BVORs]) by era of arrival (pre-Syrian and Syrian era) and by country cohort, on measures of primary care (PC) navigation using adjusted Cox proportional hazards and logistic regression. There were 34,591 (pre-Syrian) and 24,757 (Syrian era) resettled refugees, approximately half of whom were GARs. Compared with the reference group pre-Syrian era PSRs, Syrian PSRs had slightly earlier PC visits (mean = 116 days [SD = 90]) (adjusted hazard ratios [aHR] = 1.19, 95% CI 1.14-1.23). Syrian GARs (mean = 72 days [SD = 65]) and BVORs (mean = 73 days [SD = 76]) had their first PC visit sooner than pre-Syrian era PSRs (mean = 149 days [SD = 86]), with respective aHRs 2.27, 95% CI 2.19-2.35 and 1.89, 95% CI 1.79-1.99. Compared to pre-Syrian PSRs, Syrian GARs and BVORs had much greater odds of a CHC visit (adjusted odds ratios 14.69, 95% CI 12.98-16.63 and 14.08, 95% 12.05-16.44 respectively) and Syrian PSRs had twice the odds of a CHC visit. CONCLUSIONS: Less timely primary care and lower odds of a CHC visit among PSRs in the first year may be attributed to selection factors and gaps in sponsors' knowledge of healthcare navigation. Improved primary care navigation outcomes in the Syrian era suggests successful health systems engagement.

Preventive Health Care Among Children of Women With Schizophrenia: A Population-Based Cohort Study.

Objective: To compare well-baby visit and vaccination schedule adherence up to age 24 months in children of mothers with versus without schizophrenia.Methods: Using administrative health data on births in Ontario, Canada (2012-2016), children of mothers with schizophrenia (ICD-9: 295; ICD-10: F20/F25; DSM-IV schizophrenia or schizoaffective disorder) (n = 1,275) were compared to children without maternal schizophrenia (n = 520,831) on (1) well-baby visit attendance, including an enhanced well-baby visit at age 18 months, and (2) vaccine schedule adherence for diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type B (DTaP-IPV-Hib), and measles, mumps, rubella (MMR). Cox proportional hazard regression models were adjusted for each of maternal sociodemographics, maternal health, and child health characteristics in blocks and all together in a fully adjusted model.Results: About 50.3% of children with maternal schizophrenia had an enhanced 18-month well-baby visit versus 58.6% of those without, corresponding to 29.0 versus 33.9 visits/100 person-years (PY), a hazard ratio (HR) of 0.82 (95% CI, 0.76-0.89). The association was dampened after adjustment for maternal sociodemographics, maternal health, and child health factors in blocks and overall, with a fully adjusted HR of 0.91 (95% CI, 0.84-0.98). Full vaccine schedule adherence occurred in 40.0% of children with maternal schizophrenia versus 46.0% of those without (22.6 vs 25.9/100 PY), yielding a HR of 0.86 (95% CI, 0.78-0.94). The association was dampened when adjusted for maternal sociodemographics and child health characteristics and became nonsignificant when adjusted for maternal health characteristics. The fully adjusted HR was 0.95 (95% CI, 0.87-1.04).Conclusions: Increased efforts to ensure that children with maternal schizophrenia receive key early preventive health care services are warranted.

Maternal Schizophrenia and the Risk of a Childhood Chronic Condition.

BACKGROUND AND HYPOTHESIS: Maternal schizophrenia heightens the risk for certain perinatal complications, yet it is not known to what degree future childhood chronic health conditions (Childhood-CC) might arise. STUDY DESIGN: This population-based cohort study using health administrative data from Ontario, Canada (1995-2018) compared 5066 children of mothers with schizophrenia to 25 324 children of mothers without schizophrenia, propensity-matched on birth-year, maternal age, parity, immigrant status, income, region of residence, and maternal medical and psychiatric conditions other than schizophrenia. Cox proportional hazard models generated hazard ratios (HR) and 95% confidence intervals (CI) for incident Childhood-CCs, and all-cause mortality, up to age 19 years. STUDY RESULTS: Six hundred and fifty-six children exposed to maternal schizophrenia developed a Childhood-CC (20.5/1000 person-years) vs. 2872 unexposed children (17.1/1000 person-years)-an HR of 1.18, 95% CI 1.08-1.28. Corresponding rates were 3.3 vs. 1.9/1000 person-years (1.77, 1.44-2.18) for mental health Childhood-CC, and 18.0 vs. 15.7/1000 person-years (1.13, 1.04-1.24) for non-mental health Childhood-CC. All-cause mortality rates were 1.2 vs. 0.8/1000 person-years (1.34, 0.96-1.89). Risk for children exposed to maternal schizophrenia was similar whether or not children were discharged to social service care. From age 1 year, risk was greater for children whose mothers were diagnosed with schizophrenia prior to pregnancy than for children whose mothers were diagnosed with schizophrenia postnatally. CONCLUSIONS: A child exposed to maternal schizophrenia is at elevated risk of chronic health conditions including mental and physical subtypes. Future research should examine what explains the increased risk particularly for physical health conditions, and what preventive and treatment efforts are needed for these children.

From Philanthropy to Clinical Care through Research: Impact of the Norman Saunders Complex Care Initiative.

Norman Saunders was a respected academic community paediatrician who was passionate about the care of children with medical complexity. Following his untimely death at age 60, patients, friends, and colleagues raised funds to create the Norman Saunders Complex Care Initiative (NSCCI). Dr. Saunders's vision was a comprehensive, coordinated, and integrated clinical program for children with medical complexity that was informed by research evidence. The objective of this review was to evaluate the impact of targeted philanthropic funding on research, clinical care, and policy. Since 2006, NSCCI funds have been used to support interdisciplinary and innovative research. Funded projects have reflected a breadth of research questions (clinical care, training, health system delivery, social determinants), disciplines, and methods, and the research results have informed and helped build an internationally renowned clinical program in complex care. Philanthropic funding was the foundation for the NSCCI, which over the last 15 years has built research and clinical capacity, catalysed clinical and research networks, helped train paediatric residents, influenced policy, and improved the health and well-being of children with medical complexity and their families across Canada, and beyond.

Acute Care Visits for Eating Disorders Among Children and Adolescents After the Onset of the COVID-19 Pandemic.

PURPOSE: Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic. METHODS: Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3-17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates. RESULTS: In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41-1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25-1.50) increase in risk for emergency department visit and hospitalization, respectively. CONCLUSIONS: Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization.

Maternal Schizophrenia, Skin-to-Skin Contact, and Infant Feeding Initiation.

BACKGROUND: The World Health Organization recommends mothers and infants be in direct skin-to-skin contact immediately after birth and initiate breastfeeding as soon as possible. Little is known in women with schizophrenia. METHODS: We conducted a population-based cohort study using administrative health data from Ontario, Canada (2012-2014), comparing women with (n = 471) and without schizophrenia (n = 218 435), and their infants, on the primary outcomes of any skin-to-skin contact and opportunity to initiate breastfeeding within the first 2 h after birth. For dyads with available data, secondary outcomes of intention to breastfeed, breastfeeding support, any breastmilk, and exclusive breastmilk at discharge were assessed. Modified Poisson regression was used to generate relative risks (aRR) and 95% confidence intervals (CI), adjusted for maternal age, parity, neighbourhood income, region of residence, smoking in pregnancy, and maternal medical and non-psychotic psychiatric comorbidity for all outcomes. RESULTS: Maternal schizophrenia was associated with lower likelihood of skin-to-skin contact (65.2% vs 78.1%; aRR 0.88, 95% CI: 0.82-0.94), and breastfeeding initiation post-delivery (38.9% vs 52.6% aRR 0.80, CI: 0.71-0.90) compared to dyads unexposed to maternal schizophrenia. Secondary outcomes followed a similar pattern. The magnitude of the effect was slightly less when restricting the cohort to full-term, vaginal deliveries, not admitted to NICU, and infant not discharged to social services. CONCLUSIONS: Reduced maternal-infant skin-to-skin contact and breastfeeding initiation immediately after birth may significantly impact maternal-child bonding and the establishment breastfeeding in this population. Mothers with schizophrenia may require individualized support to promote these WHO recommended hospital practices in the early post-natal period.

Acute mental health service use following onset of the COVID-19 pandemic in Ontario, Canada: a trend analysis.

BACKGROUND: The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic. METHODS: This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020. RESULTS: Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations). INTERPRETATION: Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted.

Assessing the validity of administrative health data for the identification of children and youth with autism spectrum disorder in Ontario.

Population-level identification of children and youth with ASD is essential for surveillance and planning for required services. The objective of this study was to develop and validate an algorithm for the identification of children and youth with ASD using administrative health data. In this retrospective validation study, we linked an electronic medical record (EMR)-based reference standard, consisting 10,000 individuals aged 1-24 years, including 112 confirmed ASD cases to Ontario administrative health data, for the testing of multiple case-finding algorithms. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and corresponding 95% confidence intervals (CI) were calculated for each algorithm. The optimal algorithm was validated in three external cohorts representing family practice, education, and specialized clinical settings. The optimal algorithm included an ASD diagnostic code for a single hospital discharge or emergency department visit or outpatient surgery, or three ASD physician billing codes in 3 years. This algorithm's sensitivity was 50.0% (95%CI 40.7-88.7%), specificity 99.6% (99.4-99.7), PPV 56.6% (46.8-66.3), and NPV 99.4% (99.3-99.6). The results of this study illustrate limitations and need for cautious interpretation when using administrative health data alone for the identification of children and youth with ASD. LAY SUMMARY: We tested algorithms (set of rules) to identify young people with ASD using routinely collected administrative health data. Even the best algorithm misses more than half of those in Ontario with ASD. To understand this better, we tested how well the algorithm worked in different settings (family practice, education, and specialized clinics). The identification of individuals with ASD at a population level is essential for planning for support services and the allocation of resources. Autism Res 2021, 14: 1037-1045. © 2021 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC.

Accidental injury, self-injury, and assault among children of women with schizophrenia: a population-based cohort study.

OBJECTIVE: We aimed to compare the risk for injury overall and by intent (accidental injury, self-injury, and assault) among children born to women with versus without schizophrenia. METHODS: Using health administrative data from Ontario, Canada, children born from 2003 to 2017 to mothers with (n = 3769) and without (n = 1,830,054) schizophrenia diagnosed prior to their birth were compared on their risk for child injury, captured via emergency department, hospitalization, and vital statistics databases up to age 15 years. Cox proportional hazard models generated hazard ratios for time to first injury event (overall and by intent), adjusted for potential confounders (aHR). We stratified by child sex and age at follow-up: 0-1 (infancy), 2-5 (pre-school), 6-9 (primary school), and 10-15 (early adolescence) planning to collapse age categories as needed to obtain stable and reportable estimates. RESULTS: Maternal schizophrenia was associated with elevated risk for child injury overall (105.4 vs. 89.4/1000 person-years (py), aHR 1.08, 95% CI 1.03-1.14), accidental injury (104.7 vs. 88.1/1000py, 1.08, 1.03-1.14), for self-injury (0.4 vs. 0.2/1000py, 2.14 1.18-3.85), and assault (1.0 vs. 0.3/1000py, 2.29, 1.45-3.62). By child sex, point estimates were of similar magnitude and direction, though not all remained statistically significant. For accidental injury and self-injury, the risk associated with maternal schizophrenia was most elevated in 10-15-year-olds. For assault, the risk associated with maternal schizophrenia was most elevated among children in the 0-1 and 2-5-year-old age groups. CONCLUSION: The elevated risk of child injury associated with maternal schizophrenia, especially for self-injury and assault, suggests that targeted monitoring and preventive interventions are warranted.

Primary care of mothers and infants by the same or different physicians: a population-based cohort study.

BACKGROUND: Different primary care delivery models exist for mothers and their infants. We examined whether primary care system performance measures differed when mother-infant dyads received primary care from the same or different providers. METHODS: We conducted a population-based cohort study using Ontario health administrative data from 2004 to 2016. We included primiparous women and their singleton term infants and classified the primary care practitioners who provided the majority of care to the infant and the mother as concordant (same family physician for both; reference group), discordant (a different family physician for each) or pediatrician (pediatrician for the child, family physician for the mother). The primary outcome was nonobstetric maternal hospital admissions between 42 days and 2 years after delivery. RESULTS: Among 481 721 mother-child pairs, 239 033 (49.6%) received concordant care, 114 006 (23.7%) received discordant care, and 128 682 (26.7%) received pediatrician care. Mothers in the pediatrician group were older and had greater comorbidity. Relative to concordant care, maternal nonobstetric hospital admissions occurred similarly under discordant care (adjusted odds ratio [OR] 1.00, 95% confidence interval [CI] 0.96-1.04) and in the pediatrician group (adjusted OR 0.99, 95% CI 0.95-1.02). Maternal deaths were similar under discordant care (adjusted OR 1.00, 95% CI 0.62-1.63) but lower in the pediatrician group (adjusted OR 0.55, 95% CI 0.34-0.89). Maternal primary care visits were lower in both the discordant group (adjusted relative risk [RR] 0.68, 95% CI 0.68-0.69) and the pediatrician group (adjusted RR 0.75, 95% CI 0.75-0.76). Healthy children were more likely to miss the enhanced 18-month well-baby visit under discordant care (adjusted OR 1.06, 95% CI 1.03-1.09) but less likely to miss this visit under pediatrician care (adjusted OR 0.47, 95% CI 0.46-0.49). INTERPRETATION: Concordant care provided to a new mother and her infant by the same family physician was not associated with better primary care health system performance. The reason that pediatric primary care is associated with better maternal and child outcomes remains to be determined.

Discharge and post-discharge outcomes of psychiatric inpatients with a lifetime history of exposure to interpersonal trauma: A population-based study.

OBJECTIVE: To examine discharge and post-discharge outcomes for psychiatric inpatients with a history of exposure to physical, sexual, or emotional trauma. METHODS: In this population-based cohort study using health-administrative data, adult psychiatric inpatients in Ontario, Canada (2009-2016) with and without self-reported lifetime exposure to interpersonal trauma were compared on their likelihood of: discharge against medical advice; post-discharge outpatient follow-up; and post-discharge emergency department (ED) visits, rehospitalization, deliberate self-harm and suicide. Modified Poisson regressions generated relative risks (aRR) and 95% confidence intervals (CI), adjusted for age, sex, income, medical comorbidities, and psychiatric diagnosis. RESULTS: Psychiatric inpatients with a history of interpersonal trauma (n = 50,832/160,436, 31.7%) were at elevated risk for discharge against medical advice (5.6% vs. 4.6%; aRR = 1.27, 1.21-1.33), and for 1-year post-discharge psychiatric ED visits (31.0% vs. 28.3%, aRR = 1.04, 1.02-1.06), and deliberate self-harm (5.5% vs. 3.7%, aRR = 1.30, 1.23-1.36). Post-discharge 30-day follow-up with primary care was slightly more common among those with a trauma history (37.6% vs. 34.5%, aRR = 1.06, 1.04-1.08); psychiatrist follow-up was less common (35.1% vs. 37.1%, aRR = 0.87, 0.86-0.89). Elevations in risk were observed for those with primary diagnoses of psychotic, mood and anxiety disorders, but not for those with a primary diagnosis of substance-related disorders. Risk elevations were specifically observed in those without a diagnosis of post-traumatic stress disorder. CONCLUSION: Implementing supports and services during and after inpatient hospitalization that take into account a history of interpersonal trauma may help reduce certain undesirable discharge and post-discharge outcomes in this slightly higher-risk group.

Epidemiology of Interpersonal Trauma among Women and Men Psychiatric Inpatients: A Population-Based Study.

OBJECTIVE: Small clinical samples suggest that psychiatric inpatients report a lifetime history of interpersonal trauma. Since past experiences of trauma may complicate prognosis and treatment trajectories, population-level knowledge is needed about its prevalence and correlates among inpatients. METHODS: Using health-administrative databases comprising all adult psychiatric inpatients in Ontario, Canada (2009 to 2016, n = 160,436, 49% women), we identified those who reported experiencing physical, sexual, and/or emotional trauma in their lifetime, 1 year, and 30 days preceding admission. We described the prevalence of each type of trauma, comparing women and men using modified Poisson regression, and identified individual-level characteristics associated with lifetime trauma history using multivariable logistic regression. RESULTS: 31.7% of inpatients reported experiencing trauma prior to admission. Lifetime prevalence was higher in women (39.6% vs. 24.1%; age-adjusted prevalence ratio [aPR] = 1.68; 95% CI, 1.65 to 1.71), including sexual (22.7% vs. 8.4%; aPR = 2.81; 95% CI, 2.73 to 2.89), emotional (33.3% vs. 19.4%; aPR = 1.76; 95% CI, 1.72 to 1.79), and physical trauma (24.2% vs. 14.8%; aPR = 1.68; 95% CI, 1.65 to 1.72). Factors most prominently associated with lifetime trauma were witnessing parental substance use (adjusted odds ratio [aOR] = 8.68; 95% CI, 8.39 to 8.99), female sex (aOR = 2.29; 95% CI, 2.23 to 2.35), and number of recent stressful life events (aOR = 1.62; 95% CI, 1.59 to 1.65). CONCLUSIONS: These results suggest that trauma-informed approaches are essential to consider in the design and delivery of inpatient psychiatric services for both women and men.

Temporal Trends in Mental Health Service Utilization across Outpatient and Acute Care Sectors: A Population-Based Study from 2006 to 2014.

OBJECTIVE: Although evidence suggests that treatment seeking for mental illness has increased over time, little is known about how the health system is meeting the increasing demand for services. We examined trends in physician-based mental health service use across multiple sectors. METHOD: In this population-based study, we used linked health-administrative databases to measure annual rates of mental health-related outpatient physician visits to family physicians and psychiatrists, emergency department visits, and hospitalizations in adults aged 16+ from 2006 to 2014. We examined absolute and relative changes in visit rates, number of patients, and frequency of visits per patient, and assessed temporal trends using linear regressions. RESULTS: Among approximately 11 million Ontario adults, age- and sex-standardized rates of mental health-related outpatient physician visits declined from 604.8 to 565.5 per 1000 population over the study period ( Ptrend = 0.04). Over time, the rate of visits to family physicians/general practitioners remained stable ( Ptrend = 0.12); the number of individuals served decreased, but the number of visits per patient increased. The rate of visits to psychiatrists declined ( Ptrend < 0.001); the number of individuals served increased, but the number of visits per patient decreased. Concurrently, visit rates to emergency departments and hospitals increased (16.1 to 19.7, Ptrend < 0.001 and 5.6 to 6.0, Ptrend = 0.01, per 1000 population, respectively). Increases in acute care service use were greatest for anxiety and addictions. CONCLUSIONS: The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.

Risk of firearm injuries among children and youth of immigrant families.

BACKGROUND: Firearm injuries contribute to substantial morbidity and mortality. The immigrant paradox suggests that, despite being more socially disadvantaged, immigrants are less likely than nonimmigrants to have poor outcomes. We tested the association of immigrant characteristics with firearm injuries among children and youth. METHODS: We conducted a population-based cohort study involving residents of Ontario aged 24 years and younger from 2008-2012 using health and administrative databases. We estimated rate ratios of unintentional and assault-related firearm injuries by immigrant status using Poisson regression models with Generalized Estimating Equations. RESULTS: We included 15 866 954 nonimmigrant and 4 551 291 immigrant person-years in our analysis. Nonimmigrant males had 1032 unintentional (12.4 per 100 000, 95% confidence interval [CI] 11.7-13.2) and 304 assault-related (3.6 per 100 000, 95% CI 3.2-4.0) firearm injuries. Immigrant males had 148 unintentional (7.2 per 100 000, 95% CI 6.1-8.5) and 113 assault-related (5.5 per 100 000, 95% CI 4.5-6.6) firearm injuries. Compared with nonimmigrants, immigrants had a lower rate of unintentional firearm injury (adjusted rate ratio 0.5, 95% CI 0.4-0.6) but a similar rate of assault-related firearm injury. Among immigrants, refugees had a 43% higher risk of assault-related firearm injury compared with nonrefugees (adjusted rate ratio 1.4, 95% CI 1.0-2.0). Immigrants from Central America and Africa accounted for 68% of immigrants with assault-related firearm injuries. INTERPRETATION: Compared with nonimmigrants, immigrant children and youth had a lower risk of unintentional firearm injury, although the risk of assault-related firearm injury was higher among refugees and immigrants from Central America and Africa. The results suggest that prevention strategies for firearm safety should target nonimmigrant youth as well as these newly identified high-risk immigrant populations.

Focal epithelial hyperplasia caused by human papillomavirus 13.

Focal epithelial hyperplasia is a benign, papulo-nodular disease of the oral cavity. It is rare, affecting primarily Native American populations during childhood. It is closely associated with human papillomavirus 13 and 32. This report describes the diagnosis of 2 cases of focal epithelial hyperplasia in children from southern Guyana. The diagnosis was made using clinical criteria, polymerase chain reaction, and DNA sequencing.