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1.
Schizophr Res ; 241: 24-35, 2022 03.
Artículo en Inglés | MEDLINE | ID: mdl-35074529

RESUMEN

PURPOSE: Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known. METHODS: In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity. RESULTS: CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46). CONCLUSIONS: The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.


Asunto(s)
Esquizofrenia , Niño , Enfermedad Crónica , Estudios de Cohortes , Femenino , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Masculino , Ontario , Esquizofrenia/epidemiología
2.
BMC Public Health ; 22(1): 913, 2022 05 07.
Artículo en Inglés | MEDLINE | ID: mdl-35525946

RESUMEN

BACKGROUND: The African, Caribbean, and Black (ACB) population of Ontario, Canada is comprised of individuals with diverse ethnic, cultural and linguistic backgrounds and experiences; some of whom have resided in Canada for many generations, and others who have migrated in recent decades. Even though the ACB population represents less than 3.5% of the Canadian population, this group accounts for 21.7% of all new HIV infections. It is well-documented that ACB populations, compared to the general population, experience multi-level barriers to accessing appropriate and responsive HIV services. In this paper, we present qualitative findings on the ACB population's experiences with HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) and obtain their perspectives on how to improve access. METHODS: We conducted twelve Focus Group Discussions (FGDs), within a two-day World Café event and used socio-ecological framework and community-based participatory research (CBPR) approaches to guide this work. We meaningfully engaged ACB community members in discussions to identify barriers and facilitators to HIV testing, PEP and PrEP and how these may be addressed. The FGDs were transcribed verbatim and thematic analysis guided data interpretation. Credibility of data was established through data validation strategies such as external audit and peer-debriefing. RESULTS: Our analyses revealed multi-level barriers that explain why ACB community members do not access HIV testing, PEP and PrEP. Fear, health beliefs, stigma and lack of information, were among the most frequently cited individual- and community-level barriers to care. Health system barriers included lack of provider awareness, issues related to cultural sensitivity and confidentiality, cost, and racism in the health care system. Participants identified multi-level strategies to address the HIV needs including community-based educational, health system and innovative inter-sectoral strategies. CONCLUSION: CBPR, co-led by community members, is an important strategy for identifying the multi-level individual, interpersonal, community, institutional and structural factors that increase HIV vulnerability in ACB communities, notably anti-Black systemic racism. Study findings suggest the need for targeted community-based strategies and strategies aimed at reducing health system barriers to testing and care.


Asunto(s)
Fármacos Anti-VIH , Infecciones por VIH , Profilaxis Pre-Exposición , Fármacos Anti-VIH/uso terapéutico , Región del Caribe , Infecciones por VIH/diagnóstico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Prueba de VIH , Humanos , Ontario , Profilaxis Posexposición
3.
BMJ ; 377: e069164, 2022 05 04.
Artículo en Inglés | MEDLINE | ID: mdl-35508312

RESUMEN

OBJECTIVES: To compare treatment and outcomes for patients admitted to hospital with a primary diagnosis of ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI) in six high income countries with very different healthcare delivery systems. DESIGN: Retrospective cross sectional cohort study. SETTING: Patient level administrative data from the United States, Canada (Ontario and Manitoba), England, the Netherlands, Israel, and Taiwan. PARTICIPANTS: Adults aged 66 years and older admitted to hospital with STEMI or NSTEMI between 1 January 2011 and 31 December 2017. OUTCOMES MEASURES: The three categories of outcomes were coronary revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery), mortality, and efficiency (hospital length of stay and 30 day readmission). Rates were standardised to the age and sex distribution of the US acute myocardial infarction population in 2017. Outcomes were assessed separately for STEMI and NSTEMI. Performance was evaluated longitudinally (over time) and cross sectionally (between countries). RESULTS: The total number of hospital admissions ranged from 19 043 in Israel to 1 064 099 in the US. Large differences were found between countries for all outcomes. For example, the proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in hospital during 2017 ranged from 36.9% (England) to 78.6% (Canada; 71.8% in the US); use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel (48.4-65.9%) and Taiwan (49.4-70.2%). The proportion of patients with NSTEMI who underwent coronary artery bypass graft surgery within 90 days of admission during 2017 was lowest in the Netherlands (3.5%) and highest in the US (11.7%). Death within one year of admission for STEMI in 2017 ranged from 18.9% (Netherlands) to 27.8% (US) and 32.3% (Taiwan). Mean hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the US (5.0 and 5.1 days) and highest in Taiwan (8.5 days); 30 day readmission for STEMI was lowest in Taiwan (11.7%) and the US (12.2%) and highest in England (23.1%). CONCLUSIONS: In an analysis of myocardial infarction in six high income countries, all countries had areas of high performance, but no country excelled in all three domains. Our findings suggest that countries could learn from each other by using international comparisons of patient level nationally representative data.


Asunto(s)
Infarto del Miocardio , Infarto del Miocardio sin Elevación del ST , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Adulto , Estudios de Cohortes , Estudios Transversales , Países Desarrollados , Mortalidad Hospitalaria , Hospitales , Humanos , Infarto del Miocardio/epidemiología , Infarto del Miocardio/cirugía , Infarto del Miocardio sin Elevación del ST/diagnóstico , Infarto del Miocardio sin Elevación del ST/terapia , Ontario , Estudios Retrospectivos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento , Estados Unidos/epidemiología
4.
BMJ Open ; 12(5): e058324, 2022 May 02.
Artículo en Inglés | MEDLINE | ID: mdl-35501081

RESUMEN

OBJECTIVE: We sought to quantify the impact of vaping introduction on cigarette smoking across settings with varied regulatory approaches to vaping. DESIGN: Interrupted time series analysis, adjusted for cigarette tax levels. SETTING: Four Canadian provinces, UK and Australia. PARTICIPANTS: Entire population of smokers in each country. INTERVENTIONS: The year that vaping was widely introduced in each country. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome is cigarette consumption per adult, and the secondary outcome is smoking prevalence among young adults. RESULTS: Based on allowable nicotine levels, restrictions on e-cigarette advertising, sales and access, and taxation, the least to most restrictive jurisdictions were, in order, Alberta, Ontario, Quebec and British Columbia (all in Canada), UK and Australia. In most, but not all, settings where higher nicotine content was permitted in vaping products (66 mg/mL), vaping introduction led to a reduction in cigarette consumption per capita (Ontario: p=0.037, Quebec: p=0.007) or in smoking prevalence among young adults (Alberta men, p=0.027; Quebec men, p=0.008; Quebec women, p=0.008). In the UK, where the maximum permitted nicotine content in vaping products was 20 mg/mL, vaping introduction slowed the declining trend in cigarette smoking among men aged 16-24 years (p=0.031) and 25-34 years (p=0.002) but not in cigarette consumption per adult. In Australia, where nicotine was not permitted in e-cigarettes, e-cigarette introduction slowed the declining trend in cigarette consumption per capita and in smoking prevalence among men aged 18-24 years (cigarette consumption: p=0.015, prevalence: p=0.044). CONCLUSION: In environments that enable substitution of cigarettes with e-cigarettes, e-cigarette introduction reduces overall cigarette consumption. Thus, to reduce cigarette smoking, policies that encourage adults to substitute cigarette smoking with vaping should be considered.


Asunto(s)
Fumar Cigarrillos , Sistemas Electrónicos de Liberación de Nicotina , Vapeo , Fumar Cigarrillos/epidemiología , Femenino , Humanos , Análisis de Series de Tiempo Interrumpido , Masculino , Nicotina , Ontario , Vapeo/epidemiología , Adulto Joven
5.
PLoS One ; 17(5): e0266377, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35536834

RESUMEN

OBJECTIVE: To identify hospital and primary care health service use among people with mental health conditions or addictions in an integrated primary-secondary care database in Toronto, Ontario. METHOD: This was a retrospective cohort study of adults with mental health diagnoses using data from the Health Databank Collaborative (HDC), a primary care-hospital linked database in Toronto. Data were included up to March 31st 2019. Negative binomial and logistic regression were used to evaluate associations between health care utilization and various patient characteristics and mental health diagnoses. RESULTS: 28,482 patients age 18 or older were included. The adjusted odds of at least one mental health diagnosis were higher among younger patients (18-30 years vs. 81+years aOR = 1.87; 95% CI:1.68-2.08) and among female patients (aOR = 1.35; 95% CI: 1.27-1.42). Patients with one or more mental health diagnoses had higher adjusted rates of hospital visits compared to those without any mental health diagnosis including addiction (aRR = 1.74, 95% CI: 1.58-1.91) and anxiety (aRR = 1.28, 95% CI: 1.23-1.32). 14.5% of patients with a psychiatric diagnosis were referred to the hospital for specialized psychiatric services, and 38% of patients referred were eventually seen in consultation. The median wait time from the date of referral to the date of consultation was 133 days. CONCLUSIONS: In this community, individuals with mental health diagnoses accessed primary and hospital-based health care at greater rates than those without mental health diagnoses. Wait times for specialized psychiatric care were long and most patients who were referred did not have a consultation. Information about services for patients with mental health conditions can be used to plan and monitor more integrated care across sectors, and ultimately improve outcomes.


Asunto(s)
Trastornos Mentales , Salud Mental , Adolescente , Adulto , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Trastornos Mentales/epidemiología , Ontario/epidemiología , Estudios Retrospectivos
6.
Healthc Q ; 25(1): 28-33, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-35596761

RESUMEN

Boards are a powerful resource in overseeing our health system. This resource is limited in the amount of available time; therefore, boards should be as productive as possible. Boards should focus their energy on tangible, measurable results. Using natural language processing tools and quantitative outcome measures allows us to measure the impact of board focus. This analysis finds no significant relationship between a higher focus on finance or quality as measured by the board minutes and organizational performance in finance or quality. Boards focus much more on finance than quality or any other focus area with no substantive difference in outcomes. The study indicates that, at least in Ontario, boards may need to revise their approach and allocation of time to these topics.


Asunto(s)
Consejo Directivo , Hospitales , Humanos , Ontario
7.
Healthc Q ; 25(1): 34-35, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-35596762

RESUMEN

Lewis Hooper (2022) has presented findings based on his research that should be of major concern to boards of directors of hospitals and regional health authorities throughout the country. Although his research is based on studies of Ontario hospitals, my experience leads me to believe that the problems and opportunities for improvement can be applied across Canada.


Asunto(s)
Hospitales , Calidad de la Atención de Salud , Humanos , Ontario
8.
PLoS One ; 17(5): e0267946, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35500004

RESUMEN

Maternal obesity is an important risk factor for childhood obesity and influences the prevalence of metabolic diseases in offspring. As childhood obesity is influenced by postnatal factors, it is critical to determine whether children born to women with obesity during pregnancy show alterations that are detectable at birth. Epigenetic mechanisms such as DNA methylation modifications have been proposed to mediate prenatal programming. We investigated DNA methylation signatures in male and female infants from mothers with a normal Body Mass Index (BMI 18.5-24.9 kg/m2) compared to mothers with obesity (BMI≥30 kg/m2). BMI was measured during the first prenatal visit from women recruited into the Ontario Birth Study (OBS) at Mount Sinai Hospital in Toronto, ON, Canada. DNA was extracted from neonatal dried blood spots collected from heel pricks obtained 24 hours after birth at term (total n = 40) from women with a normal BMI and women with obesity matched for parity, age, and neonatal sex. Reduced representation bisulfite sequencing was used to identify genomic loci associated with differentially methylated regions (DMRs) in CpG-dense regions most likely to influence gene regulation. DMRs were predominantly localized to intergenic regions and gene bodies, with only 9% of DMRs localized to promoter regions. Genes associated with DMRs were compared to those from a large publicly available cohort study, the Avon Longitudinal Study of Parents and Children (ALSPAC; total n = 859). Hypergeometric tests revealed a significant overlap in genes associated with DMRs in the OBS and ALSPAC cohorts. PTPRN2, a gene involved in insulin secretion, and MAD1L1, which plays a role in the cell cycle and tumor suppression, contained DMRs in males and females in both cohorts. In males, KEGG pathway analysis revealed significant overrepresentation of genes involved in endocytosis and pathways in cancer, including IGF1R, which was previously shown to respond to diet-induced metabolic stress in animal models and in lymphocytes in the context of childhood obesity. These preliminary findings are consistent with Developmental Origins of Health and Disease paradigm, which posits that adverse prenatal exposures set developmental health trajectories.


Asunto(s)
Madres , Obesidad Pediátrica , Animales , Niño , Estudios de Cohortes , Metilación de ADN , Femenino , Humanos , Estudios Longitudinales , Masculino , Ontario , Obesidad Pediátrica/genética , Embarazo
9.
J Hosp Med ; 17(1): 3-10, 2022 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-35504572

RESUMEN

BACKGROUND: Admitting hospitalized patients to off-service wards ("bedspacing") is common and may affect quality of care and patient outcomes. OBJECTIVE: To compare in-hospital mortality, 30-day readmission to general internal medicine (GIM), and hospital length-of-stay among GIM patients admitted to GIM wards or bedspaced to off-service wards. DESIGN, PARTICIPANTS, AND MEASURES: Retrospective cohort study including all emergency department admissions to GIM between 2015 and 2017 at six hospitals in Ontario, Canada. We compared patients admitted to GIM wards with those who were bedspaced, using multivariable regression models and propensity score matching to control for patient and situational factors. KEY RESULTS: Among 40,440 GIM admissions, 10,745 (26.6%) were bedspaced to non-GIM wards and 29,695 (73.4%) were assigned to GIM wards. After multivariable adjustment, bedspacing was associated with no significant difference in mortality (adjusted hazard ratio 0.95, 95% confidence interval [CI]: 0.86-1.05, p = .304), slightly shorter median hospital length-of-stay (-0.10 days, 95% CI:-0.20 to -0.001, p = .047) and lower 30-day readmission to GIM (adjusted OR 0.89, 95% CI: 0.83-0.95, p = .001). Results were consistent when examining each hospital individually and outcomes did not significantly differ between medical or surgical off-service wards. Sensitivity analyses focused on the highest risk patients did not exclude the possibility of harm associated with bedspacing, although adverse outcomes were not significantly greater. CONCLUSIONS: Overall, bedspacing was associated with no significant difference in mortality, slightly shorter hospital length-of-stay, and fewer 30-day readmissions to GIM, although potential harms in high-risk patients remain uncertain. Given that hospital capacity issues are likely to persist, future research should aim to understand how bedspacing can be achieved safely at all hospitals, perhaps by strengthening the selection of low-risk patients.


Asunto(s)
Hospitales de Enseñanza , Medicina Interna , Estudios de Cohortes , Humanos , Tiempo de Internación , Ontario , Estudios Retrospectivos
10.
Health Promot Chronic Dis Prev Can ; 42(5): 209-217, 2022 May.
Artículo en Inglés, Francés | MEDLINE | ID: mdl-35544030

RESUMEN

INTRODUCTION: The provision of shade at outdoor recreation sites such as playgrounds confers a variety of public health benefits. It can prevent overexposure to solar ultraviolet radiation, and, in turn, protect against skin cancer. Further, shade mitigates heat and may promote physical activity. In this study, we evaluate and describe the amount, type and use of shade at public playgrounds. METHODS: Using a modified shade audit tool, shade audits were conducted to visually evaluate shade coverage at 85 city-operated playgrounds in Guelph, Ontario, Canada, in summer 2019. RESULTS: The main play area of most playgrounds (68%) had no shade available. Although the areas surrounding playgrounds had more shade coverage than the main play areas, we also found minimal shade coverage (> 0% to 30%) in this area for many playgrounds (48%). All shade over main play areas was provided by trees (i.e. natural shade). Permanent, built shade structures were observed in the surrounding area of 13% of playgrounds. Shade coverage in the areas surrounding playgrounds was positively correlated with the number of individuals (rs = 0.259; p = 0.017), children (rs = 0.270; p = 0.012), and active individuals (rs = 0.253; p = 0.020) using the surrounding area. This suggests that individuals seek shade at playgrounds and may be more active in shaded areas. CONCLUSION: Children have limited protective shade available to them at playgrounds. Future research is needed to determine how to best increase shade provision and to further explore the impact it has on playground usage, activity levels, temperature and UVR exposure.


Asunto(s)
Neoplasias Cutáneas , Rayos Ultravioleta , Niño , Ejercicio Físico , Humanos , Ontario , Parques Recreativos , Juego e Implementos de Juego , Neoplasias Cutáneas/prevención & control
11.
BMJ Open ; 12(5): e056868, 2022 May 09.
Artículo en Inglés | MEDLINE | ID: mdl-35534055

RESUMEN

PURPOSE: We sought to understand patients' care-seeking behaviours early in the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors. METHODS: We conducted a multisite cross-sectional patient experience survey at 13 academic primary care teaching practices between May and June 2020. An anonymised link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using χ2 tests. RESULTS: In total, 7532 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic. CONCLUSIONS: Our study suggests that newcomers, people living with a lower income and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.


Asunto(s)
COVID-19 , COVID-19/epidemiología , COVID-19/terapia , Estudios Transversales , Humanos , Ontario/epidemiología , Evaluación del Resultado de la Atención al Paciente , Atención Primaria de Salud
12.
Bone Joint J ; 104-B(5): 589-597, 2022 May.
Artículo en Inglés | MEDLINE | ID: mdl-35491583

RESUMEN

AIMS: Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups. METHODS: We conducted a retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, over a 17-year period. Patients were divided into income quintiles based on postal codes as a proxy for personal economic status. Multivariable logistic regression models were then used to primarily assess the relationship between SES and surgical complications within one year of index THA. RESULTS: Of 111,359 patients who underwent elective primary THA, those in the lower SES groups had statistically significantly more comorbidities and statistically significantly more postoperative complications. While there was no increase in readmission rates within 90 days, there was a statistically significant difference in the primary and secondary outcomes including all revisions due (with a subset of deep wound infection and dislocation). Results showed that those in the higher SES groups had proportionally more cases performed than those in lower groups. Compared to the highest SES quintile, the lower groups had 61% of the number of hip arthroplasties performed. CONCLUSION: Patients in lower socioeconomic groups have more comorbidities, fewer absolute number of cases performed, have their procedures performed in lower-volume centres, and ultimately have higher rates of complications. This lack of access and higher rates of complications is a "double hit" to those in lower SES groups, and indicates that we should be concentrating efforts to improve access to surgeons and hospitals where arthroplasty is routinely performed in high numbers. Even in a universal healthcare system where there are no penalties for complications such as readmission, there seems to be an inequality in the access to THA. Cite this article: Bone Joint J 2022;104-B(5):589-597.


Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Cadera/métodos , Estudios de Cohortes , Humanos , Ontario/epidemiología , Estudios Retrospectivos , Factores Socioeconómicos , Atención de Salud Universal
13.
BMC Res Notes ; 15(1): 187, 2022 May 21.
Artículo en Inglés | MEDLINE | ID: mdl-35597997

RESUMEN

OBJECTIVE: Person-to-person transmission can occur during outbreaks of verotoxigenic Escherichia coli (VTEC), however the impact of this transmission route is not well understood. This study aimed to examine the role of person-to-person transmission during a VTEC outbreak, and how targeting this route may reduce outbreak size. A deterministic compartmental model describing a VTEC outbreak was constructed and fit to data from a 2008 outbreak in Ontario, Canada. Using the best-fit model, simulations were run to calculate the: reduction in transmission rate after implementing interventions, proportion of cases infected through both transmission routes, and number of cases prevented by interventions. Latin hypercube sensitivity analysis was conducted to examine the sensitivity of the outbreak size to the model parameters. RESULTS: Based on the best-fit model, ~ 14.25% of the cases likely arose due to person-to-person transmission. Interventions reduced this transmission rate by ~ 73%, causing a reduction in outbreak size of ~ 17% (47 cases). Sensitivity analysis showed that the model was highly sensitive to changes in all parameters of the model. The model demonstrates that person-to-person could be an important transmission route during VTEC outbreaks. Targeting this route of transmission through hand hygiene and work exclusions could reduce the final outbreak size.


Asunto(s)
Infecciones por Escherichia coli , Escherichia coli Shiga-Toxigénica , Brotes de Enfermedades , Infecciones por Escherichia coli/epidemiología , Humanos , Ontario/epidemiología
14.
Neurology ; 98(18): e1798-e1809, 2022 05 03.
Artículo en Inglés | MEDLINE | ID: mdl-35501160

RESUMEN

BACKGROUND AND OBJECTIVES: The multiple sclerosis (MS) population's survival from breast cancer and colorectal cancer is compromised. Cancer screening and timely diagnoses affect cancer survival and have not been studied in the MS cancer population. We investigated whether the diagnostic route, cancer stage, or diagnostic interval differed in patients with cancer with and without MS. METHODS: We conducted a matched population-based cross-sectional study of breast cancers (2007-2015) and colorectal cancers (2009-2012) in patients with MS from Ontario, Canada, using administrative data. Exclusion criteria included second or concurrent primary cancers, no health care coverage, and, for the patients without MS, those with any demyelinating disease. We based 1:4 matching of MS to non-MS on birth year, sex (colorectal only), postal code, and cancer diagnosis year (breast only). Cancer outcomes were diagnostic route (screen-detected vs symptomatic), stage (stage I vs all others), and diagnostic interval (time from first presentation to diagnosis). Multivariable regression analyses controlled for age, sex (colorectal only), diagnosis year, income quintile, urban/rural residence, and comorbidity. RESULTS: We included 351 patients with MS and breast cancer, 1,404 matched patients with breast cancer without MS, 54 patients with MS and colorectal cancer, and 216 matched patients with colorectal cancer without MS. MS was associated with fewer screen-detected cancers in breast (odds ratio [OR] 0.68 [95% CI 0.52, 0.88]) and possibly colorectal (0.52 [0.21, 1.28]) cancer. MS was not associated with differences in breast cancer stage at diagnosis (stage I cancer, OR 0.81 [0.64, 1.04]). MS was associated with greater odds of stage I colorectal cancer (OR 2.11 [1.03, 4.30]). The median length of the diagnostic interval did not vary between people with and without MS in either the breast or colorectal cancer cohorts. Controlling for disability status attenuated some findings. DISCUSSION: Breast cancers were less likely to be detected through screening and colorectal cancer more likely to be detected at early stage in people with MS than without MS. MS-related disability may prevent people from getting mammograms and colonoscopies. Understanding the pathways to earlier detection in both cancers is critical to developing and planning interventions to ameliorate outcomes for people with MS and cancer.


Asunto(s)
Neoplasias de la Mama , Neoplasias Colorrectales , Esclerosis Múltiple , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/epidemiología , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/epidemiología , Estudios Transversales , Femenino , Humanos , Esclerosis Múltiple/diagnóstico , Esclerosis Múltiple/epidemiología , Ontario
15.
Artículo en Inglés | MEDLINE | ID: mdl-35510483

RESUMEN

OBJECTIVES: The first wave of the COVID-19 pandemic necessitated extensive infection control measures in long-term care (LTC) and had a significant impact on staffing and services. Anecdotal reports indicate that this negatively affected LTC residents' quality of care and wellbeing, but there is scarce evidence on the effects of COVID-19 on quality of dementia care in LTC. METHODS: From December 2020 to March 2021, we conducted a cross-sectional online survey among staff who worked in LTC homes in Ontario, Canada. Survey questions examined staffs' perceptions of the impact of COVID-19 on dementia quality of care during the initial wave of the COVID-19 pandemic (beginning 1 March 2020). RESULTS: There were a total of 227 survey respondents; more than half reported both worsened overall quality of care (51.3%) and worsening of a majority of specific quality of care measures (55.5%). Measures of cognitive functioning, mobility and behavioural symptoms were most frequently described as worsened. Medical and allied/support staff had the highest odds of reporting overall worsened quality of care, while specialized behavioural care staff and those with more experience in LTC were less likely to. LTC home factors including rural location and smaller size, staffing challenges, higher number of outbreaks and less COVID-19 preparedness were associated with increased odds of perceived worsening of quality of dementia care outcomes. CONCLUSIONS: These findings suggest that COVID-19 pandemic restrictions and related effects such as inadequate staffing may have contributed to poor quality of care and outcomes for those with dementia in LTC.


Asunto(s)
COVID-19 , Demencia , COVID-19/epidemiología , Estudios Transversales , Demencia/epidemiología , Demencia/terapia , Humanos , Cuidados a Largo Plazo , Ontario/epidemiología , Pandemias
16.
BMC Health Serv Res ; 22(1): 595, 2022 May 03.
Artículo en Inglés | MEDLINE | ID: mdl-35505321

RESUMEN

BACKGROUND: Being responsive and adaptive to local population needs is a key principle of integrated care, and traditional top-down approaches to health system governance are considered to be ineffective. There is need for more guidance on taking flexible, complexity-aware approaches to governance that foster integration and adaptability in the health system. Over the past two decades, paramedics in Ontario, Canada have been filling gaps in health and social services beyond their traditional mandate of emergency transport. Studying these grassroots, local programs can provide insight into how health systems can be more integrated, adaptive and responsive. METHODS: Semi-structured interviews were conducted with people involved in new, integrated models of paramedic care in Ontario. Audio recordings of interviews were transcribed and coded inductively for participants' experiences, including drivers, enablers and barriers to implementation. Thematic analysis was done to ascertain key concepts from across the dataset. RESULTS: Twenty-six participants from across Ontario's five administrative health regions participated in the study. Participants described a range of programs that included acute, urgent and preventative care driven by local relationship networks of paramedics, hospitals, primary care, social services and home care. Three themes were developed that represent participants' experiences implementing these programs in the Ontario context. The first theme, adapting and being nimble in tension with system structures, related to distributed versus central control of programs, a desire to be nimble and skepticism towards prohibitive legal and regulatory systems. The second theme, evolving and flexible professional role identity, highlighted the value and challenges of a functionally flexible workforce and interest in new roles amongst the paramedic profession. The third theme, unpredictable influences on program implementation, identified events such as the COVID-19 pandemic and changing government priorities as accelerating, redirecting or inhibiting local program development. CONCLUSIONS: The findings of this study add to the discourse on governing health systems towards being more integrated, adaptive and responsive to population needs. Governance strategies include: supporting networks of local organizational relationships; considering the role of a functionally flexible health workforce; promoting a shared vision and framework for collaboration; and enabling distributed, local control and experimentation.


Asunto(s)
COVID-19 , Pandemias , Atención a la Salud , Humanos , Ontario , Investigación Cualitativa
17.
CMAJ Open ; 10(2): E313-E330, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35383035

RESUMEN

BACKGROUND: In Ontario, patients with breast cancer typically receive their diagnoses through the Ontario Breast Screening Program (OBSP) after an abnormal screen, through screening initiated by a primary care provider or other referring physician, or through follow-up of symptoms by patients' primary care providers. We sought to explore the association of the route to diagnosis (screening within or outside the OBSP or via symptomatic presentation) with use of OBSP-affiliated breast assessment sites (O-BAS), wait times until diagnosis or treatment, health care use and overall survival for patients with breast cancer. METHODS: In this retrospective cohort study, we used the Ontario Cancer Registry to identify adults (aged 18-105 yr) who received a diagnosis of breast cancer from 2013 to 2017. We excluded patients if they were not Ontario residents or had missing age or sex, or who died before diagnosis. We used logistic regression to evaluate factors associated with categorical variables (whether patients were or were not referred to an OBAS, whether patients were screened or symptomatic) and Cox proportional hazards regression to identify factors associated with all-cause mortality. RESULTS: Of 51 460 patients with breast cancer, 42 598 (83%) received their diagnoses at an O-BAS. Patients whose cancer was first detected through the OBSP were more likely than symptomatic patients to be given a diagnosis at an O-BAS (adjusted odds ratio 1.68, 95% confidence interval [CI] 1.57 to 1.80). Patients screened by the OBSP were given their diagnoses 1 month earlier than symptomatic patients, but diagnosis at an O-BAS did not affect the time until either diagnosis or treatment. Patients referred to an O-BAS had significantly better overall survival than those who were not referred (adjusted hazard ratio 0.73, 95% CI 0.66 to 0.80). INTERPRETATION: Patients screened through the OBSP were given their diagnoses earlier than symptomatic patients and were more likely to be referred to an O-BAS, which was associated with better survival. Our findings suggest that individuals with signs and symptoms of breast cancer would benefit from similar referral processes, oversight and standards to those used by the OBSP.


Asunto(s)
Neoplasias de la Mama , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Mama , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/terapia , Femenino , Humanos , Mamografía , Persona de Mediana Edad , Ontario/epidemiología , Estudios Retrospectivos , Adulto Joven
18.
CMAJ Open ; 10(2): E331-E337, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35440482

RESUMEN

BACKGROUND: Community paramedicine (CP) is an emerging model of care that addresses local health needs through programs led by community paramedics; however, CP remains poorly defined and appears to lack systematic integration with the broader health system, specifically primary care, within which it is seated. The purpose of the study was to elucidate the views of community paramedics and their stakeholders in Ontario, Canada, on the topic of integrating CP with the broader health system. METHODS: This was a retrospective qualitative analysis of a public recording of a CP provincial forum held in Ontario, Canada, in 2017. Forum attendees (paramedics and stakeholders) were invited by email if they had attended a similar provincial forum in the past (no exclusion criteria for attendance). In small- and large-group discussions, attendees discussed their views on how CP could fit into primary care and what medical oversight and acceptance for the profession could involve. A recording of the large-group discussion, which is publicly available, was transcribed and thematically analyzed. RESULTS: The 89 participants varied in professional affiliation (66% from a paramedic service, n = 59). Among those from paramedic services, 33% were community paramedics (n = 14). Five major themes emerged: defining the role of community paramedics, how CP may integrate with other services, how to garner support for CP, where standardization is needed and possible oversight structures. INTERPRETATION: Community paramedics and their stakeholders have insights into barriers and facilitators for integration with the health system. These study findings could help inform the integration of health and social services in Ontario with a consideration for the unique position and potential of community paramedics.


Asunto(s)
Servicios Médicos de Urgencia , Técnicos Medios en Salud , Humanos , Ontario , Atención Primaria de Salud , Estudios Retrospectivos
19.
CMAJ Open ; 10(2): E379-E389, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35440485

RESUMEN

BACKGROUND: There have been multiple waves in the COVID-19 pandemic in many countries. We sought to compare mortality and respiratory, cardiovascular and renal dysfunction between waves in 3 Canadian provinces. METHODS: We conducted a substudy of the ARBs CORONA I study, a multicentre Canadian pragmatic observational cohort study that examined the association of pre-existing use of angiotensin receptor blockers with outcomes in adults admitted to hospital with acute COVID-19 up to April 2021 from 9 community and teaching hospitals in 3 Canadian provinces (British Columbia, Ontario and Quebec). We excluded emergency department admissions without hospital admission, readmissions and admissions for another reason. We used logistic and 0-1-inflated ß regression models to compare 28-day and in-hospital mortality, and the use of invasive mechanical ventilation, vasopressors and renal replacement therapy (RRT) between the first 3 waves of the COVID-19 pandemic in these provinces. RESULTS: A total of 520, 572 and 245 patients in waves 1, 2 and 3, respectively, were included. Patients in wave 3 were on average younger and had fewer comorbidities than those in waves 1 and 2. The unadjusted 28-day mortality rate was significantly lower in wave 3 (7.8%) than in wave 1 (18.3%) (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.24-0.78) and wave 2 (16.3%) (OR 0.46, 95% CI 0.27-0.79). After adjustment for differences in baseline characteristics, the difference in 28-day mortality remained significant (adjusted OR wave 3 v. wave 1: 0.46, 95% CI 0.26-0.81; wave 3 v. wave 2: 0.52, 95% CI 0.29-0.91). In-hospital mortality findings were similar. Use of invasive mechanical ventilation or vasopressors was less common in waves 2 and 3 than in wave 1, and use of RRT was less common in wave 3 than in wave 1. INTERPRETATION: Severity of illness decreased (lower mortality and less use of organ support) across waves among patients admitted to hospital with acute COVID-19, possibly owing to changes in patient demographic characteristics and management, such as increased use of dexamethasone. Continued application of proven therapies may further improve outcomes. STUDY REGISTRATION: ClinicalTrials.gov, no. NCT04510623.


Asunto(s)
COVID-19 , Pandemias , Adulto , Antagonistas de Receptores de Angiotensina , Inhibidores de la Enzima Convertidora de Angiotensina , Colombia Británica , COVID-19/epidemiología , COVID-19/terapia , Estudios de Cohortes , Hospitales , Humanos , Insuficiencia Multiorgánica , Ontario , Quebec/epidemiología , SARS-CoV-2
20.
CMAJ Open ; 10(2): E400-E408, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35473827

RESUMEN

BACKGROUND: In Canada, published outcome data for COVID-19 come largely from the first 2 waves of the pandemic. We examined changes in demographics and 30-day outcomes after SARS-CoV-2 infection during the first 3 pandemic waves in Alberta and Ontario; for wave 3, we compared outcomes between those infected with a variant of concern and those infected with the original "wild-type" SARS-CoV-2. METHODS: We conducted a population-based retrospective cohort study using linked health care data sets in Alberta and Ontario. We identified all-cause hospitalizations or deaths within 30 days after a positive result on a reverse transcription polymerase chain reaction test for SARS-CoV-2 in individuals of any age between Mar. 1, 2020, and June 30, 2021, with genomic confirmation of variants of concern. We compared outcomes in wave 3 (February 2021 to June 2021) with outcomes in waves 1 and 2 combined (March 2020 to January 2021) after adjusting for age, sex and Charlson Comorbidity Index score. Using wave 3 data only, we compared outcomes by vaccination status and whether or not the individual was infected with a variant of concern. RESULTS: Compared to those infected with SARS-CoV-2 during waves 1 and 2 (n = 372 070), we found a shift toward a younger and healthier demographic in those infected during wave 3 (n = 359 079). In wave 3, patients were more likely to be hospitalized (adjusted odds ratio [aOR] 1.57, 95% confidence interval [CI] 1.46-1.70) but had a shorter length of hospital stay (median 6 days v. 7 days, p < 0.001) and lower 30-day mortality (aOR 0.73, 95% CI 0.65-0.81). The 217 892 patients in wave 3 who were infected with a variant of concern (83.5% confirmed to have the Alpha variant, 1.7% confirmed to have the Delta variant) had a higher risk of death (Alpha: aOR 1.29, 95% CI 1.16-1.44; Delta: aOR 2.05, 95% CI 1.49-2.82) and hospitalization (Alpha: aOR 1.59, 95% CI 1.53-1.66; Delta: aOR 1.88, 95% CI 1.64-2.15) than those infected with wild-type SARS-CoV-2. INTERPRETATION: We observed a shift among those infected with SARS-CoV-2 toward younger patients with fewer comorbidities, a shorter length of hospital stay and lower mortality risk as the pandemic evolved in Alberta and Ontario; however, infection with a variant of concern was associated with a substantially higher risk of hospitalization or death. As variants of concern emerge, ongoing monitoring of disease expression and outcomes among vaccinated and unvaccinated individuals is important to understand the phenotypes of COVID-19 and the anticipated burdens for the health care system.


Asunto(s)
COVID-19 , Alberta/epidemiología , COVID-19/diagnóstico , COVID-19/epidemiología , COVID-19/prevención & control , Estudios de Cohortes , Demografía , Humanos , Ontario/epidemiología , Estudios Retrospectivos , SARS-CoV-2/genética , Vacunación
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