Timing of follow-up visits after hospital discharge for COPD: Application of a new method.

RATIONALE: A common strategy to reduce COPD readmissions is to encourage patient follow-up with a physician within 1 to 2 weeks of discharge, yet evidence confirming its benefit is lacking. We used a new study design called target randomized trial emulation to determine the impact of follow-up visit timing on patient outcomes. METHODS: All Ontario residents aged 35 or older discharged from a COPD hospitalization were identified using health administrative data and randomly assigned to those who received and did not receive physician visit follow-up by within seven days. They were followed to all-cause emergency department visits, readmissions or death. Targeted randomized trial emulation was used to adjust for differences between the groups. COPD emergency department visits, readmissions or death was also considered. RESULTS: There were 94,034 patients hospitalized with COPD, of whom 73.5% had a physician visit within 30 days of discharge. Adjusted hazard ratio for all-cause readmission, emergency department visits or death for people with a visit within seven days post discharge was 1.03 (95% Confidence Interval [CI]: 1.01-1.05) and remained around 1 for subsequent days; adjusted hazard ratio for the composite COPD events was 0.97 (95% CI 0.95-1.00) and remained significantly lower than 1 for subsequent days. CONCLUSION: While a physician visit after discharge was found to reduce COPD events, a specific time period when a physician visit was most beneficial was not found. This suggests that follow-up visits should not occur at a predetermined time but be based on factors such as anticipated medical need.

Young adults with a 22q11.2 microdeletion and the cost of aging with complexity in a population-based context.

PURPOSE: Information about the impact on the adult health care system is limited for complex rare pediatric diseases, despite their increasing collective prevalence that has paralleled advances in clinical care of children. Within a population-based health care context, we examined costs and multimorbidity in adults with an exemplar of contemporary genetic diagnostics. METHODS: We estimated direct health care costs over an 18-year period for adults with molecularly confirmed 22q11.2 microdeletion (cases) and matched controls (total 60,459 person-years of data) by linking the case cohort to health administrative data for the Ontario population (∼15 million people). We used linear regression to compare the relative ratio (RR) of costs and to identify baseline predictors of higher costs. RESULTS: Total adult (age ≥ 18) health care costs were significantly higher for cases compared with population-based (RR 8.5, 95% CI 6.5-11.1) controls, and involved all health care sectors. At study end, when median age was <30 years, case costs were comparable to population-based individuals aged 72 years, likelihood of being within the top 1st percentile of health care costs for the entire (any age) population was significantly greater for cases than controls (odds ratio [OR], for adults 17.90, 95% CI 7.43-43.14), and just 8 (2.19%) cases had a multimorbidity score of zero (vs 1483 (40.63%) controls). The 22q11.2 microdeletion was a significant predictor of higher overall health care costs after adjustment for baseline variables (RR 6.9, 95% CI 4.6-10.5). CONCLUSION: The findings support the possible extension of integrative models of complex care used in pediatrics to adult medicine and the potential value of genetic diagnostics in adult clinical medicine.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis.

BACKGROUND: Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. OBJECTIVES: To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC. METHODS: We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit. RESULTS: Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus. CONCLUSIONS: MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Sex differences among children, adolescents and young adults for mental health service use within inpatient and outpatient settings, before and during the COVID-19 pandemic: a population-based study in Ontario, Canada.

OBJECTIVES: The pandemic and public health response to contain the virus had impacts on many aspects of young people's lives including disruptions to daily routines, opportunities for social, academic, recreational engagement and early employment. Consequently, children, adolescents and young adults may have experienced mental health challenges that required use of mental health services. This study compared rates of use for inpatient and outpatient mental health services during the pandemic to pre-pandemic rates. DESIGN: Population-based repeated cross-sectional study. SETTING: Publicly delivered mental healthcare in primary and secondary settings within the province of Ontario, Canada. PARTICIPANTS: All children 6-12 years of age (n=2 043 977), adolescents 13-17 years (n=1 708 754) and young adults 18-24 years (n=2 286 544), living in Ontario and eligible for provincial health insurance between March 2016 and November 2021. PRIMARY OUTCOME MEASURES: Outpatient mental health visits to family physicians and psychiatrists for: mood and anxiety disorders, alcohol and substance abuse disorders, other non-psychotic mental health disorders and social problems. Inpatient mental health visits to emergency departments and hospitalisations for: substance-related and addictive disorders, anxiety disorders, assault-related injuries, deliberate self-harm and eating disorders. All outcomes were analysed by cohort and sex. RESULTS: During the pandemic, observed outpatient visit rates were higher among young adults by 19.01% (95% CI: 15.56% to 22.37%; 209 vs 175 per 1000) and adolescent women 24.17% (95% CI: 18.93% to 29.15%; 131 vs 105 per 1000) for mood and anxiety disorders and remained higher than expected. Female adolescents had higher than expected usage of inpatient care for deliberate self-harm, eating disorders and assault-related injuries. CONCLUSIONS: Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns.

Utilization of physician mental health services by birthing parents with young children during the COVID-19 pandemic: a population-based, repeated cross-sectional study.

BACKGROUND: The COVID-19 pandemic and nonpharmaceutical interventions that reduced the spread of infection had impacts on social interaction, schooling and employment. Concerns have been raised about the impact of these disruptions on the mental health of high-risk groups, including birthing parents of young children. METHODS: This population-based, repeated cross-sectional study used health administrative databases in Ontario, Canada, to link children to birth parents and to measure subsequent mental health visits of birthing parents of younger (age 0-5 yr) and school-aged (6-12 yr) children. We used a repeated cross-sectional study design to estimate expected rates for visits to physicians for mental health diagnoses, based on prepandemic trends (March 2016-February 2020), and to compare those to observed visit rates during the March 2020-November 2021 period of the pandemic. RESULTS: We identified 2 cohorts: 986 870 birthing parents of younger children and 1 012 997 birthing parents of school-aged children. In both cohorts, observed visit rates were higher than expected in the June 2020-August 2020 quarter (incidence rate ratio [IRR] 1.13, 95% confidence interval [CI] 1.10-1.16; and IRR 1.10, 95% CI 1.07-1.13, respectively), peaked in December 2020-February 2021 (IRR 1.24, 95% CI 1.20-1.27; and IRR 1.20, 95% CI 1.16-1.23) and remained higher than expected in September 2021-November 2021 (IRR 1.12, 95% CI 1.08-1.16; and IRR 1.09, 95% CI 1.06-1.13). The increases were driven mostly by visits for mood and anxiety disorders, and trends in increases were similar across physician type, birthing-parent age and deprivation quintile. INTERPRETATION: The COVID-19 pandemic was associated with increased mental health visits for parents of young children. This raises concerns about mental health impacts and highlights the need to address these concerns.

Equity Promoting Integrated Care: Definition and Future Development.

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems.

Exploring the impact of evaluation on learning and health innovation sustainability: protocol for a realist synthesis.

BACKGROUND: Within the Learning Health System (LHS) model, learning routines, including evaluation, allow for continuous incremental change to take place. Within these learning routines, evaluation assists in problem identification, data collection, and data transformation into contextualized information, which is then re-applied to the LHS environment. Evaluation that catalyzes learning and improvement may also contribute to health innovation sustainability. However, there is little consensus as to why certain evaluations seem to support learning and sustainability, while others impede it. This realist synthesis seeks to understand the contextual factors and underlying mechanisms or drivers that best support health systems learning and sustainable innovation. METHODS: This synthesis will be guided by Pawson and colleagues' 2005 and Emmel and colleagues' 2018 guidelines for conducting realist syntheses. The review process will encompass five steps: (1) scoping the review, (2) building theories, (3) identifying the evidence, (4) evidence selection and appraisal, and (5) data extraction and synthesis. An Expert Committee comprised of leaders in evaluation, innovation, sustainability, and realist methodology will guide this synthesis. Review findings will be reported using the RAMESES guidelines. DISCUSSION: The use of a realist review will allow for exploration and theorizing about the contextual factors and underlying mechanisms that make evaluations 'work' (or 'not work') to support learning and sustainability. Depending on results, we will attempt to synthesize findings into a series of recommendations for evaluations with the intention to support health systems learning and sustainability. Finalized results will be presented at national and international conferences, as well as disseminated via a peer-reviewed publication. SYSTEMATIC REVIEW REGISTRATION: This realist synthesis protocol has been registered with PROSPERO ( https://www.crd.york.ac.uk/prospero/  ID 382690).

Medication clusters at hospital discharge and risk of adverse drug events at 30 days postdischarge: A population-based cohort study of older adults.

AIMS: Certain combinations of medications can be harmful and may lead to serious adverse drug events (ADEs). Identifying potentially problematic medication clusters could help guide prescribing and/or deprescribing decisions in hospital. The aim of this study is to characterize medication prescribing patterns at hospital discharge and determine which medication clusters were associated with an increased risk of ADEs in the 30-day posthospital discharge. METHODS: All residents of the province of Ontario in Canada aged 66 years or older admitted to hospital between March 2016 and February 2017 were included. Identification of medication clusters prescribed at hospital discharge was conducted using latent class analysis. Cluster identification and categorization were based on medications dispensed up to 30-day posthospitalization. Multivariable logistic regression was used to assess the potential association between membership to a particular medication cluster and ADEs postdischarge, while also evaluating other patient characteristics. RESULTS: In total, 188 354 patients were included in the study cohort. Median age (interquartile range) was 77 (71-84) years, and patients had a median (IQR) (interquartile range [IQR]) of 9 (6-13) medications dispensed prior to admission. Within the study population, 6 separate clusters of dispensing patterns were identified: cardiovascular (14%), respiratory (26%), complex care needs (12%), cardiovascular and metabolic (15%), infection (10%), and surgical (24%). Overall, 12 680 (7%) patients had an ADE in the 30 days following discharge. After considering other patient characteristics, those belonging to the respiratory cluster had the highest risk of ADEs (adjusted odds ratio: 1.12, 95% confidence interval: 1.08-1.17) compared with all the other clusters, while those in the complex care needs cluster had the lowest risk (adjusted odds ratio: 0.82, 95% confidence interval: 0.77-0.87). CONCLUSION: This study suggests that ADEs post hospital discharge can be linked with identifiable medication clusters. This information may help clinicians and researchers better understand patient populations that are more or less likely to benefit from peri-hospital discharge interventions aimed at reducing ADEs.

An interrupted time series study using administrative health data to examine the impact of the COVID-19 pandemic on alternate care level acute hospitalizations in Ontario, Canada.

BACKGROUND: Many health systems struggle with delayed discharges (known as alternate level of care [ALC] in Canada). Our objectives were to describe and compare patient and hospitalization characteristics by ALC status, and to examine the impact of the initial period of the COVID-19 pandemic on ALC rates in Ontario, Canada. METHODS: We conducted an interrupted time series using linked administrative data for acute care hospital discharges in Ontario between Feb. 28, 2018, and Nov. 30, 2020. We measured the monthly ALC rate among discharges before and after the onset of the COVID-19 pandemic (Mar. 1, 2020). We used interrupted time series regressions to examine the association between the onset of the pandemic and average ALC monthly rates. RESULTS: We identified no meaningful differences in patient and admission characteristics, irrespective of time; however, differences were identified by ALC status. The overall average monthly rate of ALC discharges before the COVID-19 pandemic was 4.9% and after the onset of the pandemic was 5.0%. These discharges dropped to 4.3% (n = 3558) in March 2020 but then rebounded to their peak of 5.8% (n = 3915). There was no significant change in the average level of ALC rates per month after the onset of the pandemic (increase of 0.36% average per month, 95% confidence interval [CI] -0.11% to 0.83%) or monthly rate of change (slope) after the onset of the pandemic (-0.08%, 95% CI -0.15 to 0). INTERPRETATION: We identified a continued high rate of hospital discharges with an ALC component despite the considerable efforts in hospital to reduce hospital occupancy during the COVID-19 pandemic. Future research should examine why ALC rates remain high despite hospital efforts.

Case managers' reflections of a brief case management intervention in Canada.

Introduction: As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM). Objective: This study sought to explore case managers' perspectives and experiences with this new service delivery model. Methods: Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis. Results: Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention. Conclusion: The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria.

The impact of multimorbidity on severe COVID-19 outcomes in community and congregate settings.

Purpose: This study examined the impact of multimorbidity on severe COVID-19 outcomes in community and long-term care (LTC) settings, alone and in interaction with age and sex. Methods: We conducted a retrospective cohort study of all Ontarians who tested positive for COVID-19 between January-2020 and May-2021 with follow-up until June 2021. We used cox regression to evaluate the adjusted impact of multimorbidity, individual characteristics, and interactions on time to hospitalization and death (any cause). Results: 24.5% of the cohort had 2 or more pre-existing conditions. Multimorbidity was associated with 28% to 170% shorter time to hospitalization and death, respectively. However, predictors of hospitalization and death differed for people living in community and LTC. In community, increasing multimorbidity and age predicted shortened time to hospitalization and death. In LTC, we found none of the predictors examined were associated with time to hospitalization, except for increasing age that predicted reduced time to death up to 40.6 times. Sex was a predictor across all settings and outcomes: among male the risk of hospitalization or death was higher shortly after infection (e.g. HR for males at 14 days = 30.3) while among female risk was higher for both outcome in the longer term (e.g. HR for males at 150 days = 0.16). Age and sex modified the impact of multimorbidity in the community. Conclusion: Community-focused public health measures should be targeted and consider sociodemographic and clinical characteristics such as multimorbidity. In LTC settings, further research is needed to identify factors that may contribute to improved outcomes.

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada.

BACKGROUND: There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18-64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets. METHODS: Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546). FINDINGS: There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions. CONCLUSIONS: Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.

How do respondents of primary care surveys compare to typical users of primary care? A comparison of two surveys.

BACKGROUND: Primary care surveys are a key source of evaluative data; understanding how survey respondents compare to the intended population is important to understand results in context. The objective of this study was to examine the physician and patient representativeness of two primary care surveys (TRANSFORMATION and QUALICOPC) that each used different sampling and recruitment techniques. METHODS: We linked the physician and patient participants of the two surveys to health administrative databases. Patients were compared to other patients visiting the practice on the same day and other randomly selected dates using sociodemographic data, chronic disease diagnosis, and health system utilization. Physicians were compared to other physicians in the same practice, and other physicians in the intended geographic area using sociodemographic and practice characteristics. RESULTS: Physician respondents of the TRANSFORMATION survey included more males compared to their practice groups, but not to other physicians in the area. TRANSFORMATION physicians cared for a larger roster of patients than other physicians in the area. Patient respondents of the QUALICOPC survey did not have meaningful differences from other patients who visit the practice. Patient respondents of the TRANSFORMATION survey resided in more rural areas, had less chronic disease, and had lower use of health services than other patients visiting the practice. CONCLUSION: Differences in survey recruitment methods at the physician and patient level may help to explain some of the differences in representativeness. When conducting primary care surveys, investigators should consider diverse methods of ensuring representativeness to limit the potential for nonresponse bias.

Community mental health funding, stakeholder engagement and outcomes: a realist synthesis.

Mental health services continues to be a high priority for healthcare and social service systems. Funding structures within community mental health settings have shown to impact service providers' behaviour and practices. Additionally, stakeholder engagement is suggested as an important mechanism to achieving the intended goals. However, the literature on community mental health funding reform and associated outcomes is inconsistent and there are no consistent best practices for stakeholder engagement in such efforts. OBJECTIVES: This study sought to understand how stakeholder engagement impacts outcomes when there is a change in public funding within community mental health settings. DESIGN: A realist synthesis approach was used to address the research question to fully understand the role of stakeholder engagement as a mechanism in achieving outcomes (system and service user) in the context of community mental health service reform. An iterative process was used to identify programme theories and context-mechanism-outcome configurations within the literature. RESULTS: Findings highlight that in the absence of stakeholder engagement, funding changes may lead to negative outcomes. When stakeholders were engaged in some form, funding changes were more often associated with positive outcomes. Stakeholder engagement is multifaceted and requires considerable time and investment to support achieving intended outcomes when funding changes are implemented. CONCLUSIONS: To support successful transformation of community mental health programmes, it is important that stakeholders are meaningfully engaged during funding allocation changes. Stakeholder engagement may entail connecting around a shared purpose, individual participation and meaningful interactions and dialogue.

Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses.

BACKGROUND: Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched). METHODS: Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls. RESULTS: There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]). INTERPRETATION: Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods. ONTARIO: ClinicalTrials.gov : 104191.

Engagement of patient and family advisors in health system redesign in Canada.

OBJECTIVES: Globally, there has been a shift towards integrated care delivery and patient-centredness in the design of health services. Such a transformation is underway in Ontario, which is progressively using an interprofessional team-based approach known as Ontario Health Teams (OHTs) to deliver care. During their initial development, OHTs were required to integrate patient and families' preferences, experiences and opinions in the form of consultation and partnership with patient and family advisors (PFAs). This study aimed to understand how PFAs were involved in the early stages of planning for health system change and the perceived benefits of including PFAs in system reform. METHODS: This study used a qualitative descriptive design. Semi-structured interviews were conducted with 126 participants at 12 OHTs, including PFA (n = 16) and non-PFA (n = 110) members (e.g. clinicians). Data were analysed thematically. RESULTS: We identified four themes; mechanisms of engagement, motivations to engage, challenges to PFA engagement and PFAs' impact and added value. Overall, participants viewed PFA engagement positively and PFAs felt valued and empowered. There remain logistical challenges around PFA compensation, and the amount of time and training expected of PFAs. However, all participants believed that developing an understanding of the patient, caregiver and family experience will strengthen the engagement of PFAs in OHT planning, decisions and policies. CONCLUSIONS: Diverse approaches to and stages of PFA engagement fostered meaningful and highly valued contributions to OHT development. These were considered critical to successfully achieving the mandate of patient-centred care reform.

Service Needs of Clients Before and After Short Term Community Mental Health Case Management.

This study evaluated level of service need before and after a short-term community mental health case management intervention from the perspective of both clients and case managers. Ontario Common Assessment of Need data were used to describe client needs. McNemar's test was applied to assess differences in pre- and post- need scores. Psychological distress, company, daytime activities, and physical health were most commonly rated by clients as unmet needs at enrolment. At discharge, there was a significant change in psychological distress from the perspective of clients, and in psychological distress and daytime activities from the perspective of case managers. Statistically significant changes were observed for Total Need, Total Unmet Need and Met Need scores from the perspective of case managers. While both clients and case managers reported changes in total service needs between admission and discharge from short-term case management, clients were less likely to report a difference in needs.