A Call for Bigger Thinking and Meaningful Improvements in Health and Well-Being: Time to Move on From Small-Scale Changes.

Effective reforms to provinces' and territories' healthcare delivery systems are needed to generate meaningful changes in population-based health and well-being outcomes in Canada. These reforms include transformations that slow the decline of health and improve the quality of life - such as those relevant to long-term care and aged care - and are expansive enough to include prevention and health promotion.

The Eye-Opening Truth About Private Surgical Facilities in Canada.

This paper examines the contentious issue of using contracted surgical facilities (CSFs) for scheduled eye surgeries within Canada's publicly funded healthcare system. Despite the debate over the use of CSFs, there is a stark lack of Canadian-focused empirical evidence to guide policy decisions. This paper uses the Organisation for Economic Co-operation and Development's healthcare system performance conceptual model - access, quality and cost/expenditures - as a framework to explore the debates surrounding CSFs. It highlights the mixed evidence from international studies and proposes recommendations for policy makers to ensure equitable access, maintain high-quality care and achieve cost-effectiveness. The paper underscores the necessity for informed policy making supported by robust empirical research, stakeholder engagement and continuous policy evaluation to address the challenges posed by the integration of CSFs into Canada's healthcare landscape.

Patient-Physician Sex Discordance and "Before Medically Advised" Discharge from Hospital: A Population-Based Retrospective Cohort Study.

BACKGROUND: Patient-physician sex discordance (when patient sex does not match physician sex) has been associated with reduced clinical rapport and adverse outcomes including post-operative mortality and unplanned hospital readmission. It remains unknown whether patient-physician sex discordance is associated with "before medically advised" hospital discharge (BMA discharge; commonly known as discharge "against medical advice"). OBJECTIVE: To evaluate whether patient-physician sex discordance is associated with BMA discharge. DESIGN: Retrospective cohort study using 15 years (2002-2017) of linked population-based administrative health data for all non-elective, non-obstetrical acute care hospitalizations from British Columbia, Canada. PARTICIPANTS: All individuals with eligible hospitalizations during study interval. MAIN MEASURES: Exposure: patient-physician sex discordance. OUTCOMES: BMA discharge (primary), 30-day hospital readmission or death (secondary). RESULTS: We identified 1,926,118 eligible index hospitalizations, 2.6% of which ended in BMA discharge. Among male patients, sex discordance was associated with BMA discharge (crude rate, 4.0% vs 2.9%; adjusted odds ratio [aOR] 1.08; 95%CI 1.03-1.14; p = 0.003). Among female patients, sex discordance was not associated with BMA discharge (crude rate, 2.0% vs 2.3%; aOR 1.02; 95%CI 0.96-1.08; p = 0.557). Compared to patient-physician sex discordance, younger patient age, prior substance use, and prior BMA discharge all had stronger associations with BMA discharge. CONCLUSIONS: Patient-physician sex discordance was associated with a small increase in BMA discharge among male patients. This finding may reflect communication gaps, differences in the care provided by male and female physicians, discriminatory attitudes among male patients, or residual confounding. Improved communication and better treatment of pain and opioid withdrawal may reduce BMA discharge.

Physician financial incentives to reduce unplanned hospital readmissions: A propensity score weighted cohort study.

BACKGROUND: Unplanned hospital readmissions are associated with adverse patient outcomes and substantial healthcare costs. It remains unknown whether physician financial incentives for enhanced discharge planning can reduce readmission risk. METHODS: In 2012, policymakers in British Columbia, Canada, introduced a $75 fee-for-service physician payment to incentivize enhanced discharge planning (the 'G78717' fee code). We used population-based administrative health data to compare outcomes among G78717-exposed and G78717-unexposed patients. We identified all non-elective hospitalizations potentially eligible for the incentive over a five-year study interval. We examined the composite risk of unplanned readmission or death and total direct healthcare costs accrued within 30 days of discharge. Propensity score overlap weights and adjustment were used to account for differences between exposed and unexposed patients. RESULTS: A total of 5262 of 24,787 G78717-exposed and 28,096 of 136,541 unexposed patients experienced subsequent unplanned readmission or death, suggesting exposure to the G78717 incentive did not reduce the risk of adverse outcomes after discharge (crude percent, 21.1% vs 20.6%; adjusted odds ratio, 0.97; 95%CI, 0.93-1.01; p=0.23). Mean direct healthcare costs within 30 days of discharge were $3082 and $2993, respectively (adjusted cost ratio, 1.00; 95%CI, 0.95-1.05; p=0.93). CONCLUSIONS: A physician financial incentive that encouraged enhanced hospital discharge planning did not reduced the risk of readmission or death, and did not significantly increase or decrease direct healthcare costs. Policymakers should consider the baseline prevalence and effectiveness of enhanced discharge planning, the magnitude and design of financial incentives, and whether auditing of incentivized activities is required when implementing similar incentives elsewhere. TRIAL REGISTRATION: ClinicalTrials.gov ID, NCT03256734.

Replacing the Clinical Institute Withdrawal Assessment-Alcohol revised with the modified Richmond Agitation and Sedation Scale for alcohol withdrawal to support management of alcohol withdrawal symptoms: potential impact on length of stay and complications.

PURPOSE: We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care. METHODS: Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital's administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020. PRIMARY OUTCOME: mean quarterly length of stay. SECONDARY OUTCOMES: delirium, intensive care unit (ICU) admission, other post-admission complications, mortality. RESULTS: N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI - 0.03 to 0.6), intercept change, 0.06 (- 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2-7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3-5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020). CONCLUSIONS: This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.

ABSTRAIT: BUT: Nous avons évalué l'impact sur la durée du séjour et les complications possibles du remplacement de l'échelle Clinical Institute Withdrawal Assessment- Alcohol Revised (CIWA-Ar) par une échelle d'agitation et de sédation de Richmond légèrement modifiée (mRASS-AW) soutenir la prise en charge des patients admis avec des symptômes de sevrage d'alcool dans un hôpital communautaire. Étant donné que le mRASS-AW est considéré comme plus facile et plus rapide à utiliser que le CIWA-Ar, à condition que l'utilisation du mRASS-AW n'aggrave pas les résultats, il pourrait s'agir d'une solution de rechange sécuritaire dans un environnement de SU occupé et offrir une occasion de libérer du temps pour les soins infirmiers. MéTHODES: Analyse rétrospective de séries chronologiques de la durée moyenne trimestrielle du séjour. Toutes les analyses utilisaient exclusivement la base de données des diagnostics de sortie administrative de notre hôpital. Entre le 1er avril 2012 et le 14 décembre 2014, le CIWA-Ar a été utilisé dans les unités de soins intensifs et de soins aux patients hospitalisés pour guider les décisions de dosage des benzodiazépines pour les symptômes de sevrage de l'alcool. Après ce point, CIWA-Ar a été remplacé par mRASS-AW. Les données ont été évaluées jusqu'au 31 décembre 2020. Résultat principal : durée moyenne trimestrielle du séjour. Résultats secondaires : délire, admission en unité de soins intensifs (USI), autres complications post-admission, mortalité. RéSULTATS: N = 1073 patients. Aucune association entre la durée de séjour et le changement d'échelle (changement de pente 0,3 (IC à 95 % -0,03 à 0,6), changement d'interception, 0,06 (-0,03 à 0,2). CIWA-Ar (n = 317) durée moyenne trimestrielle du séjour, 5,7 jours (95 % 4,2 à 7,1), mRASS-AW (n = 756) 5,0 jours (95 % IC 4,3 à 5,6). L'incidence du délire, de l'admission aux soins intensifs ou de la mortalité n'était pas différente. Cependant, l'incidence d'autres complications post-admission était plus élevée avec CIWA-Ar (6,6%) que mRASS-AW (3,4%) (p = 0,020). CONCLUSIONS: Il s'agissait de la première étude à comparer les résultats des patients associés à l'utilisation du mRASS-AW pour les symptômes de sevrage alcoolique en dehors des soins intensifs. Le remplacement de CIWA-Ar par mRASS-AW n'a pas aggravé la durée du séjour ou les complications. Ces résultats fournissent certaines preuves que le mRASS-AW pourrait être considéré comme une alternative au CIWA-Ar et pourrait potentiellement fournir une occasion de libérer du temps de soins infirmiers.

Days alive and out of hospital for adult female and male cardiac surgery patients: a population-based cohort study.

BACKGROUND: Research shows women experience higher mortality than men after cardiac surgery but information on sex-differences during postoperative recovery is limited. Days alive and out of hospital (DAH) combines death, readmission and length of stay, and may better quantify sex-differences during recovery. This main objective is to evaluate (i) how DAH at 30-days varies between sex and surgical procedure, (ii) DAH responsiveness to patient and surgical complexity, and (iii) longer-term prognostic value of DAH. METHODS: We evaluated 111,430 patients (26% female) who underwent one of three types of cardiac surgery (isolated coronary artery bypass [CABG], isolated non-CABG, combination procedures) between 2009 - 2019. Primary outcome was DAH at 30 days (DAH30), secondary outcomes were DAH at 90 days (DAH90) and 180 days (DAH180). Data were stratified by sex and surgical group. Unadjusted and risk-adjusted analyses were conducted to determine the association of DAH with patient-, surgery-, and hospital-level characteristics. Patients were divided into two groups (below and above the 10th percentile) based on the number of days at DAH30. Proportion of patients below the 10th percentile at DAH30 that remained in this group at DAH90 and DAH180 were determined. RESULTS: DAH30 were lower for women compared to men (22 vs. 23 days), and seen across all surgical groups (isolated CABG 23 vs. 24, isolated non-CABG 22 vs. 23, combined surgeries 19 vs. 21 days). Clinical risk factors including multimorbidity, socioeconomic status and surgical complexity were associated with lower DAH30 values, but women showed lower values of DAH30 compared to men for many factors. Among patients in the lowest 10th percentile at DAH30, 80% of both females and males remained in the lowest 10th percentile at 90 days, while 72% of females and 76% males remained in that percentile at 180 days. CONCLUSION: DAH is a responsive outcome to differences in patient and surgical risk factors. Further research is needed to identify new care pathways to reduce disparities in outcomes between male and female patients.

Preoperative depression and anxiety associated with younger age and receipt of immediate breast reconstruction.

BACKGROUND: As survivorship for breast cancer continues to improve, emphasis of care falls upon improving patients' quality of life. Understanding physical and mental health in the preoperative period is needed to aid surgical decision making and improve patient experience. METHODS: Consecutive patients awaiting total mastectomy (TM), TM with immediate breast reconstruction (IBR) and breast conserving surgery (BCS) were prospectively recruited. Scores for PHQ-9, GAD-7, Breast-Q, EQ5D(5L), PEG were collected preoperatively. Association was measured with multivariate analyses. RESULTS: 477 participants (374 BSC, 46 â€‹TM, 84 IBR) were included. Younger patients and those choosing IBR reported worse depression and anxiety symptoms. Clinical tumor features did not affect patient reported outcomes. Higher Breast-Q scores were seen with BCS and lower scores with TM. CONCLUSIONS: Patients scheduled for IBR and younger patients reported worse symptoms of depression and anxiety, regardless of clinical features. This will help with surgical decision making and identify patients in need for additional perioperative supports.

An examination of rectal prolapse surgery patients' quality of life and symptoms using patient-reported outcome instruments: A prospective cohort study.

BACKGROUND: We measured changes in self-reported health and symptoms attributable to rectal prolapse surgery using patient-reported outcome (PRO) measures. METHODS: A prospectively recruited cohort of patients scheduled for rectal prolapse repair in Vancouver, Canada between 2013 and 2021 were surveyed before and 6-months after surgery using seven PROs: the EuroQol Five-Dimension Instrument (EQ-5D-5L), Generalized Anxiety Disorder Scale (GAD-7), Pain Intensity, Interference with Enjoyment of Life and General Activity (PEG), Patient Health Questionnaire (PHQ-9), Fecal Incontinence Severity Index (FISI), Gastrointestinal Quality of Life Index (GIQLI), and the Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: We included 46 participants who reported improvements in health status (EQ-5D-5L; p â€‹< â€‹0.01), pain interference (PEG; p â€‹< â€‹0.01), depressive symptoms (PHQ-9; p â€‹= â€‹0.01), fecal incontinence severity (FISI; p â€‹< â€‹0.01), gastrointestinal quality of life (GIQLI; p â€‹< â€‹0.01), and fecal incontinence quality of life (FIQL) related to lifestyle (p â€‹= â€‹0.02), coping and behaviour (p â€‹= â€‹0.02) and depression and self-perception (p â€‹= â€‹0.01). CONCLUSION: Surgical repair of rectal prolapse improved patients' quality of life with meaningful improvements in fecal incontinence severity and pain, and symptom interference with daily activities.

Content validity testing of the INTERMED Self-Assessment in a sample of adults with rheumatoid arthritis and rheumatology healthcare providers.

BACKGROUND: Care complexity can occur when patients experience health challenges simultaneously with social barriers including food and/or housing insecurity, lack of transportation or other factors that impact care and patient outcomes. People with rheumatoid arthritis (RA) may experience care complexity due to the chronicity of their condition and other biopsychosocial factors. There are few standardised instruments that measure care complexity and none that measure care complexity specifically in people with RA. OBJECTIVES: We assessed the content validity of the INTERMEDS Self-Assessment (IMSA) instrument that measures care complexity with a sample of adults with RA and rheumatology healthcare providers (HCPs). Cognitive debriefing interviews utilising a reparative framework were conducted. METHODS: Patient participants were recruited through two existing studies where participants agreed to be contacted about future studies. Study information was also shared through email blasts, posters and brochures at rheumatology clinic sites and trusted arthritis websites. Various rheumatology HCPs were recruited through email blasts, and divisional emails and announcements. Interviews were conducted with nine patients living with RA and five rheumatology HCPs. RESULTS: Three main reparative themes were identified: (1) Lack of item clarity and standardisation including problems with item phrasing, inconsistency of the items and/or answer sets and noninclusive language; (2) item barrelling, where items asked about more than one issue, but only allowed a single answer choice; and (3) timeframes presented in the item or answer choices were either too long or too short, and did not fit the lived experiences of patients. Items predicting future healthcare needs were difficult to answer due to the episodic and fluctuating nature of RA. CONCLUSIONS: Despite international use of the IMSA to measure care complexity, patients with RA and rheumatology HCPs in our setting perceived that it did not have content validity for use in RA and that revision for use in this population under a reparative framework was unfeasible. Future instrument development requires an iterative cognitive debriefing and repair process with the population of interest in the early stages to ensure content validity and comprehension. PATIENT OR PUBLIC CONTRIBUTION: Patient and public contributions included both patient partners on the study team and people with RA who participated in the study. Patient partners were involved in study design, analysis and interpretation of the findings and manuscript preparation. Data analysis was structured according to emergent themes of the data that were grounded in patient perspectives and experiences.

Shared Decision Making in Hallux Valgus Surgery: A Prospective Observational Study.

Patient-physician communication has the potential to improve outcomes and satisfaction through the shared decision-making process (SDM). This study aims to assess the relationship between perception of SDM and demographic, clinical, and patient-reported outcomes in patients undergoing Hallux Valgus (HV) correction. A prospective analysis of 306 patients scheduled for HV surgery was completed. The CollaboRATE score was used to measure SDM. Multivariable linear regression model was used to assess whether SDM scores were associated with preoperative characteristics or postoperative outcome scores. The mean CollaboRATE score was 2.9 (SD 0.9) and did not differ by age, socioeconomic status, or sex. Lower CollaboRATE scores were associated with more symptoms of depression, lower socioeconomic status, and lower general health scores (p-value < 0.05). There was no association between SDM scores and postoperative outcome scores. In this study, patients with depressive symptoms and lower socioeconomic status had worse perceptions of SDM. There was no difference in postoperative outcomes among participants based on SDM scores. Level of Evidence: Level III, prospective observational study.

Preparing for colorectal surgery: a feasibility study of a novel web-based multimodal prehabilitation programme in Western Canada.

AIM: Prehabilitation for colorectal cancer has focused on exercise-based interventions that are typically designed by clinicians; however, no research has yet been patient-oriented. The aim of this feasibility study was to test a web-based multimodal prehabilitation intervention (known as PREP prehab) consisting of four components (physical activity, diet, smoking cessation, psychological support) co-designed with five patient partners. METHOD: A longitudinal, two-armed (website without or with coaching support) feasibility study of 33 patients scheduled for colorectal surgery 2 weeks or more from consent (January-September 2021) in the province of British Columbia, Canada. Descriptive statistics analysed a health-related quality of life questionnaire (EQ5D-5L) at baseline (n = 25) and 3 months postsurgery (n = 21), and a follow-up patient satisfaction survey to determine the acceptability, practicality, demand for and potential efficacy in improving overall health. RESULTS: Patients had a mean age of 52 years (SD 14 years), 52% were female and they had a mean body mass index of 25 kg m-2 (SD 3.8 kg m-2). Only six patients received a Subjective Global Assessment for being at risk for malnutrition, with three classified as 'severely/moderately' malnourished. The majority (86%) of patients intended to use the prehabilitation website, and nearly three-quarters (71%) visited the website while waiting for surgery. The majority (76%) reported that information, tools and resources provided appropriate support, and 76% indicated they would recommend the PREP prehab programme. About three-quarters (76%) reported setting goals for lifestyle modification: 86% set healthy eating goals, 81% aimed to stay active and 57% sought to reduce stress once a week or more. No patients contacted the team to obtain health coaching, despite broad interest (71%) in receiving active support and 14% reporting they received 'active support'. CONCLUSION: This web-based multimodal prehabilitation programme was acceptable, practical and well-received by all colorectal surgery patients who viewed the patient-oriented multimodal website. The feasibility of providing active health coaching support requires further investigation.

Population-Based Trends in Complexity of Hospital Inpatients.

Importance: Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression. Objective: To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period. Design, Setting and Participants: This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023. Exposure: The passage of time (15-year study interval). Main Outcomes and Measures: Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval. Results: The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively). Conclusions and Relevance: By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.

Association between anesthesia technique and death after hip fracture repair for patients with COVID-19.

PURPOSE: Patients with COVID-19 undergoing hip fracture surgeries have a 30-day mortality of up to 34%. We aimed to evaluate the association between anesthesia technique and 30-day mortality after hip fracture surgery in patients with COVID-19. METHODS: After ethics approval, we performed a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program data set from January to December 2021. Inclusion criteria were age ≥ 19 yr, laboratory-confirmed SARS-CoV-2 infection within 14 days preoperatively, and hip fracture surgery under general anesthesia (GA) or spinal anesthesia (SA). Exclusion criteria were American Society of Anesthesiologists Physical Status V, ventilator dependence, international normalized ratio ≥ 1.5, partial thromboplastin time > 35 sec, and platelet count < 80 × 109 L-1. The primary outcome was all-cause 30-day mortality. The adjusted association between anesthetic technique and 30-day mortality was analyzed using multivariable logistic regression. RESULTS: Of 23,045 patients undergoing hip fracture surgery, 331 patients met the study criteria. The median [interquartile range] age was 82 [74-88] yr, and 32.3% were male. The 30-day mortality rate was 10.0% (33/331) for the cohort (10.7%, 29/272 for GA vs 6.8%, 4/59 for SA; P = 0.51; standardized mean difference, 0.138). The use of SA, compared with GA, was not associated with decreased mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.21 to 1.8; E-value, 2.49). CONCLUSION: Anesthesia technique was not associated with mortality in patients with COVID-19 undergoing hip fracture surgery. The findings were limited by a small sample size. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT05133648); registered 24 November 2021.

RéSUMé: OBJECTIF: Les personnes atteintes de COVID-19 bénéficiant d'une chirurgie de fracture de la hanche ont une mortalité à 30 jours allant jusqu'à 34 %. Notre objectif était d'évaluer l'association entre la technique d'anesthésie et la mortalité à 30 jours après une chirurgie de fracture de la hanche chez les personnes atteintes de COVID-19. MéTHODE: Après l'approbation du comité d'éthique, nous avons réalisé une analyse de cohorte rétrospective de l'ensemble de données du Programme national d'amélioration de la qualité chirurgicale de l'American College of Surgeons de janvier à décembre 2021. Les critères d'inclusion étaient un âge ≥ 19 ans, une infection par le SRAS-CoV-2 confirmée en laboratoire dans les 14 jours préopératoires et une chirurgie de fracture de la hanche sous anesthésie générale (AG) ou rachianesthésie (RA). Les critères d'exclusion étaient un statut physique V selon l'American Society of Anesthesiologists, la dépendance à une assistance ventilatoire, un ratio international normalisé ≥ 1,5, un temps de thromboplastine partielle > 35 sec, et une numération plaquettaire < 80 × 109 L−1. Le critère d'évaluation principal était la mortalité à 30 jours toutes causes confondues. L'association ajustée entre la technique anesthésique et la mortalité à 30 jours a été analysée à l'aide d'une régression logistique multivariée. RéSULTATS: Sur 23 045 patient·es opéré·es pour une fracture de la hanche, 331 répondaient aux critères de l'étude. L'âge médian (écart interquartile) était de 82 [74­88] ans et 32,3 % étaient des hommes. Le taux de mortalité à 30 jours était de 10,0 % (33/331) pour la cohorte (10,7 %, 29/272 pour l'AG vs 6,8 %, 4/59 pour la RA; P = 0,51; différence moyenne standardisée, 0,138). L'utilisation de la RA, par rapport à l'AG, n'a pas été associée à une diminution de la mortalité (rapport de cotes ajusté, 0,61; intervalle de confiance à 95 %, 0,21 à 1,8; valeur E, 2,49). CONCLUSION: La technique d'anesthésie n'a pas été associée à la mortalité chez les personnes atteintes de COVID-19 bénéficiant d'une chirurgie de fracture de la hanche. Les résultats ont été limités par la petite taille de l'échantillon. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT05133648); enregistrée le 24 novembre 2021.

Federal and Provincial Governments Need To Be Transparent about Trade-Offs When They Buy Healthcare.

Spending on healthcare is carefully scrutinized by the public, the media and academics because the amounts are so large and represent a very significant proportion of provincial budgets. Some quarters are calling for increases in spending, whereas others are focused on restraint owing to perceived inefficiencies and ineffectiveness. The debate over healthcare spending has continued for decades and is likely to heat up as new provincial labour agreements have locked in annual healthcare spending increases of at least five percent for 2023 (BC Nurses' Union 2023; ONA 2023).

Patterns of service utilization among youth with substance use service need: a cohort study.

BACKGROUND: Integrated youth services (IYS) are vital to addressing the needs of youth who use substances. Evidence on the characteristics of youths accessing these services and the types of services accessed have been limited. The objectives were to identify sociodemographic, self-reported health and mental health, patterns of service utilization (service type and frequency of visits) among youths with different levels of substance use service needs (low, moderate, and high), and to estimate the extent to which substance use service needs, self-reported health and mental health influenced the frequency of visits and types of service utilized. METHODS: Data were collected from youth (12-24 years) accessing IYS centres in Canada. Information on socio-demographic factors, substance use in the last month, self-rated health measures, number of service visits, and type of services utilized were included. Poisson regression was used to estimate the relationship between substance use needs and number of service visits and the different type of services utilized. RESULTS: Of 6181 youths, 48.0% were categorized as low substance use service needs, 30.6% had moderate needs and 21.4% had high needs, with higher proportion of men in the high needs group. Mental health and substance use (MHSU) services were utilized the most across all three groups, followed by counseling. The median number of visits was 4 for the low and moderate needs group and 5 in the high needs group. People with high service needs had 10% higher rate of service visits and utilized 10% more services than people with low service needs (service visits: RR = 1.1 (95%CI: 1.1-1.2); service type: RR = 1.1 (95%CI:1.0-1.1)). The rate of service visits increased by 30 to 50% and the number of services increased by 10-20% for people who rated their health good/fair/poor. Similarly, the rate of service visits increased by 40 to 60% and the number of services increased by 20% for people who rated their mental health good/fair/poor. CONCLUSIONS AND IMPACTS: Our study highlighted that regardless of service needs, youth who use alcohol and drugs have complex intersecting needs that present once they access integrated youth services.

The Tangled Web of Integrating Health and Social Services in Canada.

It is important to have all the pieces of health and social care systems working together to maintain and improve the lives and well-being of medically complex Canadians. Being medically complex means needing physical and mental healthcare for chronic conditions, addressing functional health limitations and adapting models of care to social vulnerabilities, such as rurality or cultural safety. This could happen to any of us or to our family members, at any time.

Toward Comprehensive Care Integration in Canada: Delphi Process Findings from Researchers, Clinicians, Patients and Decision Makers.

Introduction: From a larger study examining policy and program information on how Canadian provinces integrate care services, this study aimed to create "priority lists" of 10-15 services that are "absolutely needed" for care integration. Methodology: A diverse group of over 50 Canadian stakeholders participated in virtual consensus-building using the nominal group technique and a modified e-Delphi method to identify services that focused on two different groups: children and youth with high functional health needs and older adults in functional decline. Results: Three lists - containing services, processes and infrastructure elements - emerged: one per tracer condition group and a consolidated list. The latter identified the following five services as top priority for primary care integration: mental health and addictions services; home care; transition between urgent-emergency-acute care; medication reconciliation in community pharmacies; and respite care. No single social service was a clear priority, but those that mitigate material deprivation emerged within the top 10. Discussion: This humble pan-Canadian study shows that priority services in health and social services are neither well integrated nor connected to primary care. It also suggests that effective policy strategizing for primary care integration for those with complex care needs may require thinking beyond the logic of services - given their siloed organization.

Improving the quality of care of Canadians waiting for elective surgery: an important health care priority.

The backlog of cases on surgical wait lists is a substantial problem for surgical patients, their families, surgeons, health care systems and governments. There are several approaches governments can take to improve the health, well-being and surgical outcomes of waiting patients. First, provinces should consider patient-centred approaches to triaging that reflect pain, symptoms or functional gain, and approaches using multidisciplinary teams or centralized triage. Second, governments could provide prehabilitation and mental health supports aligned with patients' and families' preferences during unavoidable waits. Wait times are not going to shorten any time soon; provinces should not only find innovative approaches to reducing waits, but also organize services to improve the health and well-being of waiting patients. Such changes will allow for optimization of patients' surgical outcomes and reduce the complexity of managing the wait list for their surgeons.

Reversing the Stigma around Canada's Poor-Performing Healthcare Systems.

Recent statistics report that healthcare spending growth is persistently high; in recent years, spending growth exceeded 5% (CIHI 2022). Some portion of the outsized growth can be attributed to the COVID-19 pandemic, though the cause is irrelevant. High spending growth in the healthcare sector is not a good prospect for taxpayers or for education and social programs competing for the same pot of money. Spending is important, but it is not the only attribute for measuring the success of our provinces' and territories' efforts to fund healthcare services that maintain or improve their populations' health.