The Impact of Rural Hospital Closures and Health Service Restructuring on Provincial- and Community-Level Patterns of Hospital Admissions in New Brunswick.

In the early 2000s, the Province of New Brunswick, Canada, undertook health system restructuring, including closing some rural hospitals. We examined whether changes in geographic access to hospitals and primary care were associated with changes in patterns of hospital use. We described three measures of hospital use for ambulatory care sensitive conditions (ACSCs) among adults 75 years and younger annually during the period 2004-2013 overall, and at the community scale. We described spatial and temporal patterns in: age-standardized hospitalization rates, age-standardized incidence of hospital admissions, and rates of admissions via ambulance. Overall, rates and incidence of hospitalizations for ACSCs declined while admissions via ambulance remained largely unchanged. We observed considerable regional variation in rates between communities in 2004. This regional variation decreased over time, with rural areas demonstrating the sharpest declines. Changes in hospital service provision within individual communities had little impact on rates of ACSC admissions. Results were consistent across urban and rural communities and were robust to analyses that included older patients and those admitted for reasons other than ACSCs. Our results suggest that the restructuring and hospital closures did not result in substantial changes to regional patterns or rates of service use.

Neighbourhood characteristics related to mental health service use among adults with diabetes: a population-based cohort study in New Brunswick, Canada.

OBJECTIVE: It has been postulated that social and economic inequalities may shape the distributions of comorbid diabetes and mental illness. This observational cohort study using linked population-based administrative and geospatial datasets aimed to describe associations between neighbourhood socioenvironments and disorder-specific mental health service use among adults with diabetes in the province of New Brunswick, Canada. RESULTS: A baseline cohort of 66,275 persons aged 19 and over living with diabetes was identified. One-quarter (26.3%) had used healthcare services for mood and anxiety disorders at least once during the six-year follow-up period 2012/2013-2017/2018. Based on Cox proportional hazards models, the risk of mental health service contacts was significantly higher among those residing in the most materially deprived neighbourhoods [HR: 1.07 (95% CI: 1.01-1.14)] compared to those in the least so, and those in areas characterized with the highest residential instability [HR: 1.13 (95% CI: 1.05-1.22)] compared to those in areas with the lowest instability. Among adults with incident diabetes (N = 4410), age and sex but not neighbourhood factors were related to differential help-seeking behaviours for mental health problems. These findings underscored the gap between theoretical postulations and population-based observations in delineating the syndemics of neighbourhood socioenvironments and mental health outcomes in populations with high diabetes prevalence.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis.

BACKGROUND: Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. METHODS: Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. RESULTS: We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. CONCLUSIONS: Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Changes to telehealth practices in primary care in New Brunswick (Canada): A comparative study pre and during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, telehealth technologies were used in the primary health care setting in New Brunswick as a means to continue providing care to patients while following public health guidelines. This study aimed to measure these changes and examine if they improved timely access to primary care. A secondary goal was to identify which telehealth technologies were deemed sustainable by primary care providers. METHODS: This was a comparative study on the use of telehealth technology before and during the COVID-19 pandemic. Between April 2020 and November 2020, 114 active primary care providers (family physicians or nurse practitioners) responded to the online survey. RESULTS: The findings illustrated an increase in the use of telehealth technologies. The use of phone consultations increased by 122%, from 43.9% pre-pandemic to 97.6% during the pandemic (p < 0.001). The use of virtual consultation (19.3% pre-pandemic vs. 41.2% during the pandemic, p < 0.001), emails and texts also increased during the pandemic. Whereas the more structural organizational tools (electronic medical charts and reservation systems) remained stable. However, those changes did not coincide with a significant improvement to timely access to care during the pandemic. Many participants (40.1%) wanted to keep phone consultations, and 21.9% of participants wanted to keep virtual consultations as part of their long-term practice. INTERPRETATION: The observed increase in the use of telehealth technologies may be sustainable, but it has not significantly improved timely access to primary care in New Brunswick.

Estimating the dispersal of Lepeophtheirus salmonis sea lice within and among Atlantic salmon sites of the Bay of Fundy, New Brunswick.

The objective of this study was to estimate the impact of infestation pressures on the abundance of the parasitic sea louse, Lepeophtheirus salmonis, in the Bay of Fundy, New Brunswick (NB), Canada, using the Fish-iTrends database for the years 2009-2018. Infestation pressures were calculated as time-lagged weighted averages of the abundance of adult female (AF) sea lice within a site (internal infestation pressure: IIP) and among sites (external infestation pressure: EIP). The EIP weights were calculated from seaway distances among sites and a Gaussian kernel density for bandwidths of 5 to 60 km. The EIP with a bandwidth of 10 km had the best fit, as determined with Akaike's information criterion, and historical AF sea lice abundance. This estimated dispersal distance of 10 km was similar to previous studies in Norway, Scotland and in New Brunswick. The infestation pressures estimated from empirical AF sea lice abundance within and among sites significantly increased the abundance of AF sea lice (p < .001). This study concludes that sea lice burdens within Atlantic salmon farms in the Bay of Fundy, NB, are affected by within site management and could be improved by synchronizing treatments between sites.

Local Surveillance and Control of Raccoon Rabies Virus in Striped Skunks (Mephitis mephitis) in Southwestern New Brunswick, Canada.

Targeted surveillance for raccoon rabies virus was conducted between February and May 2017, near Waweig, New Brunswick, Canada, in response to detection of a rabid striped skunk (Mephitis mephitis) on 8 February 2017. A total of six skunks, 11 raccoons (Procyon lotor), and two porcupines (Erethizon dorsatum) were live-trapped, euthanized, and tested for rabies virus antigens using the direct rapid immunohistochemical test. Of these, only two skunks tested positive for rabies. All three rabid skunks came from the same location, an abandoned barn used as a denning site. Four of five skunks removed from this barn were males. Feeding, aggression, extreme response to noise and light stimuli, and exposure to porcupine quills were observed in two rabid skunks. No additional cases of rabies in wildlife were detected in the area since 8 March 2017. A targeted surveillance approach that removed potentially infected wildlife followed by localized oral rabies vaccine distribution was implemented in this locality.

CO-aVoID: coronavirus outbreak affecting variability of presentations to a local emergency department.

BACKGROUND: The impact of the COVID-19 pandemic on public health, specifically on patients presenting to the emergency department (ED) with non-COVID-related diseases, remains largely undocumented. OBJECTIVE: This study explored how overall rates of presentations to the emergency department were impacted immediately after the declaration of the COVID-19 pandemic, and specifically how key presenting symptoms representing emergency, standard and low-acuity conditions were impacted. METHODS: A sequential modified Delphi survey and cross-sectional analysis of administrative census data from a tertiary care center in New Brunswick, Canada, were performed. Details of ED presentations for emergency, standard and low-acuity conditions from February 1 to April 30, 2020, were compared to data from previous years. RESULTS: There was a significant decrease in the number of patients visiting the ED with emergency, standard and low-acuity complaints immediately after March 13, 2020, compared to 2019. The proportion of females and males remained similar, with a median age of 48 years in 2020 and 44 years in 2019. Total presentation patterns to the ED (registrations, admissions to hospital and left without being seen numbers) decreased, compared to previous years. CONCLUSIONS: We report a predictable decrease in patient visits to the ED with minor, non-life-threatening conditions during a pandemic. However, we also report a decrease in presentations for emergency and standard conditions. Improved messaging highlighting the need to seek help for "true" emergencies, while providing non-ED options for minor, non-life-threatening conditions, may be helpful under normal circumstances and during future pandemics.

RéSUMé: CONTEXTE: L'impact de la pandémie COVID-19 sur la santé publique, en particulier sur les patients se présentant aux services d'urgence (SU) avec des maladies non liées à la COVID, demeure en grande partie non documenté. OBJECTIF: Cette étude a exploré la façon dont les taux globaux de présentations au service des urgences ont été touchés immédiatement après la déclaration de la pandémie de COVID-19, et plus particulièrement la façon dont les principaux symptômes représentant des conditions d'urgence, standard et de faible acuité ont été touchés. MéTHODES: Une enquête Delphi séquentielle modifiée et une analyse transversale des données du recensement administratif provenant d'un centre de soins tertiaires du Nouveau-Brunswick, au Canada, ont été réalisées. Les détails des présentations du SU pour les conditions d'urgence, standard et de faible acuité du 1er février au 30 avril 2020 ont été comparés aux données des années précédentes. RéSULTATS: Il y a eu une diminution significative du nombre de patients se rendant au service d'urgence avec des plaintes d'urgence, standard et de faible gravité immédiatement après le 13 mars 2020, par rapport à 2019. La proportion de femmes et d'hommes est demeurée semblable, avec un âge médian de 48 ans en 2020 et de 44 ans en 2019. Le nombre total de modèles de présentation à l'urgence (inscriptions, admissions à l'hôpital et nombre laissé sans être vu) a diminué par rapport aux années précédentes. CONCLUSIONS: Nous faisons état d'une diminution prévisible des visites de patients aux urgences pour des affections mineures qui ne mettent pas leur vie en danger pendant une pandémie. Toutefois, nous signalons également une diminution des présentations pour les situations d'urgence et les conditions normales. Des messages améliorés soulignant la nécessité de demander de l'aide pour les urgences « réelles ¼, tout en offrant des options non urgentes pour des conditions mineures et qui ne mettent pas la vie en danger peuvent être utiles dans des circonstances normales et lors de futures pandémies.

Provider caseload volume and short-term outcomes following colorectal surgeries in New Brunswick: a provincial-level cohort study.

BACKGROUND: American studies have shown that higher provider and hospital volumes are associated with reduced risk of mortality following colorectal surgical interventions. Evidence from Canada is limited, and to our knowledge only a single study has considered outcomes other than death. We describe associations between provider surgical volume and all-cause mortality and postoperative complications following colorectal surgical interventions in New Brunswick. METHODS: We used hospital discharge abstracts linked to vital statistics, the provincial cancer registry and patient registry data. We considered all admissions for colorectal surgeries from 2007 through 2013. We used logistic regression to identify odds of dying and odds of complications (from any of anastomosis leak, unplanned colostomy, intra-abdominal sepsis or pneumonia) within 30 days of discharge from hospital according to provider volume (i.e., total interventions performed over the preceding 2 years) adjusted for personal, contextual, provider and hospital characteristics. RESULTS: Overall, 9170 interventions were performed by 125 providers across 18 hospitals. We found decreased odds of experiencing a complication following colorectal surgery per increment of 10 interventions performed per year (odds ratio 0.94, 95% confidence interval 0.91-0.96). We found no associations with mortality. Associations remained consistent across models restricted to cancer patients or to interventions performed by general surgeons and across models that also considered overall hospital volumes. CONCLUSION: Our results suggest that increased caseloads are associated with reduced odds of complications, but not with all-cause mortality, following colorectal surgery in New Brunswick. We also found no evidence of volume having differential effects on outcomes from colon and rectal procedures.

CONTEXTE: Des études américaines ont montré que le volume d'activité des chirurgiens et des hôpitaux est inversement proportionnel au risque de mortalité après la chirurgie colorectale. Les données pour le Canada sont limitées, et à notre connaissance, une seule étude a porté sur d'autres paramètres que le décès. Nous avons décrit les liens entre volume d'activité des chirurgiens et mortalité de toute cause/complications postopératoires après la chirurgie colorectale au Nouveau-Brunswick. MÉTHODES: Nous avons utilisé les registres de congés des hôpitaux reliés aux données de la Statistique de l'état civil, du registre provincial du cancer et du registre des patients. Nous avons recensé toutes les admissions pour chirurgie colorectale de 2007 à 2013. Nous avons utilisé la régression logistique pour établir le risque de décès et le risque de complications (fuite anastomotique, colostomie non planifiée, infection intra-abdominale ou pneumonie) dans les 30 jours suivant le congé de l'hôpital par rapport au volume d'activité des chirurgiens (c.-à-d., interventions totales des 2 années précédentes) ajusté en fonction des caractéristiques individuelles et contextuelles, propres aux chirurgiens et aux hôpitaux. RÉSULTATS: En tout, 125 chirurgiens ont effectué 9170 interventions dans 18 hôpitaux. Nous avons observé un risque moindre de complications après la chirurgie colorectale pour chaque palier de 10 interventions effectuées annuellement (risque relatif 0,94, intervalle de confiance de 95 %, 0,91­0,96). Nous n'avons observé aucun lien avec la mortalité. Les liens sont demeurés constants, peu importe que les modèles soient restreints aux patients cancéreux ou aux interventions effectuées par des chirurgiens généraux et entre les modèles qui tenaient également compte du volume global d'activité des hôpitaux. CONCLUSION: Selon nos résultats, l'augmentation du volume d'activité est associée à un risque moindre de complications, mais n'a pas de lien avec la mortalité de toute cause après la chirurgie colorectale au Nouveau-Brunswick. Nous n'avons pas non plus constaté de lien entre le volume d'activité et l'issue différentielle de la chirurgie du côlon et du rectum.

Development and implementation of a risk assessment and management program for enzootic bovine leukosis in Atlantic Canada.

Over the past 30 yr, the prevalence of bovine leukemia virus (BLV) infection has increased in North America, including Atlantic Canada, at both the herd and individual cow levels. This has occurred despite increased awareness of the disease and its deleterious effects and despite implementation of management practices aimed at reducing disease transmission. Our objectives were to identify risk factors associated with the within-herd prevalence of BLV-infected cows by using a risk assessment and management program workbook, as well as to determine the current level of BLV prevalence in the Atlantic Canada region. We hypothesized that previously established risk factors, including management practices associated with calf rearing and fly control, would affect within-herd BLV prevalence. Bulk tank milk (BTM) samples were collected in January and April of 2016 and again during the same months in 2017 and 2018 from all dairy farms shipping milk in the region. Samples were tested with ELISA for levels of anti-BLV antibodies to estimate within-herd prevalence. Regional BLV prevalence at the herd level was 88.39% of dairy herds infected in 2016 and 89.30% in 2018. All dairy farms shipping milk and who had BTM samples collected in 2017 (n = 605) were eligible to participate in the risk assessment and management program questionnaire (RAMP), which was developed and distributed to all bovine veterinarians in Atlantic Canada. One hundred and six RAMP were returned, with representation from all 4 provinces. The RAMP results were combined with the mean BTM ELISA results, and univariable logistic regression followed by multivariable logistic regression was performed to investigate the association between RAMP risk factors and the estimated within-herd BLV prevalence. Factors in the multivariable model significantly associated with the odds of a herd being classified as >25% estimated within-herd prevalence included history of diagnosis of clinical BLV and calves receiving colostrum from cows with unknown BLV status. Differences in within-herd prevalence were not associated with hypodermic needle and injection practices, rectal sleeve practices, or using bulls for natural breeding, based on these 106 dairy farms.

Longitudinal examination of youth readmission to mental health inpatient units.

OBJECTIVE: Significant barriers exist for youth in obtaining mental health services. These barriers are exacerbated by growing demand, attributed partially to children and adolescents who have repeat hospital admissions. The purpose of this study was to identify demographic, socioeconomic and clinical predictors of readmission to inpatient psychiatric services in New Brunswick, Canada. METHOD: Key demographic, support and clinical predictors of readmission were identified. The New Brunswick Discharge Abstract Database (DAD) was used to compile a cohort of all children and adolescents ages 3-19 years with psychiatric hospital admissions between 1 April 2003 and 31 March 2014 (N = 3825). Primary analyses consisted of Kaplan-Meier survival methods with log-rank tests to assess time-to-readmission variability, and Cox regression to identify significant predictors of readmission. RESULTS: In total, 27.8% of admitted children and adolescents experienced at least one readmission within the 10-year period, with 57.3% readmitted to hospital within 90 days following discharge. Bivariate results indicated that male, upper-middle socioeconomic status (SES) youths aged 11-15 years from nonrural communities were most likely to be readmitted. Notable predictors of increased readmission likelihood were older age, being male, higher SES, referral to care by medical practitioner, discharge to another health facility, psychosis, and previous psychiatric admission. CONCLUSION: A significant portion of the variance in readmission was accounted for by youth demographic characteristics (i.e. age, SES, geographic location) and various support structures, including referrals to inpatient care and aftercare support services. KEY PRACTITIONER MESSAGE: Readmission to inpatient psychiatric care among youth is affected by a number of multifaceted risk factors across individual, environmental and clinical domains. This study used provincial population-scale longitudinal administrative data to demonstrate the influence of various individual and demographic factors on likelihood of readmission, which is notably absent from the majority of studies that make use of smaller, short-term data samples. Ensuring that multiple factors outside of the clinical context are considered when examining readmission among youth may contribute to a more thorough understanding of youth hospitalization patterns.

Provider volume and maternal complications after Caesarean section: results from a population-based study.

BACKGROUND: A large literature search suggests a relationship between hospital/surgeon caseload volume and surgical complications. In this study, we describe associations between post-operative maternal complications following Caesarean section and provider caseload volume, provider years since graduation, and provider specialization, while adjusting for hospital volumes and patient characteristics. METHODS: Our analysis is based on population-based discharge abstract data for the period of April 2004 to March 2014, linked to patient and physician universal coverage registry data. We consider all hospital admissions (N = 20,914) in New Brunswick, Canada, where a Caesarean Section surgery was recorded, as identified by a Canadian Classification of Health Intervention code of 5.MD.60.XX. We ran logistic regression models to identify the odds of occurrence of post-surgical complications during the hospital stay. RESULTS: Roughly 2.6% of admissions had at least one of the following groups of complications: disseminated intravascular coagulation, postpartum sepsis, postpartum hemorrhage, and postpartum infection. The likelihood of complication was negatively associated with provider volume and provider years of experience, and positively associated with having a specialization other than maternal-fetal medicine or obstetrics and gynecology. CONCLUSIONS: Our results suggest that measures of physician training and experience are associated with the likelihood of Caesarean Section complications. In the context of a rural province deciding on the number of rural hospitals to keep open, this suggests a trade off between the benefits of increased volume versus the increased travel time for patients.

Prevalence and Intensity of Salmincola edwardsii in Brook Trout in Northwest New Brunswick, Canada.

Parasites can compromise the health and fitness of individual fish, and it is important to generate baseline information that can then be used to document changes in the abundance and distribution of potentially pathogenic parasites. The ectoparasitic copepod Salmincola edwardsii was assessed with respect to prevalence (percentage of infected fish per site), infection intensity (number of parasites per infected fish), and attachment location on Brook Trout Salvelinus fontinalis in northwest New Brunswick, Canada. Ten sample sites were assessed, with six sites on two streams in the Quisibis River basin and four sites on three streams in the Restigouche River basin. Parasite species identity was supported by 100% sequence identity with S. edwardsii in a variable region within 28S rDNA. The prevalence of fish infected per site ranged from 19.0% to 79.6%, with an overall prevalence of 48.5 ± 19.1% (mean ± SD) per site. Mean infection intensity was 1.5 ± 0.9 copepods/fish (range = 1-7), with parasites almost exclusively surrounding the dorsal fin and/or adipose fin (97.6%). There was no influence of trout age-class on parasite prevalence. Some fish presented with fin erosion at the site of parasite attachment (12.5%), and 6.2% also presented with hyperplastic skin lesions where no parasites were observed, that could be misinterpreted as secondary bacterial or fungal infections. Skin and fin damage were significantly more common when fish were infected with three or more individual parasites. The pathogenic potential of this parasite makes its presence noteworthy as a risk to salmonids that are both recreationally and ecologically important.

A Multiple Streams Approach to Understanding the Issues and Challenges of Lyme Disease Management in Canada's Maritime Provinces.

This study examines potential challenges facing Lyme disease patients in Canada's Maritime provinces-New Brunswick, Nova Scotia, Prince Edward Island-and considers how issues could be addressed. Reviews of both the academic and grey literature are complemented by surveys targeting both medical professionals and decision makers in government. Combined, the literature reviews and surveys demonstrate that there is considerable debate surrounding the effectiveness of testing, treatment options, and the existence of chronic Lyme disease. As the focus on the Maritimes demonstrates, these debates often pit the medical community against patients and patient advocates and, thus far, governments have been unable to produce policy that entirely pleases either side. Moving forward, this study recommends the creation of a discussion forum via a federal Commission of inquiry to review best practise guidelines for Lyme disease. The key is to foster an unbiased probe of central issues surrounding treatment and diagnosis without alienating stakeholders. This course of action will not necessarily solve the issue of Lyme disease, but would foster a greater understanding through dialogue that includes and validates the experiences of stakeholders, which is something that is currently missing.

Prevalence of lameness and associated risk factors on dairy farms in the Maritime Provinces of Canada.

Lameness in dairy cattle is a major issue for the industry due to the effects on the welfare of the animal, the economic impact, and consumer perception. The aim of this study was to determine the prevalence of lameness and explore potential risk factors in the Maritime Provinces of Canada. Cows were scored for lameness and potential risk factors and were assessed in 46 freestall herds and 33 tiestall herds in Nova Scotia, New Brunswick, and Prince Edward Island. In freestall herds, lameness was assessed using the most common method, locomotion scoring. A cow with a gait score of ≥3 out of 5 was considered to be lame. In tiestall herds, lameness was assessed using an alternative method known as stall lameness scoring. This assessment consisted of observation of the cow for 4 behavioral changes: standing on the edge of the stall, shifting weight, resting a limb, and uneven weight bearing when moved side to side. A cow displaying 2 or more of these behaviors was considered to be lame. At the time of the assessment, other animal-, environmental-, and management-based measurements were collected. These measurements were used in multivariable logistic regression analysis to determine risk factors that were associated with lameness for both freestalls and tiestalls independently. The prevalence of lameness was 21% for freestall-housed cattle and 15% for tiestall-housed cattle. Of the 1,488 tiestall-housed cows that were assessed, 68% showed no behavioral changes, whereas 15, 15, 2, and <1% showed 1, 2, 3, or 4 changes, respectively. In freestalls, higher odds of lameness were seen when cows spent ≥3 h/d in the holding area for milking compared with those that spent <3 h/d. In tiestall herds, higher odds of lameness were seen when bedding material was wet compared with when it was dry. For both lactating cow facility types, housing the dry cows and heifers on a deep bedded pack compared with tiestalls or freestalls was associated with a decreased odds of lameness. There were also many cow-level variables associated with lameness, including parity, daily milk production, stage of production, body condition, and width at the tuber coxae (hook bones). If producers become aware of the risk factors associated with lameness, they can make informed decisions on where to implement changes to help reduce the level of lameness in their herd.

Effects of Pay-for-Performance for Primary Care Physicians on Preventable Diabetes-Related Hospitalization Costs Among Adults in New Brunswick, Canada: A Quasiexperimental Evaluation.

OBJECTIVES: In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs. METHODS: We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive. RESULTS: Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes. CONCLUSIONS: The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.

Connectivity-based risk ranking of infectious salmon anaemia virus (ISAv) outbreaks for targeted surveillance planning in Canada and the USA.

Infectious salmon anaemia (ISA) can be a serious viral disease of farmed Atlantic salmon (Salmo salar). A tool to rank susceptible farms based on the risk of ISA virus (ISAv) infection spread from infectious farms after initial incursion or re-occurrence in an endemic area, can help guide monitoring and surveillance activities. Such a tool could also support the response strategy to contain virus spread, given available resources. We developed a tool to rank ISAv infection risks using seaway distance and hydrodynamic information separately and combined. The models were validated using 2002-2004 ISAv outbreak data for 30 farms (24 in New Brunswick, Canada and 6 in Maine, United States). Time sequence of infection spread was determined from the outbreak data that included monthly infection status of the cages on these farms. The first infected farm was considered as the index site for potential spread of ISAv to all other farms. To assess the risk of ISAv spreading to susceptible farms, the second and subsequent infected farms were identified using the farm status in the given time period and all infected farms from the previous time periods. Using the three models (hydrodynamic only, seaway-distance, and combined hydrodynamic-seaway-distance based models), we ranked susceptible farms within each time interval by adding the transmission risks from surrounding infected farms and sorting them from highest to lowest. To explore the potential efficiency of targeted sampling, we converted rankings to percentiles and assessed the model's predictive performance by comparing farms identified as high risk based on the rank with those that were infected during the next time interval as observed in the outbreak data. The overall predictive ability of the models was compared using area under the ROC curve (AUC). Farms that become infected in the next period were always within the top 65% of the rank predicted by our models. The overall predictive ability of the combined (hydrodynamic-seaway-distance based model) model (AUC = 0.833) was similar to the model that only used seaway distance (AUC = 0.827). Such models can aid in effective surveillance planning by balancing coverage (number of farms included in surveillance) against the desired level of confidence of including all farms that become infected in the next time period. Our results suggest that 100% of the farms that become infected in the next time period could be targeted in a surveillance program, although at a significant cost of including many false positives.

Salmonella enterica and extended-spectrum cephalosporin-resistant Escherichia coli recovered from Holstein dairy calves from 8 farms in New Brunswick, Canada.

This study was carried out to determine the frequency of fecal carriage, antimicrobial susceptibility, and resistance genes in Salmonella enterica and Escherichia coli with reduced susceptibility to extended-spectrum cephalosporins (ESC) isolated from 488 dairy calves from 8 farms in New Brunswick, Canada. Both S. enterica and E. coli with reduced susceptibility to ESC were isolated using selective culture. Minimum inhibitory concentrations to a panel of antimicrobial drugs were determined for randomly selected E. coli isolates and all of the Salmonella isolates. Multiplex PCR were conducted on the selected ESC-resistant E. coli to assess the ß-lactamase resistance genes (blaCTX-M, blaCMY-2, blaSHV, and blaTEM) and plasmid-mediated qnrB and qnrS resistant genes. Information on ceftiofur use and other farm management practices were collected by the use of a questionnaire to determine the risk factors for the fecal recovery of E. coli with reduced susceptibility to ESC. Salmonella enterica frequency in calves' fecal samples was 3.3%, and all were pansusceptible. Salmonella isolates belonged to 3 serovars namely Salmonella Senftenberg, Salmonella Typhimurium, and Salmonella Derby. The frequency of fecal carriage of E. coli with reduced susceptibility to ESC in calves was 81.2%. Of the selected isolates (n = 100), all were multi-drug resistant, whereas 88% were ESC resistant based on minimum inhibitory concentration testing. From the selected ESC-resistant E. coli isolates, blaTEM was detected in 84.1%, blaCMY-2 was detected in 52.2%, blaCTXM groups were detected in 30.7%, and blaSHV was detected in 1.1% of isolates. Plasmid-mediated quinolone resistance genes were identified in 7 of 9 isolates resistant to quinolones. Five isolates were positive for qnrB, whereas 2 isolates were positive for both qnrB and qnrS. Whereas neonatal calves [odds ratio (OR) = 2.42, 95% confidence interval (CI): 1.87-3.12], regular ceftiofur use on the farm (OR = 3.83, 95% CI: 2.29-6.39), feeding of unpasteurized nonsalable milk (OR = 1.6, 95% CI: 1.18-2.18), and use of florfenicol (OR = 2.02, 95% CI: 1.43-2.86) were statistically associated with fecal recovery of E. coli with reduced susceptibility to ESC, use of ceftiofur for the treatment of respiratory diseases (OR = 0.57, 95% CI: 0.41-0.79) was statistically associated with decreased recovery of E. coli with reduced susceptibility to ESC. This study has provided information on the resistance genes associated with the occurrence of ESC and fluoroquinolone resistance in dairy calves within this region.

Risk factors associated with time to first clinical case of Bacterial Kidney Disease (BKD) in farmed Atlantic Salmon (Salmo salar L.) in New Brunswick, Canada.

Infection with Renibacterium salmoninarum, the cause of Bacterial Kidney Disease (BKD) occurs in salmon populations in many locations, including the east coast of Canada. However, information about risk factors for BKD and their effects in the saltwater phase of the salmon aquaculture industry in the region is inadequate. We conducted a retrospective observational cohort study using industry health records in which BKD was recorded in New Brunswick, Canada, between 2006 and 2012. Several risk factors for BKD, such as stocking season, mortality percentage in the first four weeks, food conversion ratio (FCR), lice treatment, Bay Management Area (BMA), and production year were analyzed in a survival analysis using Cox proportional hazards models with cross-classified random effects to account for the structure of the data. The models incorporated effects on two different time scales, time since stocking and calendar time. The risk period was from stocking in salt water to first occurrence of clinical BKD in a pen. Results were time varying. Stocking season had a pronounced effect on time to clinical BKD after middle October of the first year after stocking, with clinical cases occurring less frequently in fall/winter-stocked fish compared to summer and spring-stocked fish; for example, in middle October, the Hazard Ratio of spring- compared to fall/winter-stocked fish was 15.8 (95% CI; 1.05, 354). Differences lasted until June and July of the second year after stocking. Effects of final hatchery before transfer to seawater, and egg source were not detected, but a limitation of this study was that this information was not available for 44.3% of the fish groups in our dataset. BKD status of a site/pen before fallow period and distance to nearest site with BKD were also not detected. Feed conversion ratio and mortality during the first four weeks affected BKD, indicating that better performing fish have a reduced hazard for BKD or vice versa, and implying that good general husbandry practices and BKD are correlated.

A traumatic tale of two cities: a comparison of outcomes for adults with major trauma who present to differing trauma centres in neighbouring Canadian provinces.

OBJECTIVES: While the use of formal trauma teams is widely promoted, the literature is not clear that this structure provides improved outcomes over emergency physician delivered trauma care. The goal of this investigation was to examine if a trauma team model with a formalized, specialty-based trauma team, with specific activation criteria and staff composition, performs differently than an emergency physician delivered model. Our primary outcome was survival to discharge or 30 days. METHODS: An observational registry-based study using aggregate data from both the New Brunswick and Nova Scotia trauma registries was performed with data from April 1, 2011 to March 31, 2013. Inclusion criteria included patients 16 years-old and older who had an Injury Severity Score greater than 12, who suffered a kinetic injury and arrived with signs of life to a level-1 trauma centre. RESULTS: 266 patients from the trauma team model and 111 from the emergency physician model were compared. No difference was found in the primary outcome of proportion of survival to discharge or 30 days between the two systems (0.88, n=266 vs. 0.89, n=111; p=0.8608). CONCLUSIONS: We were unable to detect any difference in survival between a trauma team and an emergency physician delivered model.