Maternal-Newborn Health System Changes and Outcomes in Ontario, Canada, During Wave 1 of the COVID-19 Pandemic-A Retrospective Study.

OBJECTIVE: To determine the population-level impact of COVID-19 pandemic-related obstetric practice changes on maternal and newborn outcomes. METHODS: Segmented regression analysis examined changes that occurred 240 weeks pre-pandemic through the first 32 weeks of the pandemic using data from Ontario's Better Outcomes Registry & Network. Outcomes included birth location, length of stay, labour analgesia, mode of delivery, preterm birth, and stillbirth. Immediate and gradual effects were modelled with terms representing changes in intercepts and slopes, corresponding to the start of the pandemic. RESULTS: There were 799 893 eligible pregnant individuals included in the analysis; 705 767 delivered in the pre-pandemic period and 94 126 during the pandemic wave 1 period. Significant immediate decreases were observed for hospital births (relative risk [RR] 0.99; 95% CI 0.98-0.99), length of stay (median change -3.29 h; 95% CI -3.81 to -2.77), use of nitrous oxide (RR 0.11; 95% CI 0.09-0.13) and general anesthesia (RR 0.69; 95% CI 0.58- 0.81), and trial of labour after cesarean (RR 0.89; 95% CI 0.83-0.96). Conversely, there were significant immediate increases in home births (RR 1.35; 95% CI 1.21-1.51), and use of epidural (RR 1.02; 95% CI 1.01-1.04) and regional anesthesia (RR 1.01; 95% CI 1.01-1.02). There were no significant immediate changes for any other outcomes, including preterm birth (RR 0.99; 95% CI 0.93-1.05) and stillbirth (RR 1.11; 95% CI 0.87-1.42). CONCLUSION: Provincial health system changes implemented at the start of the pandemic resulted in immediate clinical practice changes but not insignificant increases in adverse outcomes.

Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis.

OBJECTIVE: To evaluate the association between the presence of integrated systems of stroke care and stroke case-fatality across Canada. METHODS: We used the Canadian Institute of Health Information's Discharge Abstract Database to retrospectively identify a cohort of stroke/TIA patients admitted to all acute care hospitals, excluding the province of Quebec, in 11 fiscal years from 2003/2004 to 2013/2014. We used a modified Poisson regression model to compute the adjusted incidence rate ratio (aIRR) of 30-day in-hospital mortality across time for provinces with stroke systems compared to those without, controlling for age, sex, stroke type, comorbidities, and discharge year. We conducted surveys of stroke care resources in Canadian hospitals in 2009 and 2013, and compared resources in provinces with integrated systems to those without. RESULTS: A total of 319,972 patients were hospitalized for stroke/TIA. The crude 30-day mortality rate decreased from 15.8% in 2003/2004 to 12.7% in 2012/2013 in provinces with stroke systems, while remaining 14.5% in provinces without such systems. Starting with the fiscal year 2009/2010, there was a clear reduction in relative mortality in provinces with stroke systems vs those without, sustained at aIRR of 0.85 (95% confidence interval 0.79-0.92) in the 2011/2012, 2012/2013, and 2013/2014 fiscal years. The surveys indicated that facilities in provinces with such systems were more likely to care for patients on a stroke unit, and have timely access to a stroke prevention clinic and telestroke services. CONCLUSION: In this retrospective study, the implementation of integrated systems of stroke care was associated with a population-wide reduction in mortality after stroke.