Prevalence and Incidence Trends of Attention Deficit/Hyperactivity Disorder in Children and Youth Aged 1-24 Years in Ontario, Canada: A Validation Study of Health Administrative Data Algorithms: Tendances de la prévalence et de l'incidence du trouble de déficit de l'attention/hyperactivité chez les enfants et les jeunes âgés de 1 à 24 ans, en Ontario, Canada: une étude de validation des algorithmes de données administratives de santé.

OBJECTIVE: To estimate prevalence and incidence rates over time in children and youth with attention deficit/hyperactivity disorder from the validation of population-based administrative data algorithms using family physicians' electronic medical records as a reference standard. METHODS: A retrospective cohort study was conducted in Ontario, Canada to identify attention deficit/hyperactivity disorder among children and youth aged 1-24 years in health administrative data derived from case-finding algorithms using family physicians' electronic medical records. Multiple administrative data algorithms identifying attention deficit/hyperactivity disorder cases were developed and tested from physician-diagnosis of attention deficit/hyperactivity disorder in the electronic medical record to determine their diagnostic accuracy. We calculated algorithm performance using sensitivity, specificity, and predictive values. The most optimal algorithm was used to estimate prevalence and incidence rates of attention deficit/hyperactivity disorder from 2014 to 2021 in Ontario. RESULTS: The optimal performing algorithm was "2 physician visits for attention deficit/hyperactivity disorder in 1 year or 1 attention deficit/hyperactivity disorder-specific prescription" with sensitivity: 83.2% (95% confidence interval [CI], 81.8% to 84.5%), specificity: 98.6% (95% CI, 98.5% to 98.7%), positive predictive value: 78.6% (95% CI, 77.1% to 80.0%) and negative predictive value: 98.9% (95% CI, 98.8% to 99.0%). From 2014, prevalence rates for attention deficit/hyperactivity disorder increased from 5.29 to 7.48 per 100 population in 2021 (N = 281,785). Males had higher prevalence rates (7.49 to 9.59 per 100 population, 1.3-fold increase) than females (2.96-5.26 per 100 population, 1.8-fold increase) from 2014 to 2021. Incidence rates increased from 2014 (0.53 per 100 population) until 2018, decreased in 2020 then rose steeply in 2021 (0.89 per 100 population, N = 34,013). Males also had higher incidence rates than females from 2014 to 2020 with females surpassing males in 2021 (0.70-0.81 per 100 male population,1.2-fold increase versus 0.36-0.97 per 100 female population, 2.7-fold increase). CONCLUSIONS: Attention deficit/hyperactivity disorder is increasing in prevalence. We developed an administrative data algorithm that can reliably identify children and youth with attention deficit/hyperactivity disorder with good diagnostic accuracy.

Ethnic and Immigrant Variations in the Time Trends of Dementia and Parkinsonism.

OBJECTIVE: We assessed long-term incidence and prevalence trends of dementia and parkinsonism across major ethnic and immigrant groups in Ontario. METHODS: Linking administrative databases, we established two cohorts (dementia 2001-2014 and parkinsonism 2001-2015) of all residents aged 20 to 100 years with incident diagnosis of dementia (N = 387,937) or parkinsonism (N = 59,617). We calculated age- and sex-standardized incidence and prevalence of dementia and parkinsonism by immigrant status and ethnic groups (Chinese, South Asian, and the General Population). We assessed incidence and prevalence trends using Poisson regression and Cochran-Armitage trend tests. RESULTS: Across selected ethnic groups, dementia incidence and prevalence were higher in long-term residents than recent or longer-term immigrants from 2001 to 2014. During this period, age- and sex-standardized incidence of dementia in Chinese, South Asian, and the General Population increased, respectively, among longer-term immigrants (by 41%, 58%, and 42%) and long-term residents (28%, 7%, and 4%), and to a lesser degree among recent immigrants. The small number of cases precluded us from assessing parkinsonism incidence trends. For Chinese, South Asian, and the General Population, respectively, prevalence of dementia and parkinsonism modestly increased over time among recent immigrants but significantly increased among longer-term immigrants (dementia: 134%, 217%, and 117%; parkinsonism: 55%, 54%, and 43%) and long-term residents (dementia: 97%, 132%, and 71%; parkinsonism: 18%, 30%, and 29%). Adjustment for pre-existing conditions did not appear to explain incidence trends, except for stroke and coronary artery disease as potential drivers of dementia incidence. CONCLUSION: Recent immigrants across major ethnic groups in Ontario had considerably lower rates of dementia and parkinsonism than long-term residents, but this difference diminished with longer-term immigrants.

The Effects of Walking or Nordic Walking in Adults 50 Years and Older at Elevated Risk of Fractures: A Systematic Review and Meta-Analysis.

Walking is a common activity among older adults. However, the effects of walking on health-related outcomes in people with low bone mineral density (BMD) are unknown. The authors included randomized controlled trials comparing walking to control in individuals aged ≥50 years with low BMD and at risk of fractures. The authors identified 13 randomized controlled trials: nine multicomponent interventions including walking, one that was walking only, and three Nordic walking trials. Most studies had a high risk of bias. Nordic walking may improve the Timed Up-and-Go values (1.39 s, 95% CI [1.00, 1.78], very low certainty). Multicomponent interventions including walking improved the 6-min walk test (39.37 m, 95% CI [21.83, 56.91], very low certainty) and lumbar spine BMD (0.01 g/cm2, 95% CI [0.00, 0.03], low certainty evidence). The effects on quality of life or femoral neck BMD were not significant. There were insufficient data on fractures, falls, or mortality. Nordic walking may improve physical functioning. The effects on other outcomes are less certain; one may need to combine walking with other exercises to be of benefit.

Time Trends of the Incidence, Prevalence, and Mortality of Parkinsonism.

OBJECTIVES: We assessed trends in the incidence, prevalence, and post-diagnosis mortality of parkinsonism in Ontario, Canada over 18 years. We also explored the influence of a range of risk factors for brain health on the trend of incident parkinsonism. METHODS: We established an open cohort by linking population-based health administrative databases from 1996 to 2014 in Ontario. The study population comprised residents aged 20-100 years with an incident diagnosis of parkinsonism ascertained using a validated algorithm. We calculated age- and sex-standardized incidence, prevalence, and mortality of parkinsonism, stratified by young onset (20-39 years) and mid/late onset (≥40 years). We assessed trends in incidence using Poisson regression, mortality using negative binomial regression, and prevalence of parkinsonism and pre-existing conditions (e.g., head injury) using the Cochran-Armitage trend test. To better understand trends in the incidence of mid/late-onset parkinsonism, we adjusted for various pre-existing conditions in the Poisson regression model. RESULTS: From 1996 to 2014, we identified 73,129 incident cases of parkinsonism (source population of ∼10.5 million), of whom 56% were male, mean age at diagnosis was 72.6 years, and 99% had mid/late-onset parkinsonism. Over 18 years, the age- and sex-standardized incidence decreased by 13.0% for mid/late-onset parkinsonism but remained unchanged for young-onset parkinsonism. The age- and sex-standardized prevalence increased by 22.8%, while post-diagnosis mortality decreased by 5.5%. Adjustment for pre-existing conditions did not appreciably explain the declining incidence of mid/late-onset parkinsonism. CONCLUSION: Young-onset and mid/late-onset parkinsonism exhibited differing trends in incidence over 18 years in Ontario. Further research to identify other factors that may appreciably explain trends in incident parkinsonism is warranted.

Development and validation of an administrative data algorithm to estimate the disease burden and epidemiology of multiple sclerosis in Ontario, Canada.

BACKGROUND: Few studies have assessed the accuracy of administrative data for identifying multiple sclerosis (MS) patients. OBJECTIVES: To validate administrative data algorithms for MS, and describe the burden and epidemiology over time in Ontario, Canada. METHODS: We employed a validated search strategy to identify all MS patients within electronic medical records, to identify patients with and without MS (reference standard). We then developed and validated different combinations of administrative data for algorithms. The most accurate algorithm was used to estimate the burden and epidemiology of MS over time. RESULTS: The accuracy of the algorithm of one hospitalisation or five physician billings over 2 years provided both high sensitivity (84%) and positive predictive value (86%). Application of this algorithm to provincial data demonstrated an increasing cumulative burden of MS, from 13,326 patients (0.14%) in 2000 to 24,647 patients in 2010 (0.22%). Age-and-sex standardised prevalence increased from 133.9 to 207.3 MS patients per 100,000 persons in the population, from 2000 - 2010. During this same period, age-and-sex-standardised incidence varied from 17.9 to 19.4 patients per 100,000 persons. CONCLUSIONS: MS patients can be accurately identified from administrative data. Our findings illustrated a rising prevalence of MS over time. MS incidence rates also appear to be rising since 2009.

Are family physicians comprehensively using electronic medical records such that the data can be used for secondary purposes? A Canadian perspective.

BACKGROUND: With the introduction and implementation of a variety of government programs and policies to encourage adoption of electronic medical records (EMRs), EMRs are being increasingly adopted in North America. We sought to evaluate the completeness of a variety of EMR fields to determine if family physicians were comprehensively using their EMRs and the suitability of use of the data for secondary purposes in Ontario, Canada. METHODS: We examined EMR data from a convenience sample of family physicians distributed throughout Ontario within the Electronic Medical Record Administrative data Linked Database (EMRALD) as extracted in the summer of 2012. We identified all physicians with at least one year of EMR use. Measures were developed and rates of physician documentation of clinical encounters, electronic prescriptions, laboratory tests, blood pressure and weight, referrals, consultation letters, and all fields in the cumulative patient profile were calculated as a function of physician and patient time since starting on the EMR. RESULTS: Of the 167 physicians with at least one year of EMR use, we identified 186,237 patients. Overall, the fields with the highest level of completeness were for visit documentations and prescriptions (>70%). Improvements were observed with increasing trends of completeness overtime for almost all EMR fields according to increasing physician time on EMR. Assessment of the influence of patient time on EMR demonstrated an increasing likelihood of the population of EMR fields overtime, with the largest improvements occurring between the first and second years. CONCLUSIONS: All of the data fields examined appear to be reasonably complete within the first year of adoption with the biggest increase occurring the first to second year. Using all of the basic functions of the EMR appears to be occurring in the current environment of EMR adoption in Ontario. Thus the data appears to be suitable for secondary use.

A validation study of administrative data algorithms to identify patients with Parkinsonism with prevalence and incidence trends.

BACKGROUND: Epidemiological studies for identifying patients with Parkinson's disease (PD) or Parkinsonism (PKM) have been limited by their nonrandom sampling techniques and mainly veteran populations. This reduces their use for health services planning. The purpose of this study was to validate algorithms for the case ascertainment of PKM from administrative databases using primary care patients as the reference standard. METHODS: We conducted a retrospective chart abstraction using a random sample of 73,003 adults aged ≥ 20 years from a primary care Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Physician diagnosis in the EMR was used as the reference standard and population-based administrative databases were used to identify patients with PKM from the derivation of algorithms. We calculated algorithm performance using sensitivity, specificity, and predictive values and then determined the population-level prevalence and incidence trends with the most accurate algorithms. RESULTS: We selected, '2 physician billing codes in 1 year' as the optimal administrative data algorithm in adults and seniors (≥ 65 years) due to its sensitivity (70.6-72.3%), specificity (99.9-99.8%), positive predictive value (79.5-82.8%), negative predictive value (99.9-99.7%), and prevalence (0.28-1.20%), respectively. CONCLUSIONS: Algorithms using administrative databases can reliably identify patients with PKM with a high degree of accuracy.

An administrative data validation study of the accuracy of algorithms for identifying rheumatoid arthritis: the influence of the reference standard on algorithm performance.

BACKGROUND: We have previously validated administrative data algorithms to identify patients with rheumatoid arthritis (RA) using rheumatology clinic records as the reference standard. Here we reassessed the accuracy of the algorithms using primary care records as the reference standard. METHODS: We performed a retrospective chart abstraction study using a random sample of 7500 adult patients under the care of 83 family physicians contributing to the Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Using physician-reported diagnoses as the reference standard, we computed and compared the sensitivity, specificity, and predictive values for over 100 administrative data algorithms for RA case ascertainment. RESULTS: We identified 69 patients with RA for a lifetime RA prevalence of 0.9%. All algorithms had excellent specificity (>97%). However, sensitivity varied (75-90%) among physician billing algorithms. Despite the low prevalence of RA, most algorithms had adequate positive predictive value (PPV; 51-83%). The algorithm of "[1 hospitalization RA diagnosis code] or [3 physician RA diagnosis codes with ≥1 by a specialist over 2 years]" had a sensitivity of 78% (95% CI 69-88), specificity of 100% (95% CI 100-100), PPV of 78% (95% CI 69-88) and NPV of 100% (95% CI 100-100). CONCLUSIONS: Administrative data algorithms for detecting RA patients achieved a high degree of accuracy amongst the general population. However, results varied slightly from our previous report, which can be attributed to differences in the reference standards with respect to disease prevalence, spectrum of disease, and type of comparator group.

Factors associated with plans for early retirement among Ontario family physicians during the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: Higher numbers of family physicians (FPs) stopped practicing or retired during the COVID-19 pandemic, worsening the family doctor shortage in Canada. Our study objective was to determine which factors were associated with FPs' plans to retire earlier during the COVID-19 pandemic. METHODS: We administered two cross-sectional online surveys to Ontario FPs asking whether they were "planning to retire earlier" as a result of the pandemic during the first and third COVID-19 pandemic waves (Apr-Jun 2020 and Mar-Jul 2021). We used logistic regression to determine which factors were associated with early retirement planning, adjusting for age. RESULTS: The age-adjusted proportion of FP respondents planning to retire earlier was 8.2% (of 393) in the first-wave and 20.5% (of 454) in the third-wave. Planning for earlier retirement during the third-wave was associated with age over 50 years (50-59 years odds ratio (OR) 5.37 (95% confidence interval (CI):2.33-12.31), 60 years and above OR 4.18 (95% CI: 1.90-10.23)), having difficulty handling increased non-clinical responsibilities (OR 2.95 (95% CI: 1.79-4.94)), feeling unsupported to work virtually (OR 1.96 (95% CI: 1.19-3.23)) or in-person (OR 2.70 (95% CI: 1.67-4.55)), feeling unable to provide good care (OR 1.82 (95% CI: 1.10-3.03)), feeling work was not valued (OR 1.92 (95% CI: 1.15-3.23)), feeling frightened of dealing with COVID-19 (OR 2.01 (95% CI: 1.19-3.38)), caring for an elderly relative (OR 2.36 (95% CI: 1.69-3.97)), having difficulty obtaining personal protective equipment (OR 2.00 (95% CI: 1.16-3.43)) or difficulty implementing infection control practices in clinic (OR 2.10 (95% CI: 1.12-3.89)). CONCLUSIONS: Over 20% of Ontario FP respondents were considering retiring earlier by the third-wave of the COVID-19 pandemic. Supporting FPs in their clinical and non-clinical roles, such that they feel able to provide good care and that their work is valued, reducing non-clinical (e.g., administrative) responsibilities, dealing with pandemic-related fears, and supporting infection control practices and personal protective equipment acquisition in clinic, particularly in those aged 50 years or older may help increase family physician retention during future pandemics.

Patient visits and prescriptions for attention-deficit/hyperactivity disorder from 2017-2021: Impacts of COVID-19 pandemic in primary care.

OBJECTIVE: To determine whether more patients presented with Attention-deficit/hyperactivity disorder (ADHD)-related visits and/or sought care from family physicians more frequently during the COVID-19 pandemic. METHODS: Electronic medical records from the University of Toronto Practice-Based Research Network were used to characterize changes in family physician visits and prescriptions for ADHD medications. Annual patient prevalence and visit rates pre-pandemic (2017-2019) were used to calculate the expected rates in 2020 and 2021. The expected and observed rates were compared to identify any pandemic-related changes. RESULTS: The number of patients presenting for ADHD-related visits during the pandemic was consistent with pre-pandemic trends. However, observed ADHD-related visits in 2021 were 1.32 times higher than expected (95% CI: 1.05-1.75), suggesting that patients visited family physicians more frequently than before the pandemic. CONCLUSION: Demand for primary care services related to ADHD has continued to increase during the pandemic, with increased health service use among those accessing care.

Trends in health service use among persons with Parkinson's disease by rurality: A population-based repeated cross-sectional study.

BACKGROUND: The global burden of Parkinson's disease (PD) has more than doubled over the past three decades, and this trend is expected to continue. Despite generally poorer access to health care services in rural areas, little previous work has examined health system use in persons with PD by rurality. We examined trends in the prevalence of PD and health service use among persons with PD by rurality in Ontario, Canada. METHODS: We conducted a repeated, cross-sectional analysis of persons with prevalent PD aged 40+ years on April 1st of each year from 2000 to 2018 using health administrative databases and calculated the age-sex standardized prevalence of PD. Prevalence of PD was also stratified by rurality and sex. Negative binomial models were used to calculate rate ratios with 95% confidence intervals comparing rates of health service use in rural compared to urban residents in 2018. RESULTS: The age-sex standardized prevalence of PD in Ontario increased by 0.34% per year (p<0.0001) and was 459 per 100,000 in 2018 (n = 33,479), with a lower prevalence in rural compared to urban residents (401 vs. 467 per 100,000). Rates of hospitalizations and family physician visits declined over time in both men and women with PD in rural and urban areas, while rates of emergency department, neurologist, and other specialist visits increased. Adjusted rates of hospitalizations were similar between rural and urban residents (RR = 1.04, 95% CI [0.96, 1.12]), while rates of emergency department visits were higher among rural residents (RR = 1.35, 95% CI [1.27, 1.42]). Rural residents had lower rates of family physician (adjusted RR = 0.82, (95% CI [0.79, 0.84]) and neurologist visits (RR = 0.74, 95% CI [0.72, 0.77]). INTERPRETATION: Lower rates of outpatient health service use among persons residing in rural regions, contrasting with higher rates of emergency department visits suggest inequities in access. Efforts to improve access to primary and specialist care for persons with PD in rural regions are needed.

Effects of COVID-19 pandemic on anxiety and depression in primary care: A retrospective cohort study.

BACKGROUND: Population-based surveys indicate that many people experienced increased psychological distress during the COVID-19 pandemic. We aimed to determine if there was a corresponding increase in patients receiving services for anxiety and depression from their family physicians. METHODS: Electronic medical records from the University of Toronto Practice Based-Research Network (UTOPIAN; N = 322,920 patients) were used to calculate incidence rates for anxiety/depression related visits and antidepressant prescriptions before the COVID-19 pandemic (January 2018-February 2020) and during the COVID-19 pandemic (March-December 2020). Data from the pre-pandemic period were used to predict expected rates during the pandemic period which was compared to the observed rate. RESULTS: The number of patients presenting with anxiety/depression symptoms in primary care varied across age groups, sex, and time since pandemic onset. Among the youngest patients (ages 10-18 years), there were fewer patients than pre-pandemic visiting for new episodes of anxiety/depression and being prescribed antidepressants in April 2020, but by the end of 2020 this trend had reversed such that incidence rates for anxiety/depression related visits were higher than pre-pandemic levels. Among older adults, incidence rates of anxiety/depression related visits increased in April 2020 with the onset of the pandemic, and remained higher than expected throughout 2020. LIMITATIONS: A convenience sample of 362 family physicians in Ontario was used. CONCLUSION: Demand for mental health services from family physicians varied by patient age and sex and changed with the onset of the COVID-19 pandemic. By the end of 2020, more patients were seeking treatment for anxiety/depression related concerns.

The effects of Pilates on health-related outcomes in individuals with increased risk of fracture: a systematic review.

This systematic review examined the effect of Pilates on health-related outcomes in individuals with increased fracture risk to inform the 2021 Clinical Practice Guidelines for Management of Osteoporosis and Fracture Prevention in Canada. Seven electronic databases were searched to December 2020. Studies of Pilates in men and postmenopausal women aged ≥50 years with low bone mineral density (BMD), history of fragility fracture, or moderate-high risk of fragility fracture were included. Two reviewers independently screened studies and performed risk of bias assessment. Of 7286 records and 504 full-text articles, 5 studies were included, encompassing data from 143 participants (99% female). Data were insufficient for meta-analyses. There is low-certainty evidence that Pilates improved physical functioning and health-related quality of life. The effect of Pilates on falls and BMD is uncertain. No evidence was available for the effect of Pilates on mortality, fractures, or adverse events. Overall, Pilates may improve physical functioning and quality of life. Evidence of benefits relative to harms of Pilates in people with increased fracture risk, particularly males, is limited. PROSPERO registration: CRD42019122685. Novelty: Pilates may improve physical functioning and quality of life in women with osteoporosis. Evidence of the effect of Pilates on BMD, falls, fractures, or adverse events is limited.

Effect of yoga on health-related outcomes in people at risk of fractures: a systematic review.

We summarized the effects of yoga on health-related outcomes and adverse events in men and postmenopausal women ≥50 years-old at increased risk of fracture, to inform the updated Osteoporosis Canada clinical practice guidelines. Six databases were searched for observational studies, randomized controlled trials and case series. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation handbook. Nine studies were included and reported using narrative syntheses due to the limited available evidence. Overall, the available evidence was of very low certainty. There was no effect of yoga on health-related quality of life in randomized trials. Effects on other health-related outcomes were mixed or not available in the literature. Five studies reported no adverse events directly related to the study intervention, and 2 studies did not report whether adverse events occurred. However, 2 case series reported vertebral fractures related to yoga participation, possibly due to excessive spinal flexion. Due to the limited and very low certainty evidence, guideline developers will need to draw indirect evidence from yoga studies among middle aged or older adults that are not at fracture risk. PROSPERO: CRD42019124898. Novelty: Evidence in general was of very low certainty. Yoga had no effect on health-related quality of life in randomized trials. Evidence was mixed or unavailable for other outcomes. Case studies reported yoga poses involving spinal flexion coincided with incidents of vertebral compression fracture among older adults with increased fracture risk.

Using a data entry clerk to improve data quality in primary care electronic medical records: a pilot study.

BACKGROUND: The quality of electronic medical record (EMR) data is known to be problematic; research on improving these data is needed. OBJECTIVE: The primary objective was to explore the impact of using a data entry clerk to improve data quality in primary care EMRs. The secondary objective was to evaluate the feasibility of implementing this intervention. METHODS: We used a before and after design for this pilot study. The participants were 13 community based family physicians and four allied health professionals in Toronto, Canada. Using queries programmed by a data manager, a data clerk was tasked with re-entering EMR information as coded or structured data for chronic obstructive pulmonary disease (COPD), smoking, specialist designations and interprofessional encounter headers. We measured data quality before and three to six months after the intervention. We evaluated feasibility by measuring acceptability to clinicians and workload for the clerk. RESULTS: After the intervention, coded COPD entries increased by 38% (P = 0.0001, 95% CI 23 to 51%); identifiable data on smoking categories increased by 27% (P = 0.0001, 95% CI 26 to 29%); referrals with specialist designations increased by 20% (P = 0.0001, 95% CI 16 to 22%); and identifiable interprofessional headers increased by 10% (P = 0.45, 95 CI -3 to 23%). Overall, the intervention was rated as being at least moderately useful and moderately usable. The data entry clerk spent 127 hours restructuring data for 11 729 patients. CONCLUSIONS: Utilising a data manager for queries and a data clerk to re-enter data led to improvements in EMR data quality. Clinicians found this approach to be acceptable.

Changes in family medicine visits across sociodemographic groups after the onset of the COVID-19 pandemic in Ontario: a retrospective cohort study.

BACKGROUND: It has been suggested that the COVID-19 pandemic has worsened socioeconomic disparities in access to primary care. Given these concerns, we investigated whether the pandemic affected visits to family physicians differently across sociodemographic groups. METHODS: We conducted a retrospective cohort study using electronic medical records from family physician practices within the University of Toronto Practice-Based Research Network. We evaluated primary care visits for a fixed cohort of patients who were active within the database as of Jan. 1, 2019, to estimate the number of patients who visited their family physician (visitor rate) and the number of distinct visits (visit volume) between Jan. 1, 2019, to June 30, 2020. We compared trends in visitor rate and visit volume during the pandemic (Mar. 14 to June 30, 2020) with the same period in the previous year (Mar. 14 to June 30, 2019) across sociodemographic factors, including age, sex, neighbourhood income, material deprivation and ethnic concentration. RESULTS: We included 365 family physicians and 372 272 patients. Compared with the previous year, visitor rates during the pandemic period dropped by 34.5%, from 357 visitors per 1000 people to 292 visitors per 1000 people. Declines in visit volume during the pandemic were less pronounced (21.8% fewer visits), as the mean number of visits per patient increased during the pandemic (from 1.64 to 1.96). The declines in visitor rate and visit volume varied based on patient age and sex, but not socioeconomic status. INTERPRETATION: Although the number of visits to family physicians dropped substantially during the first few weeks of the COVID-19 pandemic in Ontario, patients from communities with low socioeconomic status did not appear to be disproportionately affected. In this primary care setting, the pandemic appears not to have worsened socioeconomic disparities in access to care.

Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada.

PURPOSE: We aimed to determine the degree to which reasons for primary care visits changed during the COVID-19 pandemic. METHODS: We used data from the University of Toronto Practice Based Research Network (UTOPIAN) to compare the most common reasons for primary care visits before and after the onset of the COVID-19 pandemic, focusing on the number of visits and the number of patients seen for each of the 25 most common diagnostic codes. The proportion of visits involving virtual care was assessed as a secondary outcome. RESULTS: UTOPIAN family physicians (N = 379) conducted 702,093 visits, involving 264,942 patients between March 14 and December 31, 2019 (pre-pandemic period), and 667,612 visits, involving 218,335 patients between March 14 and December 31, 2020 (pandemic period). Anxiety was the most common reason for visit, accounting for 9.2% of the total visit volume during the pandemic compared to 6.5% the year before. Diabetes and hypertension remained among the top 5 reasons for visit during the pandemic, but there were 23.7% and 26.2% fewer visits and 19.5% and 28.8% fewer individual patients accessing care for diabetes and hypertension, respectively. Preventive care visits were substantially reduced, with 89.0% fewer periodic health exams and 16.2% fewer well-baby visits. During the pandemic, virtual care became the dominant care format (77.5% virtual visits). Visits for anxiety and depression were the most common reasons for a virtual visit (90.6% virtual visits). CONCLUSION: The decrease in primary care visit volumes during the COVID-19 pandemic varied based on the reason for the visit, with increases in visits for anxiety and decreases for preventive care and visits for chronic diseases. Implications of increased demands for mental health services and gaps in preventive care and chronic disease management may require focused efforts in primary care.

The Effect of Impact Exercise (Alone or Multicomponent Intervention) on Health-Related Outcomes in Individuals at Risk of Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Exercise is commonly recommended to prevent and manage osteoporosis. High magnitude strains at rapid rate and short bouts should theoretically elicit an osteogenic response; however, the effects of different levels of impact exercises on several outcomes in people at risk of fracture are still unknown. OBJECTIVE: To report the effect of impact exercise on falls, fractures, adverse events, mortality, bone mineral density (BMD), physical functioning, and health-related quality of life (QoL). METHODS: We included randomized controlled trials testing the effect of impact exercise compared with a non-exercise control on outcomes in adults ≥ 50 years with low BMD or fragility fractures. Two reviewers selected studies and extracted data. Where possible, we pooled outcomes using mean difference (MD) with a fixed-effects model and 95% confidence interval (CI). We reported risk of bias using Cochrane and certainty of evidence using GRADE. RESULTS: We included 29 trials; 19 studies evaluated impact exercise alone, and the remaining trials combined impact with resistance or balance training. Impact exercise alone or combined with resistance training improved Timed Up-and-Go values (MD - 0.95 s, 95% CI - 1.09 to - 0.81, low certainty evidence) and lumbar spine (MD 0.04 g/cm2, 95% CI 0.02-0.06, low certainty evidence) and femoral neck BMD (MD 0.04 g/cm2, 95% CI 0.02-0.07, low certainty evidence). Impact exercise did not improve health-related QoL assessed with QUALEFFO-41 (MD 0.06, 95% CI - 2.18 to 2.30, moderate certainty evidence). The effects of impact exercise on falls, fractures, and mortality are uncertain due to insufficient data. Many trials had a high risk of bias for two or more items. CONCLUSIONS: There is low certainty evidence that impact exercise may improve physical function and BMD in people at risk of fracture. The effect of impact exercises on falls, fractures, and mortality remains unclear. Our findings should be interpreted with caution due to risk of bias and small sample sizes. TRIAL REGISTRATION: Registered in Prospero (CRD42018115579) on January 30, 2019.

Progressive Resistance Training for Improving Health-Related Outcomes in People at Risk of Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Osteoporosis clinical practice guidelines recommend exercise to prevent fractures, but the efficacy of exercise depends on the exercise types, population studied, or outcomes of interest. The purpose of this systematic review was to assess the effects of progressive resistance training (PRT) on health-related outcomes in people at risk of fracture. METHODS: Multiple databases were searched in October 2019. Eligible articles were randomized controlled trials of PRT interventions in men and women ≥50 years with low bone mineral density (BMD) or fracture history. Descriptive information and mean difference (MD) and SD were directly extracted for included trials. A total of 53 studies were included. RESULTS: The effects of PRT on the total number of falls (incidence rate ratio [IRR] = 1.05; 95% CI = 0.91 - 1.21; 7 studies) and on the risk of falling (risk ratio [RR] = 1.23; 95% CI = 1.00 - 1.51; 5 studies) are uncertain. PRT improved performance on the Timed "Up and Go" test (MD = -0.89 seconds; 95% CI = -1.01 to -0.78; 13 studies) and health-related quality of life (standardized MD = 0.32; 95% CI = 0.22-0.42; 20 studies). PRT may increase femoral neck (MD = 0.02 g/cm2; 95% CI = 0.01-0.03; 521 participants, 5 studies) but not lumbar spine BMD (MD = 0.02 g/cm2; 95% CI = -0.01-0.05; 4 studies), whereas the effects on total hip BMD are uncertain (MD = 0.00 g/cm2; 95% CI = 0.00-0.01; 435 participants, 4 studies). PRT reduced pain (standardized MD = -0.26; 95% CI = -0.37 to -0.16; 17 studies). Sensitivity analyses, including PRT-only studies, confirmed these findings. CONCLUSION: Individuals at risk of fractures should be encouraged to perform PRT, as it may improve femoral neck BMD, health-related quality of life, and physical functioning. PRT also reduced pain; however, whether PRT increases or decreases the risk of falls, the number of people experiencing a fall, or the risk of fall-related injuries is uncertain. IMPACT: Individuals at risk of fractures should be encouraged to perform PRT, as it may have positive effects on femoral neck BMD, health-related quality of life, physical functioning, and pain, and adverse events are rare. LAY SUMMARY: Exercise is recommended for people at risk of osteoporotic fractures. Our study showed that progressive resistance training improves physical functioning, quality of life, and reduces pain. The effects of progressive resistance training on the risk of falling are unclear. Adverse events are rare, and often minor (eg, soreness, pain, musculoskeletal injury). Considering the benefits and safety, people at risk of fractures should engage in progressive resistance training interventions.

A patient-oriented approach to the development of a primary care physical activity screen for embedding into electronic medical records.

Physical activity questionnaires exist, but effective implementation in primary care remains an issue. We sought to develop a physical activity screen (PAS) for electronic medical record (EMR) integration by 1) identifying healthcare professionals' (HCPs), patients' and stakeholders' barriers to and preferences for physical activity counselling in primary care; and 2) using the information to co-create the PAS. We conducted semi-structured interviews with primary care HCPs, patients and stakeholders, and used content and thematic analyses to inform iterative co-design of the PAS. Interviews with 38 participants (mean age 41 years) resulted in 2 themes: 1) HCPs are willing to conduct physical activity screening, but acknowledge they don't do it well; and 2) HCPs have limited opportunity and capacity to discuss physical activity, and need a streamlined process for EMR that goes beyond quantifying physical activity. HCPs, patients and stakeholders co-designed a physical activity screen for integration into the EMR that can be tested for feasibility and effects on HCP behaviour and patients' physical activity levels. Novelty: EMR-integration of physical activity screening needs to go beyond just asking about physical activity minutes. Primary care professionals have variable knowledge and time, and need physical activity counselling prompts and resources. We co-developed a physical activity EMR tool with patients and primary care providers.