Care In Ontario Research Articles

Association Between Immigrant Status and End-of-Life Care in Ontario, Canada

People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care. To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life. This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts. All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care. Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities. Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia. Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.

Home-based care: barriers and facilitators to expanded personal support worker roles in Ontario, Canada

ABSTRACTTo accommodate the increasing demand for home care in Ontario, Canada, some care tasks traditionally performed by regulated health professionals are being transferred to personal support workers (PSW). However, this expansion of PSW roles is not uniform across the province. Between December 2014 and April 2015, barriers and facilitators to expansion of PSW roles in home care were explored in a series of 13 focus groups. Home care staff identified seven categories of factors affecting the expansion of PSW roles in home care including: communication and documentation; organization and structures of care; attitudes and perceptions of the expanding PSW role; adequate staffing; education, training and support; PSW role clarity and variation in practices, policies, and procedures. Addressing barriers and promoting facilitators at the funder and employer levels will enable the provision of safe, effective, and equitable care by PSWs.

Children with medical complexities: Addressing the gaps in respite care during transition from paediatrics to adult health care in Ontario

Respite care is one integral component of the transition process from paediatric to adult health care, and is of particular importance to individuals with medical complexities. Numerous gaps that exist within the current system limit a child and family's ability to access quality respite care during a time when it is often most needed. Identifying and addressing these gaps in a systematic and collaborative way presents an opportunity to improve the quality of life for this vulnerable, ever growing population and their families.

VARIATION IN THE RATES OF NORMAL DIAGNOSTIC CORONARY CATHETERIZATIONS AND NON-INVASIVE PRE-CATHETERIZATION CARDIAC DIAGNOSTIC TESTING BY REFERRING PHYSICIAN IN ONTARIO

The Cardiac Care Network of Ontario (CCN) serves as a system support to the Ministry of Health and Long Term Care as well as hospitals, and care providers in the province of Ontario, Canada. CCN works to plan, coordinate, implement and evaluate adult cardiovascular care in Ontario, and is responsible for the CCN Cardiac Registry, a clinical registry. Nineteen hospitals in Ontario perform diagnostic coronary catheterizations (CATH) and all enter data into the CCN Cardiac Registry. CATH data in the CCN Cardiac Registry from patients with stable CAD in Ontario were analyzed. Recognizing that non-elective CATH patients may present with acute symptoms that warrant immediate intervention and non-invasive cardiac diagnostic testing may not be appropriate, we excluded these patients from our analysis. Rates were analyzed at the level of the performing cardiac centre as well as the referring physician. Analysis of data in the CCN Cardiac Registry revealed considerable variation in rate of CATHs performed in Ontario in which significant CAD was found with rates ranging from 34% to 60% at the various cardiac centres across the province for the 2016/17 fiscal year. There was also considerable variation observed in the rate of pre-CATH non-invasive cardiac diagnostic testing being performed, ranging from 44% to 87% across centres. Data were also analyzed at the level of the referring physician. Interestingly, 65% of referring physicians in Ontario refer less than 10 CATHs in a year with a mean of 23 referrals per physician per year. The rate of significant CAD found in patients referred by each referring physician varied widely from 0% to 100%. Similarly the rate of referring physicians that referred their patients for CATH and had done some sort of pre-CATH non-invasive cardiac diagnostic testing also varied widely ranging from 0% to 100%. While a proportion of CATH results are expected to be in the range of normal or non-significant CAD, the target rate is unknown. Our analysis revealed large variation in the rate of CATHs in which significant CAD was found across cardiac centres in Ontario and a larger variation across referring physicians in Ontario. A similar variation was observed in pre-CATH non-invasive cardiac diagnostic testing across centres and referring physicians. These results indicate that CATH referring physicians in Ontario represent an important target for quality improvement. Educational interventions aimed at the referring physician may be an opportunity to reduce variation in these CATH utilization metrics.

The Delivery of Palliative and End-of-Life Care in Ontario.

Healthcare use in the year prior to death represents a large portion of healthcare spending by older adults. While Canada is considered to have advanced integration of palliative care services within our healthcare system, much of this care is still delivered in hospitals and with varying levels of access according to cause of death trajectory and geography. Results presented in a series of studies from the Institute for Clinical Evaluative Sciences (ICES) unveil gaps in current palliative care delivery and offer directions for future research and policy development.

A comparison of the policy and institutional environment relevant to community-based primary health care in Ontario, Quebec and New Zealand

Introduction: Community-based primary health care (CBPHC) describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for CBPHC have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional path dependencies. This paper compares key features of the policy and institutional environments relevant to community-based primary health care in Ontario, Quebec and New Zealand. Theory/Methods: Drawing on existing literature and our collective expertise, we sought to identify the key organisational landscapes, service models, integrating mechanisms, and relevant policy developments within each jurisdiction. From these descriptions we develop a comparative analysis of enablers and facilitators. Results: Our analysis suggests that Ontario has the most significant institutional barriers to organisational integration and the fewest available policy levers, whilst New Zealand has the most conducive organisational landscape and strongest policy levers. Quebec has significant capacity for reform the structure of the health system, but reforms to date these have not incorporated primary health care. Conclusions: (comprising key findings) Our analysis suggests that two key conditions include the integration of relevant health and social sector organisations, and the range of policy levers available and used by governments. On both dimensions, the New Zealand environment appears to offer the largest scope, with Ontario’s environment significantly less conducive, with Quebec situated in between. Nevertheless, in each case there remain important institutional barriers to implementation of policies that promote CBPHC. Lessons Learned: Although New Zealand has more powerful policy levers, the effectiveness of levers is largely dependent on implementation strategies. Here the differences between New Zealand, Quebec and Ontario are less marked. Limitations: This research constitutes a preliminary, high-level understanding of the complex policy environments of three comparable policy and institutional environments. However, the degree to which the factors identified are key facilitators and inhibitors of CBPHC requires empirical investigation such that other significant policy and institutional constraints and enablers can be identified. Suggestions for Future Research: This research serves to inform the broader iCoach research collaboration, which investigates a range of specific local CBPHC initiatives and embedded practices that focus on older adults with complex conditions. Moving forward our research will focus on the analysis of key stakeholder interviews conducted within Ontario, Quebec and New Zealand to identify key institutional and policy settings that may enable and constrain the implementation and diffusion of these initiatives.

Evaluating the ‘Health Links’: A Case Study of the Role of Organizational Factors in Integrating Care in Ontario, Canada

Introduction: Adults with multiple chronic illnesses account for more than 75% of health care spending. Many are considered complex due to multimorbidity, high service use, and psychosocial vulnerability. Practice Change Implemented: The Health Links (HLs) are networks of multiple health and social service organizations that voluntarily partner to deliver integrated care to complex, high-cost patients in Ontario, Canada. Aim and Theory of Change: We explored how organizational and network factors (e.g., resources, culture) influenced the implementation of the HLs. We conducted case studies of three HLs within one regional health authority. Data was analyzed using The Context and Capabilities for Integrating Care (CCIC) Framework, which stipulates that organizational and network factors (within the Basic Structures, People & Values, and Key Processes domains) influence an organization/network’s readiness and capacity to integrate. Targeted Population and Stakeholders: The HLs initiative is targeted at patients with four or more chronic or “high-cost” conditions, including a focus on individuals living with mental health and addictions, palliative care patients, and the frail elderly. The organizations involved vary by HL and often include hospitals, primary care practices, community support agencies, social services organizations, and emergency response. Timeline: The HLs were implemented in 2012 with 19 early adopters; there are now 82 HLs in various stages of implementation in the province. In the spring/summer of 2016, we conducted semi-structured interviews with leaders and providers working within three HLs. Interviews were supplemented with surveys and document review. Highlights: (Innovation, Impact and Outcomes) Preliminary results show that successful implementation was linked to the key organizational facilitators of leadership, patient-centredness, and team-based delivery of care. Leaders that prioritized the initiative were able to facilitate inter-organizational collaboration. Similarly, partnerships were facilitated by an explicit focus on patient-centredness and patient outcomes, rather than on formal governance and accountability structures. Comments on Sustainability: Partnering organizations will have to address several barriers going forward, including: poor awareness of HLs in the community, inefficient identification of patients, dwindling clinician engagement due to low perceived value of the initiative over and above regular care, and limitations to patient data sharing within the network. Comments on Transferability: Using the CCIC Framework, we identified organizational and network factors that supported integration of care in HLs networks. The findings are limited to three HLs networks in Ontario, however, the framework can be used across cases to support the measure of factors and the transfer of best practices to other integrated care initiatives. Conclusions: (Comprising Key Findings) Preliminary results suggest that there are common factors that most influence the implementation of integrated care initiatives, including leadership, clinician engagement, patient-centeredness, and delivery of care. Discussions: The CCIC Framework enabled a comprehensive analysis of organizational and network context. These results can be used to help prioritize key areas for discussion, measurement, and change management. Lessons Learned: Despite continued interest in partnering, we found a loss of clinician engagement and buy-in over time in HLs that did not meaningfully involve clinicians and did not demonstrate value to the patient.

Regionalization and Outcomes of Lung Cancer Surgery in Ontario, Canada.

Purpose Regionalization of complex surgery to high-volume hospitals has been advocated based on cross-sectional volume-outcome studies. In April 2007, the agency overseeing cancer care in Ontario, Canada, implemented a policy to regionalize lung cancer surgery at 14 designated hospitals, enforced by economic incentives and penalties. We studied the effects of implementation of this policy. Methods Using administrative health data, we used interrupted time series models to analyze the immediate and delayed effects of implementation of the policy on the distribution of lung cancer surgery among hospitals, surgical outcomes, and health services use. Results From 2004 to 2012, 16,641 patients underwent surgery for lung cancer. The proportion of operations performed in designated hospitals increased from 71% to 89% after the policy was implemented. Although operative mortality decreased from 4.1% to 2.9% (adjusted odds ratio, 0.68; 95% CI, 0.58 to 0.81; P < .001), the reduction was due to a preexisting declining trend in mortality. In contrast, in the years after implementation of the policy, length of hospital stay decreased more than expected from the baseline trend by 7% per year (95% CI, 5% to 9%; P < .001), and the distance traveled by all patients to the hospital for surgery increased by 4% per year (95% CI, 0% to 8%; P = .03), neither of which were explained by preexisting trends. Analyses limited to patients ≥ 70 years of age demonstrated a reduction in operative mortality (odds ratio, 0.80 per year after regionalization; 95% CI, 0.67 to 0.95; P = .01). Conclusion A policy to regionalize lung cancer surgery in Ontario led to increased centralization of surgery services but was not independently associated with improvements in operative mortality. Improvements in length of stay and in operative mortality among elderly patients suggest areas where regionalization may be beneficial.

Neglect, educational success, and young people in out-of-home care: Cross-sectional and longitudinal analyses

Maltreated young persons in out-of-home care often have poor educational outcomes, heightening their risk of long-term psychosocial disadvantage (Forsman, Brännström, Vinnerljung, & Hjern, 2016). In their systematic reviews, Romano, Babchishin, Marquis, and Fréchette (2014) and O’Higgins, Sebba, and Gardner (in press) found evidence that neglect was more often linked with low academic achievement, whereas abuse was more likely to be associated with behavioral difficulties. In large samples of young persons in out-of-home care in Ontario, Canada, who had experienced mainly neglect, we investigated risk and protective factors as predictors of educational success. In a cross-sectional hierarchical regression analysis (N=3659, aged 11–17 years), female gender, youth educational aspirations, caregiver educational aspirations for youth, time with current caregiver, internal developmental assets, and positive mental health were associated with better educational success. Neglect, grade retention, special educational needs, ethnic minority status, behavioral problems, and soft-drug use were associated with poorer educational outcomes. Gender significantly moderated caregiver educational aspirations and youth placement type. In a longitudinal analysis of a subsample (N=962, aged 11–15 years at Time 1), covering three years, a large decline in educational success (d=−0.80) was observed. Female gender, internal developmental assets, and positive mental health positively predicted, and soft drug use negatively predicted, greater educational success at Time 2. These results point to factors that help or hinder educational success among young people in care and should inform new interventions or improved versions of existing ones that address educational success in the context of neglect.

Overview of surgery for laryngeal and hypopharyngeal cancer in Ontario, 2003-2010.

The primary purpose of this study was to describe variations in incidence rates, resections rates, and types of surgical resection for patients diagnosed with laryngeal and hypopharyngeal cancers in Ontario. All laryngeal and hypopharyngeal cancer cases in Ontario (2003-2010) were identified from the Ontario Cancer Registry (n = 3034). Variations in incidence rates, resection rates, and type of surgical resection were compared by sex, age group, neighborhood income, community population, health region, and physician specialty. Incidence rates per 100000 vary significantly by sex, age, neighborhood income, and community size. Women, the elderly (75+ years), those in the higher income quintiles, and those living in larger communities were significantly less likely to receive a laryngectomy procedure. Laryngeal and hypopharyngeal cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age, sex, and health region. These disparities warrant further evaluation to improve the quality of delivered care in Ontario.

Gastrointestinal Symptom Distress is Associated With Worse Mental and Physical Health-Related Quality of Life.

The prevalence of self-reported gastrointestinal (GI) symptoms and distress is high, but few studies have quantified their impact on health-related quality of life (HRQoL). We conducted a prospective cohort study of patients with HIV in care in Ontario, Canada (2007-2014). General linear mixed models were used to assess the impact of GI symptoms (diarrhea/soft stool, nausea/vomiting, bloating/painful abdomen, loss of appetite, weight loss/wasting) and distress (range: 0-4) on physical and mental HRQoL summary scores (range: 0-100) measured by the Medical Outcomes Survey SF-36. A total of 1787 participants completed one or more questionnaires {median 3 [interquartile range (IQR): 1-4]}. At baseline, 59.0% were men who had sex with men, 53.7% white, median age 45 (IQR: 38-52), median CD4 count 457 (IQR: 315-622), and 71.0% had undetectable HIV viremia. The mean (standard deviation [SD]) mental and physical HRQoL scores were 49.2 (8.6) and 45.3 (13.0), respectively. In adjusted models, compared with those reporting no symptoms, all GI symptom distress scores from 2 ("have symptom, bothers me a little") to 4 ("have symptom, bothers a lot") were associated with lower mental HRQoL. Loss of appetite distress scores ≥ 1; scores ≥ 2 for diarrhea, nausea/vomiting, and bloating; and a score ≥ 3 for weight loss were independently associated with lower physical HRQoL scores (P < 0.0001). Increasing GI symptom distress is associated with impaired mental and physical HRQoL (P < 0.0001). Increasing GI symptom distress is associated with impaired mental and physical HRQoL. Identifying, treating, and preventing GI symptoms may reduce overall symptom burden and improve HRQoL for patients with HIV.

Reduction in Wait-Times to Colonoscopy after Positive Fecal Occult Blood Test Among Patients having Colonoscopy in a Diagnostic Assessment Program Compared to Usual Care in Ontario's Organized Colorectal Cancer Screening Program

Reduction in Wait-Times to Colonoscopy after Positive Fecal Occult Blood Test Among Patients having Colonoscopy in a Diagnostic Assessment Program Compared to Usual Care in Ontario's Organized Colorectal Cancer Screening Program

Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study.

In Ontario, a province-wide quality-improvement program (Quality Improvement and Innovation Partnership [QIIP]) was implemented between 2008 and 2010 to support improved outcomes in Family Health Teams, a care model that includes many features of the patient-centred medical home. We assessed the impact of this program on diabetes management, colorectal and cervical cancer screening and access to health care. We used comprehensive linked administrative data sets to conduct a population-based controlled before-and-after study. Outcome measures included diabetes process-of-care measures (test ordering, retinal examination, medication prescribing and completion of billing items specific to diabetes management), colorectal and cervical cancer screening measures and use of health care services (emergency department visits, hospital admission for ambulatory-care-sensitive conditions and rates of readmission to hospital). The control group consisted of Family Health Team physicians with at least 100 assigned patients during the study follow-up period (November 2009-February 2013). There were 53 physicians in the intervention group and 1178 physicians in the control group. Diabetes process-of-care measures improved more in the intervention group than in the control group: hemoglobin A1c testing 4.3% (95% confidence interval [CI] 1.2-7.5) more, retinal examination 2.5% (95% CI 0.8-4.4) more and preventive care visits 8.9% (95% CI 2.9-14.9) more. Medication prescribing also improved for use of statins (3.4% [95% CI 0.8-6.0] more) and angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers (4.1% [95% CI 1.8-6.4] more). Colorectal cancer screening improved 5.4% (95% CI 3.1-7.8) more in the intervention group than in the control group, and cervical cancer screening improved 2.7% (95% CI 0.9-4.6) more. There were no significant differences in any of the measures of use of health care services. This large controlled evaluation of a broadly implemented quality-improvement initiative showed improvement for diabetes process of care and cancer screening outcomes, but not for proxy measures of access related to use of health care services.

Trajectories of Stroke Care in Ontario: Which Path to Best Care?

Few studies have tracked stroke survivors through transitions across the health system and identified the most common trajectories and quality of care received. The objectives of our study were to examine the trajectories that incident stroke patients experience and to quantify the extent to which their care adhered to the best practices for stroke care. A population-based cohort of first-ever stroke/transient ischemic attack (TIA) patients from the 2012/13 Ontario Stroke Audit was linked to administrative databases using an encrypted health card number to identify dominant trajectories (N=12,362). All trajectories began in the emergency department (ED) and were defined by the transitions that followed immediately after the ED. Quality indicators were calculated to quantify best practice adherence within trajectories. Six trajectories of stroke care were identified with significant variability in patient characteristics and quality of care received. Almost two-thirds (64.5%) required hospital admission. Trajectories that only involved the ED had the lowest rates of brain and carotid artery imaging (91.5 and 44.2%, respectively). Less than 20% of patients in trajectories involving hospital admissions received care on a stroke unit. The trajectory involving inpatient rehabilitation received suboptimal secondary prevention measures. There are six main trajectories stroke patients follow, and adherence to best practices varies by trajectory. Trajectories resulting in patients being transitioned to home care following ED management only are least likely and those including inpatient rehabilitation are most likely to receive stroke best practices. Increased time in facility-based care results in greater access to best practices. Stroke patients receiving only ED care require closer follow-up by stroke specialists.

Characteristics and Incidence of Traumatic Brain Injury in Older Adults Using Home Care in Ontario from 2003-2013.

ObjectivesDescribe the characteristics and determine the annual cumulative incidence of traumatic brain injury (TBI) in older adults receiving home care in Ontario from 2003 to 2013.MethodsA retrospective cohort study of longitudinal data from the Ontario Association of Community Care Access Centers (N = 554,313). TBI, demographic variables, depression, neurological conditions, and recent falls were measured from the Resident Assessment Instrument–Home Care. Comparisons were made between service users with and without TBI using odds ratios. Standardized incidence rates were calculated and the 10-year trend of annual cumulative incidence rates was examined.ResultsCharacteristics associated with TBI: male sex (OR: 1.54), aboriginal origin (OR: 1.98), increasing age (low of OR: 1.22, in 70–74 years; high of OR: 2.31, in 90 years and older; comparison 65–69 years), being widowed (OR: 1.59), having one or more falls (OR: 2.31), the use of antidepressants (OR: 1.49) and the presence of depression (OR: 1.57), dementia (OR: 1.65), hemiplegia (OR: 4.34), multiple sclerosis (OR: 3.19) or parkinsonism (OR: 1.22). TBI incidence was significantly higher than rates previously reported in the literature. There was no change in the overall annual cumulative incidence over the 10-year period (p = .13).ConclusionsCertain demographic characteristics, neurological diseases, antidepressant use, and a recent fall are associated with TBI. Incidence of TBI is higher than previous estimates and the overall incidence is not changing over time. These results can be used to improve care of the elderly and to generate hypotheses for future research regarding TBI in the home care setting.

Principles for Health System Capacity Planning: Insights for Healthcare Leaders.

Jurisdictions across Canada and around the world face the challenge of planning high-performing and sustainable health systems in response to growing healthcare demands. In this paper, we report on the process of developing principles for health system capacity planning by the Ministry of Health and Long-Term Care in Ontario. Integrating the results of a literature review on health system planning and a symposium with representatives from local health integration networks, we describe the following six principles in detail: (1) develop an aspirational vision, (2) establish clear leadership, (3) commit to stakeholder engagement, (4) engage patients and the public, (5) build analytics infrastructure and (6) revise policy when necessary.

Patient Characteristics, Length of Stay, and Functional Improvement for Schizophrenia Spectrum Disorders: A Population Study of Inpatient Care in Ontario 2005 to 2015.

Schizophrenia and associated illnesses account for a large proportion of mental illness burden and health care expenditures, with the majority of expense involving inpatient care. To date, the literature exploring factors associated with length of stay (LOS) and functional improvement during inpatient care is underdeveloped. In response, this study examined the association between patient characteristics, LOS, and functional improvement using Ontario Mental Health Reporting System (OMHRS) data from 2005 to 2015. The associations of patient characteristics (including key demographics, psychosocial variables, reasons for admission, and service use history) and 2 outcome measures (LOS and Global Assessment of Functioning [GAF]) were analysed with generalised linear mixed modelling (GLMM). From 2005 to 2015, a total of 48,498 episodes for distinct patients from 18 psychiatric hospitals and 57 general hospitals in Ontario were included. For psychiatric and general hospitals, mean LOS was 96.6 and 20.5 days, and mean GAF improvement was 14.8 and 16.1, respectively. The majority of associations probed demonstrated a high degree of significance with similar patterns across general and tertiary facility contexts. Older age and more recent readmission following a psychiatric discharge were associated with longer LOS and less GAF improvement. Recent experience of adverse life events and substance misuse were associated with shorter LOS. While the findings of this exploratory cross-sectional analysis will require further inquiry with respect to validity and reliability, they suggest that a different service pathway is likely required for individuals with greater psychosocial challenge and extensive service use histories.

P139 Early Integration of Palliative Care in Ontario: INTEGRATE Quality Improvement Project

P139 Early Integration of Palliative Care in Ontario: INTEGRATE Quality Improvement Project

Determinants of alternate-level-of-care delayed discharge among acute care survivors of hypoxic-ischemic brain injury: a population-based cohort study.

Delayed discharge, captured as alternate-level-of-care days, represents inefficient use of high-demand acute care resources and results in potentially poorer patient outcomes. We performed a study to determine the extent of alternate-level-of-care days among patients who survived hypoxic-ischemic brain injury in inpatient hospital care in Ontario and to identify predictors of alternate-level-of-care use in this population. A population-based cohort of acute care survivors of hypoxic-ischemic brain injury aged 20 years or more from 2002/03 through 2011/12 was identified. We used 2 case definitions, the more specific identifying patients with a most responsible diagnosis of "anoxic brain damage," and the more sensitive capturing additional likely causative conditions as the most responsible diagnosis. Multivariable zero-inflated negative binomial regression was used to estimate independent effects on the relative incidence of alternate-level-of-care days. We identified 491 patients using the specific case definition and 669 patients using the extended case definition. After deaths were excluded, 232 patients (47.2%) and 278 patients (41.6%), respectively, had at least 1 alternate-level-of-care day (median 20 and 19 d, respectively). In both cohorts, decreasing age, no special care unit hours and acute care episode earlier in the study period were predictive of increased alternate-level-of-care days relative to length of stay. Discharge disposition and psychiatric/behavioural comorbidity were most predictive of having any alternate-level-of-care days. Patients with hypoxic-ischemic brain injury had a greater proportion of alternate-level-of-care days than has been reported for patients with other types of acquired brain injury. This finding suggests that substantial barriers to appropriate discharge exist for this population. Predictors of increased alternate-level-of-care days were also shown to be unique. Further study of care deficits among patients with hypoxic-ischemic brain injury is warranted.

Phase-specific and lifetime costs of cancer care in Ontario, Canada.

BackgroundCancer is a major public health issue and represents a significant economic burden to health care systems worldwide. The objective of this analysis was to estimate phase-specific, 5-year and lifetime net costs for the 21 most prevalent cancer sites, and remaining tumour sites combined, in Ontario, Canada.MethodsWe selected all adult patients diagnosed with a primary cancer between 1997 and 2007, with valid ICD-O site and histology codes, and who survived 30 days or more after diagnosis, from the Ontario Cancer Registry (N = 394,092). Patients were linked to treatment data from Cancer Care Ontario and administrative health care databases at the Institute for Clinical and Evaluative Sciences. Net costs (i.e., cost difference between patients and matched non-cancer control subjects) were estimated by phase of care and sex, and used to estimate 5-year and lifetime costs.ResultsMean net costs of care (2009 CAD) were highest in the initial (6 months post-diagnosis) and terminal (12 months pre-death) phases, and lowest in the (3 months) pre-diagnosis and continuing phases of care. Phase-specific net costs were generally lowest for melanoma and highest for brain cancer. Mean 5-year net costs varied from less than $25,000 for melanoma, thyroid and testicular cancers to more than $60,000 for multiple myeloma and leukemia. Lifetime costs ranged from less than $55,000 for lung and liver cancers to over $110,000 for leukemia, multiple myeloma, lymphoma and breast cancer.ConclusionsCosts of cancer care are substantial and vary by cancer site, phase of care and time horizon analyzed. These cost estimates are valuable to decision makers to understand the economic burden of cancer care and may be useful inputs to researchers undertaking cancer-related economic evaluations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-016-2835-7) contains supplementary material, which is available to authorized users.