Ministry Of Health And Long-Term Care Research Articles

PD29-02 BENCHMARKING BLADDER CANCER CARE: A REAL-LIFE POPULATION-BASED STUDY

You have accessJournal of UrologyCME1 Apr 2023PD29-02 BENCHMARKING BLADDER CANCER CARE: A REAL-LIFE POPULATION-BASED STUDY Nicolas Vanin-Moreno, Marlo Whitehead, and Robert Siemens Nicolas Vanin-MorenoNicolas Vanin-Moreno More articles by this author , Marlo WhiteheadMarlo Whitehead More articles by this author , and Robert SiemensRobert Siemens More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003315.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators with associated benchmarks created utilizing available evidence and expert opinion to inform and measure future performance. Herein we report real-life benchmark performance for the management of muscle invasive bladder cancer (MIBC) relative to expert opinion guidance. METHODS: This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009 and 2013. Electronic records of treatment from 1,573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators first as median values obtained across hospitals or providers as well as a “pared-mean” approach to identify a benchmark population of "top performance" as defined as the best outcome accomplished for at least 10 percent of the population. RESULTS: Overall, performance in Ontario across all indicators fell short of expert-opinion determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark>6, percent of institutions meeting benchmark =20%), percent of patients with MIBC referred pre-operatively to Medical Oncology (MO; benchmark >90%, percent of institutions meeting benchmark =2%) and Radiation Oncology (RO; benchmark >50%, percent of institutions meeting benchmark =0%), time to cystectomy within 6 weeks of TURBT in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark =0%), percent of patients with adequate lymph node dissection (defined as >14 nodes, benchmark >85%, percent of institutions meeting benchmark =0%), percent of patients with positive margins post RC (benchmark <10%, percent of institutions meeting benchmark =46%), and 90 day mortality (benchmark <5%, percent of institutions meeting benchmark =37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly under-estimated benchmarks that were possible by top-performing hospitals. CONCLUSIONS: Performance through the majority of BC quality of care indicators fall short of benchmarks proposed by expert-opinion. Different methodologies such as a pared-mean approach of top performers may provide more realistic benchmarking. Source of Funding: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by CIHI. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e824 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolas Vanin-Moreno More articles by this author Marlo Whitehead More articles by this author Robert Siemens More articles by this author Expand All Advertisement PDF downloadLoading ...

Antimicrobial resistance and mortality following E. coli bacteremia

Global estimates suggest millions of deaths annually are associated with antimicrobial resistance (AMR) but these are generated from scarce data on the relative risk of death attributable to drug-resistant versus drug-sensitive infections. We examined all episodes of E.coli bloodstream infection in Ontario, Canada between 2017 and 2020, and measured 90 day mortality among those with resistant versus sensitive isolates for each of 8 commonly used antibiotic classes and a category of difficult to treat resistance (DTTR). We used multivariable logistic regression to calculate an adjusted odds of mortality associated with AMR, after accounting for patient demographics, comorbidities, and prior healthcare exposure. Among 14,548 eligible episodes of E.coli bloodstream infection, resistance was most common to aminopenicillins (46.8%), followed by first generation cephalosporins (38.8%), fluoroquinolones (26.5%), sulfonamides (24.1%), third generation cephalosporins (13.8%), aminoglycosides (11.7%), beta-lactam-beta-lactamase-inhibitors (9.1%) and carbapenems (0.2%). Only 18 (0.1%) episodes exhibited DTTR. For each antibiotic class, the unadjusted odds of mortality (OR) were higher among resistant isolates, but after accounting for patient characteristics the adjusted odds (aOR) of mortality were attenuated: aminopenicillins (OR 1.22, 95% CI 1.12-1.33; aOR 1.09, 95% CI 0.99-1.20), first generation cephalosporins (OR 1.24, 95% CI 1.14-1.35; aOR 1.07, 95% CI 0.97-1.18), third generation cephalosporins (OR 1.64, 95% CI 1.47-1.82; aOR 1.29, 95% CI 1.15-1.46), beta-lactam-beta-lactamase-inhibitors (OR 1.69, 95% CI 1.52-1.89, aOR 1.28, 95% CI 1.13-1.45), carbapenems (OR 3.11, 95% CI 1.52-6.34; aOR 2.06, 95% CI 0.91-4.66), sulfonamides (OR 1.19, 95% CI 1.07-1.31, aOR 1.06, 95% CI 0.95-1.18), fluoroquinolones (OR 1.49, 95% CI 1.36-1.64, aOR 1.16, 95% CI 1.05-1.29), aminoglycosides (OR 1.43, 95% CI 1.27-1.62; aOR 1.27, 95% CI 1.11-1.46), and DTTR (OR 3.71, 95% CI 1.46-9.41; aOR 2.58, 95% CI 0.87-7.66). AMR is associated with substantial increased mortality among patients with E.coli bloodstream infection, particularly for resistance to classes commonly used as empiric treatment. Surveillance for AMR-associated mortality should incorporate adjustment for patient characteristics and prior healthcare utilization. This work was supported by a project grant from CIHR (grant number 159503). This study was also supported by ICES, which is funded by an annual grant from Ontario Ministry of Health and Long-Term Care (MOHLTC).

Characterizing mental health related service contacts in children and youth: a linkage study of health survey and administrative data

BackgroundTo inform the provision and organization of care, and to improve equitable access to mental health services for children and youth, we must first characterize the children and youth being served, taking into consideration factors related to mental health need. Our objective was to use a population-based survey linked with health administrative data to estimate mental health related contacts and determine socio-demographic correlates, after adjusting for factors related to mental health need.MethodsData from the 2014 Ontario Child Health Study (OCHS) were linked at the individual level to health administrative databases from Ontario’s Ministry of Health and Long-Term Care (MOHLTC). Mental health related service contacts were identified in the 6-months prior to the OCHS survey date. Service contacts with physicians were obtained from health administrative data, and non-physician service contacts from survey data (parent-report).Results21.7% of Ontarian children (4–11 years) and youth (12–17 years) had at least one mental health related contact in the 6-months prior to their OCHS survey date (18.8% non-physician, 8.0% physician, 5.2% both). Children and youth contacting both physician and non-physician services (ref. contact with physician or non-physician services alone) had higher mean symptom ratings of mental disorders across all classes of disorder. After adjusting for total symptom ratings, children and youth with immigrant parent(s) (ref. non-immigrant) (Prevalence Ratio: 0.65, 95% CI 0.55, 0.75) were less likely to have any mental health related service contact.ConclusionsResults indicate that children and youth with the highest mental health symptom ratings are more likely to have contact with multiple providers across sectors. As such, the coordination of care across and within sectors are critical components of mental health related services for children and youth. Our results indicate that the greatest disparities in mental health related service contacts may exist for children and youth with immigrant parent(s) and that targeted outreach efforts are required to reduce barriers to care and improve equitable access to mental health related services for children and youth in Ontario.

Association of neighbourhood-level poverty with outcomes and clinical care following atrial fibrillation diagnosis in a universal healthcare system

Abstract Background There are limited data on the association of poverty with outcomes and care patterns after an atrial fibrillation (AF) diagnosis in jurisdictions with universal healthcare. The Canadian province of Ontario provides publicly funded healthcare and prohibits private payment for medically necessary physician and in-hospital care. It also covers prescription medications for residents aged &amp;gt;65 years. Purpose Determine the association of neighbourhood-level poverty with outcomes and processes of care after AF diagnosis in older people within a universal healthcare system. Methods Using linked administrative databases, we conducted a population-based cohort study of community-dwelling adults aged ≥66 years who were newly diagnosed with AF in Ontario between April 1, 2007 and March 31, 2019. The primary exposure was material deprivation of patients' neighborhood of residence. This metric is derived using Canadian census data to estimate inability to access and attain basic material needs. Neighborhoods were categorized by quintile of material deprivation from Q1 (wealthiest) to Q5 (poorest). We used cause-specific hazards regression models to study the association of deprivation quintile with time to the following outcomes over one year from AF diagnosis: death, ischemic stroke, bleeding, heart failure (HF) hospitalization, cardiology services, and AF-specific treatments. Models accounted for clustering by region of residence and adjusted for age, sex, diabetes, HF, stroke/transient ischemic attack, vascular disease, hypertension, bleeding history, rural residence, renal function, and setting of AF diagnosis (hospital, emergency department [ED] or outpatient). Results We studied 350,353 patients with AF (median age 78 years, 48.9% female). People from neighborhoods in higher deprivation quintiles (poorer) were more likely to be diagnosed in hospital/ED than outpatient settings. Relative to people from the wealthiest neighbourhoods (Q1), patients in the poorest neighbourhoods (Q5) had higher prevalence of baseline hypertension, diabetes, HF, vascular disease and other comorbidities. In adjusted analyses (Figure), higher quintiles of neighborhood poverty were associated with greater rates of death, ischemic stroke, bleeding, and HF hospitalization, but lower rates of cardiology visits, cardiac testing, anticoagulation, anti-arrhythmic medications, cardioversion, or AF ablation. Conclusions In a setting of universal healthcare and prescription medication coverage, people living in poorer neighbourhoods had worse baseline health and higher rates of adverse outcomes after an AF diagnosis. Despite this, people in poorer neighbourhoods had less cardiology visits and diagnostic tests and were less likely to receive anticoagulation and rhythm control interventions. This shows that universal healthcare and medication coverage are insufficient to achieve equitable health care and outcomes for people with AF. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This research was funded by a Canadian Institutes of Health Research Foundation grant; and is supported by ICES (formerly the Institute for Clinical Evaluative Sciences), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

POS0050 ARE PATIENTS WITH IMMUNE MEDIATED INFLAMMATORY DISEASES (IMID) MORE LIKELY TO RECEIVE COVID-19 TESTS AND TEST POSITIVE FOR SARS-COV-2? A MATCHED POPULATION-BASED STUDY

Background:Population-based data about the COVID-19 risk in patients with IMID remain scarce.Objectives:To investigate the cumulative incidence and risk factors for laboratory-confirmed COVID-19 infection and SARS-CoV2 testing in patients with IMID compared with matched non-IMID patients from the general population.Methods:A population-based, matched cohort study was conducted using health administrative data from adults living in Ontario, Canada from January to December 2020. Cohorts for each of the following IMID were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases (including lupus, systemic sclerosis, Sjogren’s, inflammatory myositis), multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica (PMR) and vasculitis. Each patient was matched with 5 non-IMID comparators based on age, sex, area of residence and living in long term care (LTC). Standardized cumulative rates of testing for SARS-CoV2, and for receiving a positive test between IMID and non-IMID were compared between IMID and non-IMID patients. Multivariable logistic regression analyses assessed sociodemographic factors associated with COVID-19 testing and positivity.Results:A total of 493,499 IMID patients and 2,466,946 non-IMID comparators were assessed. Significantly more IMID patients versus non-IMID were tested for SARS-CoV2 (27.4% vs. 22.7%), while the proportions of those positive for COVID-19 were identical (0.9% of all patients in both groups). Overall, IMID patients were more likely to undergo SARS-CoV2 testing (odds ratio (OR) 1.28, 95% CI 1.27, 1.29), but their overall risk of laboratory-confirmed COVID-19 was not elevated (OR 0.97 (95% CI 0.93, 1)). However, the risk of laboratory-confirmed COVID-19 infection was lower in IBD (OR 0.75), MS (OR 0.77) and psoriasis (OR 0.94) and marginally higher in RA (OR 1.07) and iritis (OR 1.13) compared with non-IMID comparators (Figure 1A). The highest standardized rates of COVID-19 infection were found in vasculitis (115 per 10,000 patients) and iritis (109 per 10,000 patients) (Figure 1B). Risk factors for COVID-19 infection included younger age, living in LTC, multimorbidity, urban living and lower income (Table 1).Conclusion:Patients across all IMID were more likely to be tested for COVID-19 versus non-IMID patients. IMID patients were not at higher risk for testing positive for COVID-19 as an overall group, yet risk varied across disease subgroups.Table 1.Factors associated with COVID-19 infection in IMID vs. Non-IMID – Multivariable Logistic RegressionVariableORCI 95%IMID vs. Non-IMID0.970.93, 1.00Age (10-year increase)0.890.89, 0.90Sex: Female vs. Males0.950.93, 0.97LTC18.6417.9, 19.42ADG score:•5-9 vs. 0-41.401.35, 1.45•10-14 vs. 0-41.731.67, 1.80•15+ vs. 0-41.181.13, 1.23Urban vs. Rural3.493.26, 3.72Income quintile•Quintile 2 vs. 10.920.89, 0.96•Quintile 3 vs. 10.900.86, 0.93•Quintile 4 vs. 10.730.70, 0.76•Quintile 5 vs. 10.600.58, 0.63ADG - Aggregated Diagnosis Groups; IMIDs – Immune medicated inflammatory disease; LTC – long term careAcknowledgements:The study is supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by MOHLTC and the Canadian Institute for Health Information. The opinions, results and conclusions reported in this paper are those of the authors and are independent of the funding or data sources; no endorsement is intended or should be inferred.Disclosure of Interests:None declared.

Twinship and Childhood Atopic Disease: Understanding Early-Life Factors Among Discordant Twins in Ontario, Canada

Background: Parents often question why one of their children have asthma while their siblings do not. With twins, this is especially perplexing. The gene-environment interaction hypothesis suggests that early-life environmental exposures interact with genes, leading to asthma and atopic diseases. This study aims to investigate potential risk factors that modifies the risk of asthma and other atopic diseases between twins in shared early-life environments. Methods: A paired population-based open cohort study was conducted using health administrative data between April 1, 2004 and March 31, 2019 from Ontario, Canada. The study population consisted of Ontario twins born between 2004-2017. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for associations between discordance (asthma, allergic rhinitis, and eczema) and early-life factors. Results: This study included 24,392 twin-pairs from Ontario Canada aged 1 to 15 years. 15·7%, 17·9%, and 31·9% of twin-pairs had discordant asthma, allergic rhinitis, and eczema respectively. Compared to female-female twin-pairs, male-female and male-male twin-pairs were 69% (95% CI: 1·54-1·84) and 35% (95% CI: 1·23-1·49) higher odds to have asthma discordance, respectively. Twins who were delivered by Caesarian-section had significantly higher odds of asthma (aOR: 1·09, 95% CI: 1·01-1·18) and allergic rhinitis (aOR: 1·11, 95% CI: 1·04-1·20), and is strongly suggested for eczema discordance (aOR: 1·05, 95% CI: 1·00-1·12), compared to pairs who had vaginal births. Conclusion: This population-based study found associations of various early-life factors and asthma and allergic diseases discordance between twins. While early-life factors were associated with disease risks in children, genetic factors played a strong underlying role. Funding: This study was funded by the Asthma and COPD Program, Ontario Ministry of Health and Long-Term Care (MOHLTC). Declaration of Interest: None to declare. Ethical Approval: Ethics approval for this study was obtained from the Hospital for Sick Children Research Ethics Board in Toronto, Ontario.

Characterizing the Process of Urgent Referrals and Transfers to a Large Tertiary Care Apheresis Centre in Ontario

Background: Therapeutic plasma exchange (TPE) and red blood cell exchange (RBCX) are potentially life-saving treatments. Given the specialized nature of care, apheresis is only offered in 7 centres in Ontario (population: 14.5 million), and therefore effectively functions as a provincial service. Patients can be referred to any apheresis centre, regardless of home local health integration network (LHIN). Referrals are directed by CritiCall Ontario (CritiCall), a 24/7 consultation and referral service funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). CritiCall facilitates the MOHLTC Life or Limb Policy, which provides that patients with life or limb threatening conditions will receive timely consultation, and if necessary, transfer to an appropriate centre within a best effort window of 4 hours. We used CritiCall data to examine referral, acceptance, and transfer processes of urgent TPE and RBCX apheresis calls to our centre. Methods: Time and process data for all CritiCall transfers to our centre for TPE and RBCX between October 2013 and December 2018 were included. TPE cases were analyzed if transferred for codes related to thrombotic thrombocytopenic purpura (TTP) or other thrombotic microangiopathies, and RBCX cases were analyzed only for acute sickle cell indications (e.g. stroke, acute chest syndrome). As such, we assumed all transfers to be "life or limb." Continuous variables were analyzed by linear regression. Categorical variables were analyzed using nonparametric tests. Data were provided in accordance with the Personal Health Information Protection Act, 2004 (www.criticall.org/Article/Privacy). Results: A total of 69 cases (43 TPE, 26 RBCX) were included. Median patient age was 51 (IQR 37) years for TPE and 29 (IQR 16) for RBCX. Most patients (61%) were female. Total time from referral to patient arrival at our centre was 243 (IQR 168) minutes. The greatest proportion of this total was from patient acceptance to arrival (169 [IQR 108] minutes), whereas time from referral to contact with the physician, and time from contact to patient acceptance were 23 (IQR 53) and 12 (IQR 41) minutes, respectively. The life or limb benchmark was met in 74% of cases, assessing time between acceptance and arrival. Fifty-two percent of the patients were accepted by the first apheresis physician contacted, with an average of 3 physicians contacted before a patient was accepted. Distance between referring and accepting centres was 39 (IQR 39) kilometres, and ground transportation was used most often. A minority of cases (7%) transferred were within our own LHIN. Multiple linear regression examining factors that contribute to total time from referral to arrival demonstrated that distance was independently associated with total time (p&amp;lt;0.001). Transfers took an additional 6.7 minutes for every 10 km between the referring and accepting centres. Male sex was also independently associated with total time (p=0.041), with 55 additional minutes required per transfer of male patients compared to female. Transfer time was not significantly associated with age, procedure (TPE vs. RBCX), mode of transport, number of centres contacted, or within-LHIN referral. Conclusions: We have described the processes of urgent apheresis referrals to our centre. The 4 hour "life or limb" benchmark was met in just under 75% of transfers, with the greatest delay occurring between patient acceptance and arrival. This is important given that time to initiate treatment is associated with better outcomes. Distance between centres is an important factor and potential target for improvement. Our analysis shows that &amp;gt;90% of cases were from outside our LHIN, reflecting a truly provincial catchment. Quality improvement strategies should be aimed at pairing referrals with nearest apheresis centres, and creating efficiency in the interval between patient acceptance and arrival. It is unclear from these data why male sex is associated with longer transfer times, but it is a target for further analysis. There are limitations of this analysis: data were not available for cases that were not ultimately transferred, nor for transfers to other centres. Future work will include examining patterns of province-wide transfers, as well as including blood bank data to further characterize steps involved in initiating aphaeresis. Acknowledgements: We thank M. Shaikh, J. Dempsey, M. Gavel at CritiCall for their contributions. Disclosures Kuo: Pfizer: Consultancy, Research Funding; Celgene: Consultancy; Apellis: Consultancy; Bioverativ: Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria; Alexion: Consultancy, Honoraria; Bluebird Bio: Consultancy; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees. Patriquin:Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Apellis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Octapharma: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Uptake of the Heart Failure Management Incentive Billing Code by Family Physicians in Ontario, Canada: A Retrospective Cohort Study

In 2008, the Ontario Ministry of Health and Long-Term Care (MOHLTC) implemented an incentive payment, Q050A billing code, to family physicians for provision of comprehensive guideline-based care for patients with heart failure in the community. Our objective was to report on the uptake of this program from fiscal years 2008-2014. We determined the numbers of claims billed per year and the proportion of eligible patients with congestive heart failure (CHF) for whom a physician billed. The code was billed by 10.4% of all family physicians in 2008-2009, which increased to 15.1% in 2014-2015. The code was claimed for 4.1% of all identified patients with CHF in 2008-2009 and 5.9% of patients with CHF in 2014-2015. Given these findings, it is estimated that MOHLTC paid an additional CAD$10,118,514 to family physicians managing patients with CHF. This is the first study to examine the uptake of a CHF-specific incentive program, which will help to inform health policy makers in implementing such programs in Ontario.

Access to Migraine Treatments in Ontario, Canada: A Review of the Ontario Drug Benefit Program.

This paper provides a critical review of the decision-making process of the Ontario Ministry of Health and Long-Term Care (MOHLTC) regarding which migraine treatment drugs will be covered under the Ontario Drug Benefit Formulary (ODB). Under MOHLTC policy, triptans and OnabotulinumtoxinA are available to patients only through the Exceptional Access Program (EAP). This policy, and justifications for it, are examined with reference to clinical guidelines, patient experiences, and health policy literature. The contexts and consequences of compromised access are outlined. Improvements in access to these treatments are suggested by highlighting how a country with similar healthcare infrastructure - Australia - employs policies that more adequately meet the needs of migraine patients as they secure treatments. Despite clinically significant gains in the discovery of safe and effective migraine-specific treatments the ODB thus far has failed to align its practice with current clinical recommendations. This forces patients to rely heavily on medication that, while still effective for some, is potentially suboptimal. This review concludes it is prudent, at minimum, to follow clinical recommendations that advocate for the removal of triptans from EAP and recategorize them as Limited Use drugs. Ideally, moving them to a general benefit would further remove the barriers experienced by patients attempting to access this treatment.

Understanding health professional role integration in complex adaptive systems: a multiple-case study of physician assistants in Ontario, Canada

BackgroundTo meet the complex needs of healthcare delivery, the Ministry of Health and Long Term Care (MOHLTC) introduced Physician Assistants (PAs) into the Ontario health care system in 2006 with the goal of helping to increase access to care, decrease wait times, improve continuity of care and provide a flexible addition to the healthcare workforce. The characterization of healthcare organizations as complex adaptive systems (CAS) may offer insight into the relationships and interactions that optimize and restrict successful PA integration. The aim of this study is to explore the integration of PAs across multiple case settings and to understand the role of PAs within complex adaptive systems.MethodsAn exploratory, multiple-case study was used to examine PA role integration in four settings: family medicine, emergency medicine, general surgery, and inpatient medicine. Interviews were conducted with 46 healthcare providers and administrators across 13 hospitals and 6 family medicine clinics in Ontario, Canada. Analysis was conducted in three phases including an inductive thematic analysis within each of the four cases, a cross-case thematic analysis, and a broader, deductive exploration of cross-case patterns pertaining to specific complexity theory principles of interest.ResultsForty-six health care providers were interviewed across 19 different healthcare sites. Support for PA contributions across various health care settings, the importance of role awareness, supervisory relationship attributes, and role vulnerability are interconnected and dynamic. Findings represent the experiences of PAs and other healthcare providers, and demonstrate how the PAs willingness to work and ability to build relationships allows for the establishment of interprofessional, collaborative, and person-centered care. As a self-organizing agent in complex adaptive systems (i.e., health organizations), PA role exploration revealed patterns of team behavior, non-linear interconnections, open relationships, dynamic systems, and the legacy of role implementation as defined by complexity theory.ConclusionsBy exploring the role of PAs across multiple sites, the complexity theory lens concurrently fosters an awareness of emerging patterns, relationships and non-linear interactions within the defined context of the Ontario healthcare system. By establishing collaborative, interprofessional care models in hospital and community settings, PAs are making a significant contribution to Ontario healthcare settings.

Effective Detection of Compensated Cirrhosis Using Machine Learning

Background: Cirrhosis is often diagnosed once complications such as ascites, encephalopathy and variceal bleeding have occurred. Current non-invasive tests to detect cirrhosis have limited performance, with many patients falling into the indeterminate category. Objectives: To identify patients with well-compensated liver cirrhosis of all-causes using machine learning algorithms (MLAs) trained on routinely measured clinical and laboratory parameters. Design, Setting, and Participants: Retrospective, cross-sectional study on patients with F0, F1, and F4 fibrosis staged via biopsy at the Toronto Liver Clinic, validated on 508 patients with F0 to F4 fibrosis staged via biopsy locally as well as at the McGill University Health Centre. Patients with decompensated cirrhosis were excluded. We trained 7 MLAs to identify patients with compensated cirrhosis. Performance was benchmarked against the Aspartate aminotransferase (AST)-to-Platelet Ratio Index (APRI), Fibrosis-4 index (FIB-4), nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), Transient Elastography (TE), and an independent panel of 5 experts. Results: The best MLA achieved a cross-validation area under the receiver operating characteristic curve (AUROC) of 0.88 for identifying patients with well-compensated cirrhosis, with less than 8% indeterminate classifications. The MLA achieved higher or comparable AUROC to FIB-4 on both validation sets with 20% fewer indeterminate classifications. Additionally, we show that by altering cutoffs, the MLA outperformed expert hepatologists and the NFS score and achieved superior specificity to transient elastography. Conclusion: In this study, we have demonstrated that an MLA outperforms non-imaging based methods in detecting well-compensated cirrhosis across multiple etiologies of liver disease. Our MLA was superior to APRI, FIB-4, and NFS with significantly fewer indeterminate classifications, while achieving performance comparable to an independent panel of experts. MLAs using routinely collected data could flag patients with well-compensated liver cirrhosis among patients with chronic liver disease, allowing intervention prior to onset of decompensation and associated complications. Funding Statement: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Declaration of Interests: We have no competing interests to declare. Ethics Approval Statement: Ethics approval was obtained from the Research Ethics Boards at the University Health Network, SickKids Research Institute, and MUHC.

Long-Term Outcomes After Transcatheter Atrial Septal Defect Closure Among Adults in Comparison to Surgery and General Population

Background: Owing to the limited data on long-term outcomes following the implantation of atrial septal occluders, their permanent nature and potential for adverse outcomes remain concerning. Methods: In this retrospective cohort study, the long-term outcomes of adult patients who underwent transcatheter and surgical closure at Peter Munk Cardiac Centre, Toronto, Canada between 1991-2015 were determined using administrative databases linkages. The transcatheter group was compared to an age-sex matched population (each included 1278 participants) in 1:1 fashion and to a surgical group (240 patients) using propensity weighting. The primary endpoint was all-cause mortality. Results: Median age was 48 years and 39 years for the transcatheter and surgical groups respectively. Compared to age-sex matched group, mortality following transcatheter closure was not significantly different after a median follow-up of 9 years [7.9 vs 6.4 per 1000-patient-years, (difference-95%CI, -0.68,4.49), P=0.20], with non-significantly different rates of stroke [1.9 vs 1.1 per 1000-patient-years, (difference-95% CI, -0.2,2.69), P=0.16] but significantly higher rates of atrial fibrillation [22 vs 4.4 per 1000-patient-years, (difference-95% CI, 11.6,25.9), P<0.001] and heart failure [2.3 vs 0.5 per 1000-patient-years, (difference-95% CI,0.43,5.64), P<0.001]. Compared to surgery, rates of stroke [1.4 vs 11.4 per 1000-patient-years, (difference-95% CI, -11.3, -2.22), P=0.03] and atrial fibrillation [79.1 vs 142 per 1000-patient-years, (difference-95% CI, -89.5, -22.4), P<0.001] were significantly lower over 1 year follow-up. Mortality rates were not significantly different over 1 year [7.4 vs 6.3 per 1000-patient-years, (difference-95% CI, -5,35.4), P=0.85] and in long-term follow-up [8.2 vs 9.7 per 1000-patient-years, (difference-95% CI, -3.98,2.22), P=0.39] for the transcatheter and surgery groups, respectively. The need for any open-heart surgery during follow-up was not significantly different between the two approaches [3.6 vs 3.5 per 1000-patient-years, (difference-95% CI, -1.54, 2.94) P=0.95]. Conclusions and Interpretation: Among patients undergoing transcatheter or surgical closure between 1991 and 2015, there was no significant difference in mortality after a median 9 years of follow-up. Transcatheter closure was also not associated with greater mortality than age- and sex-matched individuals from the general population. Funding Statement: ICES is supported in part by a grant from the Ontario Ministry of Health and Long Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed in the material are those of the authors and not necessarily of CIHI and no endorsement by MOHLTC or ICES is intended or should be inferred. The statistical analysis was conducted independently by ICES. The study was supported by funding from the Peter Munk Chair in Structural intervention and a grant from Abbott Structural Heart®. Declaration of Interests: Dr. Lee is supported by a Mid-Career investigator award from the Heart and Stroke Foundation and the Ted Rogers Chair in Heart Function Outcomes, a joint Hospital468 University Chair of the University Health Network and the University of Toronto. Dr. Austin is a Mid-Career investigator of the Heart and Stroke Foundation. Dr. Eric Horlick and Dr. Mark Osten were consultants for Abbott Structural Heart®. Dr. Meier is supported by an educational grant from the Gottfried und Julia Bangerter-Rhyner-Stiftung Foundation. All other authors have no disclosures. Ethics Approval Statement: This study was approved by the University Health Network Ethics Review Board and had a waiver of participant consent granted by the institutional ethics board.

Distribution gaps in cataract surgery care and impact on seniors across Ontario

ObjectiveTo assess recent cataract service delivery across communities of all sizes in Ontario. DesignRetrospective analysis of health records. ParticipantsAll Ontario Health Insurance Plan users. MethodsRaw physician Ontario Health Insurance Plan claims data for cataract surgery (E140A, E214A) from April 1, 2009, to March 31, 2014, were extracted from the Ontario Ministry of Health and Long-Term Care (MOHLTC) IntelliHealth database. Cataract surgery claims data were sorted by sex, by age, and by Ontario's 444 municipalities based on patient residence. Cataract surgery distribution was examined by population centre: Large Urban (≥100 000 persons), Medium (30 000–99 999 persons), Small (1000–29 999 persons), and Rural (<1000 persons) as defined by Statistics Canada. Wait times were extracted from the MOHLTC wait times database. Cataract surgery rate (CSR), defined as the number of cataract surgeries performed per million, was calculated. ResultsCataract surgery volumes remained unchanged from 2010 to 2014. Mean patient age was 71.6 ± 10 years. Patients lived in large urban (63%), medium (15%), small (21%), and rural (0.6%) communities. Mean wait times increased by 28% to 68.5 days, and 90th percentile wait times increased by 44% to 154.3 days. A reduction in CSR was observed among seniors aged 65–74 years (−10%) and 75+ years (−16%). Rural communities showed the largest decline (−19%). Among seniors aged ≥75 years, CSR declined the most for those living in rural communities (−25%). ConclusionsAdjusting the current government policy of zero-growth in cataract surgery volumes will support growing demands for cataract care in our aging population.

From (Ontario Ministry of Health and Long-Term Care) policy to implementation: A retrospective look at a community-based patient-centered model of care for chronic pain

ABSTRACT Background Chronic pain is one of the most widely recognized, disabling, and expensive health problems in Canada. Interdisciplinary multimodal pain management is effective in helping chronic pain patients lessen symptoms and reclaim functionality, but most patients lack access to such treatments. Aim The aim of this study was to describe the development and implementation of a publicly funded and patient-centered model of care in the community. Methods The study was set in the Pain & Wellness Centre (PWC) in Vaughan, the only community-based chronic pain clinic in Ontario funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC) as a demonstration project of a template for similar future community clinics. The study is descriptive, including a brief review of the Ontario comprehensive pain strategy framework and an overview of the PWC and the process involved in the development of an interdisciplinary pain program (IDP), based on the biopsychosocial model of chronic pain management. Results During a 2.5-year period, the PWC has offered 1055 new patient medical consultations and 1921 follow-up visits and admitted 242 patients in the IDP program (demonstrating significant success in patient outcomes at the 3-month exit from the program). It established robust outcomes research, organized educational programs for pain trainees, and cultivated a collaborative relationship with the Toronto Academic Pain Medicine (TAPMI) network and the community at large. Conclusions This demonstration program has shown the feasibility and applicability of the principles of the MOHLTC comprehensive pain strategy, providing an effective, evidence-based, and accountable approach to chronic pain diagnosis and management in the community.

DEVELOPMENT OF AN ECHOCARDIOGRAPHIC QUALITY IMPROVEMENT AND ACCREDITATION PROCESS THROUGH A SUCCESSFUL GOVERNMENT-MEDICAL COLLABORATION

Echocardiography (echo) is a frequently used diagnostic test in Ontario with significant implications for clinical care, patient outcomes, and health system costs. To help ensure quality echo services, the Ontario Ministry of Health and Long Term Care (MOHLTC) and Ontario Medical Association (OMA) convened the Hospital Outpatient and Community-based Echocardiography Working Group, whose recommendations subsequently resulted in CorHealth Ontario releasing the Standards for Provision of Echocardiography in Ontario. Along with the Standards, and in collaboration with the MOHLTC and the Ontario Association of Cardiologists (OAC), CorHealth launched the Echo Quality Improvement Program (EQIP), a process designed to ensure that echo facilities practice according to the Standards. The core elements of the EQIP include an echo facility site visit along with process and case reviews. To facilitate quality improvement in alignment with the Standards, detailed and meaningful feedback is provided in a consistent and structured format. In April 2016 participation in the EQIP became a requirement for physician payment from the Ontario Health Insurance Program. Working with the Ontario Association of Cardiologists (OAC) and the MOHLTC, the EQI Program developed consistent, objective, and transparent processes and reporting requirements to address the shared desire for accountability and quality. As of April 26, 2018, 432 out of 766 operational echo facilities have been reviewed. 175 of the reviewed echo facilities have completed quality improvements and achieved accreditation. The success of the EQIP to date demonstrates the value of government-medical collaboration to improve the quality of echo services across both publicly funded hospitals and independent physician practices in Ontario. The benefits arising from the collaborative effort is positively impacting clinical decision making and patient care and could serve as a foundation for similar diagnostic quality improvement initiatives.

MS Risk in Immigrants in the McDonald Era: A Population-Based Study in Ontario, Canada

Background: Migration studies may provide insights into environmental determinants of multiple sclerosis (MS) and whether a critical window for exposure exists. We aimed to determine risk factors for MS in immigrants and compare MS risk in immigrants versus long-term residents in Ontario, Canada. Methods: We applied a validated algorithm to linked, population-based immigration and health claims data to identify incident MS cases in immigrants and long term-residents between 1994 and 2016. We conducted two multivariable Cox proportional hazards regression analyses including one limited to the immigrant cohort assessing potential risk factors for developing MS; and one comparing MS risk between immigrants and matched long-term residents (1:3 match). Results: We identified 2,304,302 immigrants for the immigrant-only analysis, of whom 1,526 (0.066%) developed MS. Younger age at migration, female sex, greater co-morbidity burden, lower neighbourhood income, and time since landing were associated with increased MS risk. Risk was greatest in those <15 years old at landing (Ref: <15 years; 16-30 years: HR 0.73, 95%CI: 0.63-0.85; 31-45 years: HR 0.55, 95%CI: 0.47-0.64). Region/country of origin was also associated with MS risk. Immigrants from the Middle East (HR 1.22, 95%CI: 1.06-1.40) were at greater risk than immigrants from Western nations; all other regions had lower MS risk (p<.0001). The matched analysis included 2,207,751 immigrants and 6,362,169 long-term residents. Immigrants were less likely to develop MS than long-term residents (p<.0001), although this lower risk was attenuated with longer residence in Canada. Interpretation: MS incidence in immigrants to Ontario, Canada varied widely by region of origin, with greatest risk seen in those from the Middle East. Although MS risk declined with increasing age at arrival, considerable risk was sustained with migration after age 15, suggesting that environmental exposures into adulthood contribute to MS risk. Funding Statement: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Declaration of Interests: DR has received research support from the Consortium of Multiple Sclerosis Centers and from the Multiple Sclerosis Society of Canada. She has served as a consultant for Sanofi Aventis, Biogen, Novartis, EMD Serono, and Roche. RAM receives research funding from the Canadian Institutes of Health Research, Multiple Sclerosis Society of Canada, National Multiple Sclerosis Society, Research Manitoba, the Consortium of MS Centers, Crohn’s and Colitis Canada, and the Waugh Family Chair in Multiple Sclerosis. CJM has received research funding from the Canadian Institutes of Health Research, P.S.I. Foundation, MS Society of Canada, Consortium of MS Centers, MS Scientific Research Foundation, Ontario Ministry of Health and Long-Term Care-Health System Research Fund, Canadian Frailty Network, Partners for Canadian Consortium on Neurodegeneration in Aging, Network for Aging Research-University of Waterloo. She is supported by a University Research Chair at the University of Waterloo. KT receives a research scholar award from the Department of Family and Community Medicine at the University of Toronto. Ethics Approval Statement: This study was approved by the research ethics boards at St. Michael’s Hospital in Toronto, Ontario, Canada. Informed consent by participants was not required.

Attending Nurse Practitioners in Long-Term Care Homes Evaluation

IntroductionIn 2014, the Ontario Ministry of Health and Long-Term Care (MOHLTC) announced funding for 75 nurse practitioners (NPs) over three years in long-term care (LTC) homes. This evaluation was approved by ICES’ Applied Health Research Question (AHRQ) team, a portfolio which answers questions from stakeholders having impact on healthcare policy.&#x0D; Objectives and ApproachThe purpose of this project is to evaluate the impact of the first thirty NPs hired. Changes will be evaluated using key outcome measures of resident care (e.g., early hospital discharge, emergency room bed days) identified through a literature review conducted by the MOHLTC. LTC home residents were identified using all individuals with claims in OHIP during the 2016-17 fiscal year with a location of a LTC home. LTC homes with a hired NP were considered to be cases and all other LTC homes were considered to be controls.&#x0D; ResultsFor part one of this evaluation, case and control LTC homes were stratified by bed size, Case Mix Index, rurality and Local Health Integration Network. Hospitalization records and emergency visits (from Discharge Abstract Database and National Ambulatory Care Reporting System) were determined for LTCH residents 6 months before and after the NP hire date of October 1, 2016. Overall, the rate of hospital admissions (per 100 residents) increased by 3.44% (8.51% to 11.94%) following the NP hire date; whereas, the rate of hospital admissions increased by 2.29% (6.55% to 8.83%) among controls. Following the NP hire date, the rate of emergency department visits also increased by 3.15% among cases (16.62% to 19.77%) in comparison to a 2.31% increase among controls (12.55% to 14.86%).&#x0D; Conclusion/ImplicationsThe findings from this evaluation will inform further implementation strategies of the NP program and guide decision-making of future funding opportunities. In summary, the results will inform policies to strengthen care of LTC homes and improve the quality of care of residents.

Publicly Funded Oral Chronic Hepatitis B Treatment Patterns in Ontario over 16 Years: An Ecologic Study.

Reimbursement for the use of hepatitis B virus (HBV) treatments has not been previously reported for public payers. To describe the number of users and total cost of HBV treatments over the last 16 years among residents of Ontario, Canada, who were covered by the public drug program. We conducted a repeated cross-sectional study for HBV treatments reimbursed by the public drug program in Ontario from January 1, 2000, to December 31, 2015. We projected total spending to 2020 based on current utilization trends. HBV drug users per year increased 30-fold, from 132 users in 2000 to 4,035 users in 2015. Total spending on HBV treatments increased 150-fold, from $136,368 annually in 2000 to $21.0 million in 2015. The spending on HBV agents is projected to increase by 65%, with an estimated drug cost of $34.6 million by 2020. Although not reimbursed as first-line therapy, tenofovir disoproxil fumarate has become the most commonly reimbursed HBV treatment and was associated with an increase in HBV treatment use and total spending. Results of this study found that rapid growth of HBV treatments led to a sustained increase in spending for public payers in Ontario. This study was funded by grants from the Ontario Ministry of Health and Long-Term Care (MOHLTC) and Ontario Strategy for Patient-Orientated Research (SPOR) Support Unit, which is supported by the Canadian Institutes of Health Research and the Province of Ontario. This study was also supported by the Institute for Clinical Evaluative Sciences (ICES), a non-profit research institute sponsored by the Ontario MOHLTC. The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the authors and not necessarily those of CIHI. Mamdani has received honoraria from Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb, and Bayer. Janssen has received research support, consulting, and/or speaking fees from Gilead, Roche, Merck, AbbVie, Bristol-Myers Squibb, Arbutus, Janssen, and MedImmune. No other authors have any conflicts of interest to declare.

Cost savings of implementing the SickKids Paediatric Orthopaedic Pathway for proximal humerus fractures in Ontario, Canada

The SickKids Paediatric Orthopaedic Pathway (SKPOP) for proximal humerus fractures may safely reduce the number of radiographs and follow-up assessments for children with these injuries. The study objective was to examine potential cost-savings of the SKPOP from the perspective of the Ministry of Health and Long-term Care (MOHLTC). Two sets of resource profiles, based on direct health care costs were created for a cohort of patients treated at our institution: the first based on actual follow-up assessment values, and the other based on follow-up assessments according to the SKPOP. Differences between the two profiles represent potential cost-savings. A decision-analysis and associated probabilistic sensitivity analysis (PSA) were performed. In a cohort of 239 patients treated between 2009 and 2014, 92.9% (222) would have met SKPOP eligibility. Management according to this pathway would have reduced orthopaedic assessments and shoulder radiograph series by 83.6% (470/562) and 70.8% (367/589), respectively. For the cohort examined, a potential cost-savings of $30,040.56 ($135.32/patient) was observed. A PSA, accounting for variable SKPOP adherence and health care utilization, yielded cost-savings in 96.5% of the iterations run through the decision-analysis model and an average cost-savings of $57.82/patient. Based on these results and the annual provincial incidence rate of eligible patients (n=575), the MOHLTC could potentially save $33,249.45 annually with province-wide implementation. Implementation of the SKPOP for a cohort of patients managed at our institution could have resulted in cost-savings due to substantial reductions in health care utilization. Cost-savings are likely to occur with provincial implementation of the SKPOP for proximal humerus fractures.

Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: a population-based linked administrative database study.

Involuntary admissions to psychiatric hospitals are common; however, research examining the trends in prevalence over time and predictors is limited. Aims To examine trends in prevalence and risk factors for involuntary admissions in Ontario, Canada. We conducted an analysis of all mental health bed admissions from 2009 to 2013 and assessed the association between patient sociodemographics, service utilisation, pathway to care and severity characteristics for involuntary admissions using a modified Poisson regression. We found a high and increasing prevalence of involuntary admissions (70.7% in 2009, 77.1% in 2013, 74.1% overall). Individuals with police contact in the prior week (risk ratio (RR)=1.20) and immigrants both experienced greater likelihood of being involuntarily admitted, regardless of control for other characteristics (RR=1.07) (both P<0.0001). We identified numerous modifiable and non-modifiable risk factors for involuntary admissions. The prevalence of involuntary admissions was high, linearly increasing over time. Declaration of interest The authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This study was conducted using funding entirely from public sources. P.K. has received operational support via an Ontario Ministry of Health and Long-Term Care (MOHLTC) Health Services Research Fund Capacity Award to support this project. The Institute for Clinical Evaluative Sciences (ICES) is funded by the Ontario MOHLTC. The study results and conclusions are those of the authors, and should not be attributed to any of the funding agencies or sponsoring agencies. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. All decisions regarding study design, publication, and data analysis were made independent of the funding agencies.