Neighbourhood Income Quintile Research Articles

Virtual care use before and during the COVID-19 pandemic: a repeated cross-sectional study.

Background:The coronavirus disease 2019 (COVID-19) pandemic is thought to have increased use of virtual care, but population-based studies are lacking. We aimed to assess the uptake of virtual care during the COVID-19 pandemic using comprehensive population-based data from Ontario.Methods:This was a repeated cross-sectional study design. We used administrative data to evaluate changes in in-person and virtual visits among all residents of Ontario before (2012–2019) and during (January–August 2020) the COVID-19 pandemic. We included all patients who had an ambulatory care visit in Ontario. We excluded claims for patients who were not Ontario residents or had an invalid or missing health card number. We compared monthly or quarterly virtual care use across age groups, neighbourhood income quintiles and chronic disease subgroups. We also examined physician characteristics that may have been associated with virtual care use.Results:Among all residents of Ontario (population 14.6 million), virtual care increased from 1.6% of total ambulatory visits in the second quarter of 2019 to 70.6% in the second quarter of 2020. The proportion of physicians who provided 1 or more virtual visits per year increased from 7.0% in the second quarter of 2019 to 85.9% in the second quarter of 2020. The proportion of Ontarians who had a virtual visit increased from 1.3% in 2019 to 29.2% in 2020. Older patients were the highest users of virtual care. The proportion of total virtual visits that were provided to patients residing in rural areas (v. urban areas) declined significantly between 2012 and 2020, reflecting a shift in virtual care to a service increasingly used in urban centres. The rates of virtual care use increased similarly across all conditions and across all income quintiles.Interpretation:Our findings show that Ontario’s approach to virtual care led to broad adoption across all provider groups, patient age, types of chronic diseases and neighborhood income. These findings have policy implications, including use of virtual care billing codes, for the ongoing use of virtual care during the second wave of the pandemic and beyond.

Do socioeconomic and birth order gradients in child maltreatment differ by immigrant status?

BackgroundWhile literature has documented strong gradients in child maltreatment (CM) by socioeconomic status and family composition in the general population, how these patterns extend to immigrants remain inconclusive. Using population-based...

Outcome Among Adolescents and Young Adults with Mature B-Cell Non Hodgkin Lymphoma at Pediatric Versus Adult Centers: A Population-Based Study Using the IMPACT Cohort

Background: Disparities in survival between adolescents and young adults (AYA) treated for acute lymphoblastic leukemia in pediatric versus adult centers are well documented. Whether similar disparities exist among AYA with mature B-cell non-Hodgkin lymphoma (B-NHL) is unknown, despite substantial differences between pediatric and adult treatment protocols. We compared outcomes among AYA with B-NHL by locus of care (LOC; pediatric versus adult) using a population-based clinical AYA database. We also assessed whether socioeconomic status or geographic area impacted outcome in this population. Methods: The IMPACT cohort comprises all Ontario, Canada AYA aged 15-21 years diagnosed with one of six common cancers (including NHL) between 1992-2012. Detailed demographic, disease (histology, stage), treatment, and outcome data were collected through chart abstraction and validated by content experts. Postal code at diagnosis allowed determination of neighbourhood income quintile and rural residence. Linkage to population-based health administrative data identified additional events (second cancers, relapse, death). Event-free (EFS) and overall survival (OS) were determined using Kaplan-Meier methods. The impact of LOC on EFS and OS was determined using multivariable Cox proportional hazard models, adjusted for demographics and disease-related variables. Results: Among 176 AYA with B-NHL, 62 (35.2%) received therapy at a pediatric center. Pediatric center AYA were more likely to have Burkitt lymphoma (BL) than diffuse large B-cell lymphoma (DLBCL) as compared to adult center AYA [26/62 (41.9%) vs. 21/114 (18.4%); p<0.001], and more likely to have advanced stage (i.e. Stage III/IV) disease [38/62 (61.3%) vs. 46/114 (40.4%); p=0.006]. The 5-year EFS and OS (with standard errors) for the whole cohort were 72.2%±3.4% and 76.1%±3.2%. Both EFS and OS were superior among pediatric center patients (EFS 82.2%±4.9% vs. 66.7%±4.4%; p=0.02), (OS 85.5%±4.5% vs. 71.1%±4.3%; p=0.03). When stratified by histology (BL vs. DLBCL), the EFS and OS were similar. However, the superior outcome of pediatric center AYA retained statistical significance only among those with DLBCL (Table 1). Adjusted for histology (BL vs. DLBCL), stage, and time period of diagnosis, adult center AYA had inferior EFS [hazard ratio (HR) 2.4, 95% confidence interval (95CI) 1.1-4.9, p=0.02] and OS (HR 2.5, CI 1.1-5.7, p=0.03). Neither neighbourhood income quintile nor rural residence was associated with EFS or OS. Conclusions: In this population-based cohort, AYA with B-NHL treated at pediatric centers experienced substantially superior EFS and OS compared to those treated at adult centers, even accounting for disease characteristics. In subgroup analyses, this difference retained statistical significance among patients with DLBCL but not among patients with BL, though the latter analyses were limited by small sample sizes. Future analyses will analyze whether patterns of treatment failure and late effects vary by locus of care. Further confirmatory studies are warranted, as are studies to determine the relative contribution of pediatric protocols versus other components of care. Our results nonetheless suggest that similar to AYA with acute lymphoblastic leukemia, AYA with B-NHL may benefit from being treated in pediatric centers with pediatric protocols. Disclosures Baxter: Servier: Membership on an entity's Board of Directors or advisory committees.

Emergency Department Quality of Care for Sickle Cell Disease in Ontario, Canada: A Population-Based Matched Cohort Study

Background: Acute vaso-occlusive crisis (VOC) in sickle cell disease (SCD) frequently leads patients to seek emergency department (ED) care. Whether or not health inequities exist, and their exact nature, is poorly understood in ED visits for SCD VOC within a universal publicly funded healthcare system. In this study, we aimed to address this knowledge gap by characterizing the landscape of ED care burden and quality indicators for SCD VOC management in the province of Ontario, Canada. Methods: We used population-level health administrative data to identify patients with SCD in Ontario who presented to the ED with SCD VOC (ICD-10-CA code D57.0) from 2006 to 2018. We evaluated quality of care indicators in the ED for this population and compared these with a general population group matched by age, sex, neighbourhood income quintile, geography (forward sortation area) and date of ED visit (-15 to +15 days per visit) (35,370 ED visits; 27,195 patients). Results: We identified 1,811 patients who presented to the ED with SCD VOC for a total of 13,123 ED visits over the study period. Of ED presentations, 40% were pediatric (< 18 years), 47% were male and 99% lived in urban settings. Compared to ED visits for the matched group, ED visits for SCD VOC had a significantly higher proportion of high acuity triage scores (CTAS 1 or 2) (74% vs 18%; p < 0.001), shorter time to initial physician assessment (76 ± 82 vs 90 ± 86 minutes; mean ± SD, p < 0.001), longer period of ED assessment and observation (432 ± 261 vs 212 ± 179 minutes; p < 0.001), increased likelihood of hospital admission (62% vs 5%; p < 0.001), longer duration of inpatient stay (5.2 ± 6.7 vs 4.0 ± 8.1 days; p < 0.001), and higher rates of repeat ED visits within 30 days of ED discharge (0.57 ± 1.44 vs 0.26 ± 0.79 visits; p < 0.001). We found specific socio-demographic variables associated with a poorer quality of care in ED visits for SCD VOC, including patients who were adults, male, from a low-income neighbourhood, having a greater number of dependents, a higher neighbourhood level of material deprivation, from an ethnically-concentrated neighbourhood, and those who lived in a residentially unstable region. Bivariate analyses for clinically meaningful outcomes (defined as ED disposition, repeat ED visit within 30 days, length of hospital admission stay, and being among the highest user bracket of ED care) further revealed significant socio-demographic associations that validated the clinical relevance of these determinants underlying ED metric disparities found within the SCD cohort (Table 1). In subgroup comparisons, we observed a significant difference in triage acuity scoring for adults compared with children with SCD VOC, with a 25% lower rate of high acuity triage score (CTAS 1 or 2) (66% vs 86%). We also found that despite a majority of adults with SCD VOC receiving these scores compared to those in the matched group (66% vs 18%), their mean times to initial physician assessment were not significantly different (90 ± 94 vs 91 ± 89 minutes), reflecting an average SCD VOC wait time longer than the clinical practice guideline recommendation of first dose analgesic within the first 60 minutes of ED arrival. Furthermore, we identified a negative correlation between poor ED metrics and patients with SCD who were highly dependent on ED care (defined as 4-9 or ≥ 10 ED visits for SCD VOC per year) at levels significantly above the matched comparative baseline. Conclusions: Indicators of ED care for SCD largely reflect the clinical acuity and severity of VOC presentations in Ontario, Canada. However, significant disparities in the quality of care received and in clinical outcomes for specific subgroups of patients with SCD, including those most vulnerable within this patient population, raises concern from a health equity perspective.By leveraging this landscape of SCD ED care, future policy, clinical and research efforts must work to understand, address and close these gaps in order to achieve best and equitable care for all. Disclosures No relevant conflicts of interest to declare.

Epidemiological Trends of Anterior Cruciate Ligament Reconstruction in a Canadian Province

To determine epidemiological trends of anterior cruciate ligament reconstruction (ACL-R) in a Canadian province, estimate the national incidence, and compare with internationally published data. Retrospective review. All hospitals that performed ACL reconstructions in Manitoba between 1980 and 2015. All patients that underwent ACL-R in Manitoba between 1980 and 2015. This is a retrospective review looking at deidentified, individual-level administrative records of health services used for the entire population of Manitoba (approximately 1.3 million). Codes for ACL and cruciate ligament reconstruction were searched from 1980 to 2015. Patient demographics included age, sex, geographic area of residence, and neighborhood income quintile. Trends of ACL reconstructions from 1980 to 2015. A total of 10 114 ACL-R were performed during the 36-year study period and patients were predominantly male (63.1%). The mean age at ACL-R was 29.5 years (SD 10.0) for males and 28.5 years (SD 11.9) for females, whereas age younger than 40 years accounted for 81.7% of all ACL-R. The incidence of ACL-R increased from 7.56/100 000 inhabitants in 1980 to 48.45/100 000 in 2015. The proportion of females undergoing ACL-R has increased from 29.3% in 1980% to 41.9% in 2015, and female patients now comprise the majority of ACL-R in the under-20 age category. The incidence of ACL-R has significantly increased since 1980; female patients now make up a greater proportion than males of the ACL-R population younger than 20 years. This information can be used to guide resource allocation planning and focus injury prevention initiatives.

Is Prostate Brachytherapy a Dying Art? Evidence of Increasing Utilization in Ontario, Canada

A worldwide decline in prostate brachytherapy (BT) utilization has been reported in multiple health care settings/jurisdictions, despite strong evidence for efficacy and safety compared to other alternatives. We sought to evaluate contemporary trends in BT, EBRT and prostatectomy utilization in a publicly funded healthcare system. Men with localized prostate cancer diagnosed and treated between 2007 and 2017 in Ontario, Canada were identified using administrative data from the Institute for Clinical Evaluative Sciences. Men were coded to have received EBRT, BT (monotherapy or boost) or prostatectomy as initial definitive management. Trends were evaluated using the Cochran-Armitage test. Multivariate logistic regression was used to evaluate patient-, tumor-, and provider-factors on treatment utilization over time. There were 57,655 men were included in our study. Prostate BT use increased from 7.5% of all treatments in 2007 to 15.4% in 2017 (p<0.01), primarily due to increased use of BT boost (1.7% in 2007 to 10.4% in 2017, p<0.01). Relative to EBRT, BT use increased from 17.9% in 2007 to 28.1% in 2017 (p<0.01). On multivariate analysis (MVA), BT boost use increased by 28% per year (OR 1.28, 95% CI 1.26–1.31, p<0.01) and BT monotherapy use increased by 12% per year (OR 1.12, 95% CI 1.10–1.14, p<0.01), offset by decreasing prostatectomy use (12% per year, OR 0.88, 95% CI 0.87–0.89, p<0.01). Comparing BT to EBRT, the strongest predictors of receiving BT were geographic residence (OR 27.6, 95% CI: 20.3–37.6, p<0.01 between highest/lowest Local Health Integration Networks) and whether the first consulting radiation oncologist performed BT (OR 3.46, 95% CI: 3.15–3.80, p<0.01). Other significant factors predicting BT use vs. EBRT included lower age, lower PSA, lower Charlson comorbidity score and increasing neighborhood income quintile. Low-intermediate, high-intermediate and high-risk groups were predictive of receiving BT boost, whereas BT monotherapy was predominantly used in low-risk disease. Contrary to trends observed in other jurisdictions, utilization of prostate BT is increasing over time in Ontario. However, substantial variation in BT utilization was found, strongly driven by both geographic region and radiation oncologist BT practice patterns. To our knowledge, this is the first study to report increasing BT utilization in the era of dose-escalated EBRT, with Ontario potentially serving as a model to promote BT utilization elsewhere.

Utilisation and outcomes of allogeneic hematopoietic cell transplantation in Ontario, Canada, and New York State, USA: a population-based retrospective cohort study

ObjectiveAllogeneic haematopoietic cell transplantation (HCT) is a potentially curative treatment for haematologic and oncologic diseases. There is a perception that the United States of America (USA) offers greater access to...

Incidence of Total Knee Replacement in Patients With Previous Anterior Cruciate Ligament Reconstruction.

To determine the rate of total knee replacement (TKR) after anterior cruciate ligament reconstruction (ACL-R) compared to the general population. Retrospective review. All hospitals that performed TKR and ACL-R in Manitoba between 1980 and 2015. All patients that underwent TKR and ACL-R in Manitoba between 1980 and 2015. Patient factors gathered at time of surgery included: age, sex, urban or rural residence, neighborhood income quintile, and resource utilization band (RUB). Each person was matched with up to 5 people from the general population who had never had ACL-R and had not had a TKR at the time of the case ACL-R. The rate of TKR after ACL-R. Overall from 1980 to 2015, 8500 ACL-R were identified within the 16 to 60 years age group with a resultant 42 497 population matches. Sex was predominantly male. The mean age of the ACL-R group at the time of TKR was 53.7 years, whereas the mean age for the matched cohort was 58.2 years, P < 0.001. Those with ACL-R were 4.85 times more likely to go on to have TKR. Apart from age, no other risk factors examined (location, year of surgery, place of residence, income quintile, and RUB) seemed to increase risk of TKR after ACL-R. Patients who underwent ACL-R were 5 times more likely to undergo TKR.

Induced abortion according to immigrants\u2019 birthplace: a population-based cohort study

BackgroundMost abortions occur due to unintended pregnancy. Unintended pregnancies are linked to poor health outcomes. Canada receives immigrants from countries with disparate sexual and reproductive health contexts which may influence abortion rates post-migration. We examined the association between abortion and region of birth and birth order among Canadian immigrants.MethodsWe conducted a population-based person-years (PY) cohort study in Ontario, Canada using administrative immigration (1991–2012) and health care data (1991–2013). Associations between induced abortion and an immigrant’s region of birth were estimated using poisson regression. Rate ratios were adjusted for age, landing year, education, neighborhood income quintile and refugee status and stratified by birth order within regions.ResultsImmigrants born in almost all world regions (N = 846,444) were 2–5 times more likely to have an induced abortion vs. those born in the US/Northern & Western Europe/Australia & New Zealand (0.92 per 100 PY, 95% CI 0.89–0.95). Caribbean (Adjusted Rate Ratio [ARR] = 4.71, 95% CI 4.55–4.87), West/Middle/East African (ARR = 3.38, 95% CI 3.26–3.50) and South American (ARR = 3.20, 95% CI 3.09–3.32) immigrants were most likely to have an abortion. Most immigrants were less likely to have an abortion after vs. prior to their 1st birth, except South Asian immigrants (RR = 1.60, 95% CI 1.54–1.66; RR = 2.23, 95% CI 2.12–2.36 for 2nd and 3rd vs 1st birth, respectively). Secondary analyses included further stratifying regional models by year, age, education, income quintile and refugee status.ConclusionsInduced abortion varies considerably by both region of birth and birth order among immigrants in Ontario.

Prevalence and Predictors of Reincarceration after Correctional Center Release: A Population-based Comparison of Individuals with and without Schizophrenia in Ontario, Canada: Prévalence et prédicteurs de la réincarcération après la libération d'un centre correctionnel : une comparaison dans la population-de personnes souffrant ou non de schizophrénie en Ontario, Canada.

Individuals with schizophrenia are overrepresented in correctional facilities relative to their population-based prevalence. The purpose of this study was to determine the rate and predictors of reincarceration of individuals with schizophrenia after release from correctional facilities. This was a retrospective cohort study that included all people released from Ontario's provincial correctional facilities from January 1 to December 31, 2010. Individuals with schizophrenia were identified using a population-based algorithm. The primary outcome was time to reincarceration. Covariates included sociodemographic characteristics (age, sex, neighborhood income quintile, urban/rural residence), health service utilization (primary care physician visits, psychiatrist visits, psychiatric and nonpsychiatric hospitalizations, emergency department visits), and other clinical comorbidity. Survival analysis was used to examine the association between schizophrenia and reincarceration. Among 46,928 individuals, N = 3,237 (7%) had a diagnosis of schizophrenia. Approximately 67.5% of these individuals were reincarcerated within 5 years following their first release in 2010, compared to 58.8% of individuals without schizophrenia. Individuals with schizophrenia were 40% (HR = 1.39, 95% CI, 1.33 to 1.45) more likely to be reincarcerated following release than the control group after adjusting for demographic characteristics. This association reduced to 8% (HR = 1.08, 95% CI,1.03 to 1.14) after adjusting for prior health service utilization, prior correctional involvement, and comorbidities. Individuals with schizophrenia were more likely to experience reincarceration after release from correctional facilities. This risk is partly explained by prior correctional involvement, health service utilization, and comorbidities. Future research should focus on risk factors predicting the higher reincarceration rate and interventions to reduce correctional involvement.

58 Overweight and obesity in children with autism spectrum disorder: Findings from primary care electronic medical records

Abstract Introduction/Background Paediatric overweight and obesity are important public health problems worldwide. Children with autism spectrum disorder (ASD) may be at increased risk compared to their typically-developing peers; however, prevalence estimates in ASD have varied widely and existing studies have largely been limited by use of an external comparison group. Objectives To compare prevalence of overweight and obesity in children and youth (&amp;lt;19 years of age) with and without ASD, using electronic medical record data from paediatric primary care visits. Design/Methods This was a cross-sectional analysis of EMRPC (Electronic Medical Records Primary Care) data, representing 385 family physicians in 43 clinics in Ontario, Canada. Age- and sex-standardized body mass index (BMI) z-scores were calculated using abstracted heights and weights from the most recent visit between January 2011 and December 2015. Weight status was determined using World Health Organization growth reference standards. ASD was defined using a previously-validated algorithm in EMRPC, based on an ASD-related term in the ‘Cumulative Patient Profile.’ Chi-square test statistics and multinomial logistic regression were used to compare weight status of those with and without ASD. Results In total, 44,625 children and youth were included, 632 [1.42%] with ASD. Distribution of weight status was significantly different between those with and without ASD (p&amp;lt;0.001) [Table 1]. Compared to their typically-developing peers, children with ASD had significantly higher odds of overweight (unadjusted odds ratio [OR] 1.52; 95% confidence interval [CI] 1.24-1.87), obesity (unadjusted OR 2.55 (2.00-3.26) and severe obesity (unadjusted OR 3.09; 95% CI 2.08-4.60); these associations persisted after adjusting for sex, age, neighborhood income quintile and rural residence (Table 2). Conclusion Data from a large primary care database suggest that children with ASD are at substantially increased risk of overweight, obesity and severe obesity. Findings support the need for anticipatory guidance, prevention and management strategies specific to this clinical population. Future work will aim to better understand at what age differences in weight status emerge, and what nutritional, behavioural, or medical factors differentially affect weight status in the ASD population.

Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study

The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction. Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics. At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%). This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

Association between mothers' postoperative opioid prescriptions and opioid-related events in their children: A population-based cohort study.

Postoperative opioid prescriptions may be associated with risks of unintentional poisoning and drug diversion in other household members. The objective of this study was to explore the association between mothers' postoperative opioid prescriptions and incidence of opioid-related events in their children (aged 1 to 24 years). This retrospective cohort study used individually linked administrative health data from Ontario, Canada. A population-based sample of 170,156 opioid-naïve mothers (aged 15 to 64) (see Figure 1) who underwent surgery between 2013 and 2017 in Ontario was linked through birth records to create a cohort of their 283,550 opioid-naïve children (aged 1 to 24). The association between postoperative opioid analgesic prescriptions filled by mothers within seven days of discharge after surgery and opioid-related events (emergency department presentations or inpatient admissions for opioid poisoning, or mental and behavioural disorders attributable to opioid use) in their children within one year of their mother's discharge was assessed. Overall, 60.4% of the children in the cohort had a mother who filled a postoperative opioid prescription. The incidence of opioid-related events in children in the year after a mother's surgery was low overall (n=36/283,550, 0.01%), but higher among children whose mother filled a postoperative opioid prescription (n=29/171,139, 0.02%, vs. n=7/112,411, 0.01%, p=0.02), including in an analysis adjusting for child's age, mother's age, rural residence, neighbourhood income quintile and mother's Charlson comorbidity index score (adjusted odds ratio, 2.42 [95% confidence interval (CI), 1.05 to 5.54], p=0.04). Postoperative opioid prescriptions for mothers may contribute to opioid-related events in their children. These findings further underscore the importance of safe, effective opioid prescribing, as well as of patient and public education about the use, storage and disposal of these medications.

Patient-level Characteristics and Inequitable Access to Inpatient Electroconvulsive Therapy for Depression: A Population-based Cross-sectional Study: Caractéristiques au niveau du patient et accès inéquitable à la thérapie électroconvulsive pour patients hospitalisés.

A variety of patient characteristics drive the use of electroconvulsive therapy (ECT) in depression. However, the extent to which each characteristic influences the receipt of ECT, and whether they are appropriate, is unknown. The aim of this study is to identify patient-level characteristics associated with receiving inpatient ECT for depression. We identified all psychiatric inpatients with a major depressive episode admitted to hospital ≥3 days in Ontario, Canada (2009 to 2017). The association between patient-level characteristics at admission and receipt of inpatient ECT was determined using logistic regression, where a generalized estimating equations approach accounted for repeat admissions. The cohort included 53,174 inpatients experiencing 75,429 admissions, with 6,899 admissions involving ECT (9.2%). Among demographic factors, age was most associated with ECT-younger adults had reduced (OR = 0.30, 95%CI, 0.24 to 0.37; 18 to 25 years) while older adults had increased (OR = 3.08, 95%CI, 2.41 to 3.93; 85+ years) odds compared to middle-aged adults (46 to 55 years). The likelihood of ECT was greater for individuals who were married/partnered, had postsecondary education, and resided in the highest neighborhood income quintile. Among clinical factors, illness polarity was most associated with receiving ECT-bipolar depression had reduced odds of receiving ECT (OR = 0.62, 95%CI, 0.57 to 0.69) The likelihood of receiving ECT was greater in psychotic depression, more depressive symptoms, and incapable to consent to treatment and was reduced with comorbid substance use disorders and several medical comorbidities. Nearly 1 in 10 admissions for depression in Ontario, Canada, involve ECT. Many clinical factors associated with receiving inpatient ECT were concordant with clinical guidelines; however, nonclinical factors associated with its use warrant investigation of their impact on equitable access to ECT.

Implementation of a Physician Incentive Program for 18-Month Developmental Screening in Ontario, Canada

To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada. Population-based cohort study using linked administrative data of children (17-24months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics. Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5years in practice vs ≥21years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening. In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

Is prostate brachytherapy a dying art? Evidence of increasing utilization in Ontario, Canada.

e17608 Background: A worldwide decline in prostate brachytherapy (BT) utilization has been reported in multiple health care settings/jurisdictions, despite strong evidence for efficacy and safety compared to other alternatives. We sought to evaluate contemporary trends in BT, EBRT and prostatectomy utilization in a publicly funded healthcare system. Methods: Men with localized prostate cancer diagnosed and treated between 2007 and 2017 in Ontario, Canada were identified using administrative data from the Institute for Clinical Evaluative Sciences. Men were coded to have received EBRT, BT (monotherapy or boost) or prostatectomy as initial definitive management. Trends were evaluated using the Cochran-Armitage test. Multivariate logistic regression was used to evaluate patient-, tumour-, and provider-factors on treatment utilization over time. Results: 57,655 men were included in our study. Prostate BT use increased from 7.5% of all treatments in 2007 to 15.4% in 2017 ( p&lt; 0.01), primarily due to increased use of BT boost (1.7% in 2007 to 10.4% in 2017, p &lt; 0.01). Relative to EBRT, BT use increased from 17.9% in 2007 to 28.1% in 2017 ( p&lt; 0.01). On multivariate analysis (MVA), BT boost use increased by 28% per year (OR 1.28, 95% CI 1.26–1.31, p&lt; 0.01) and BT monotherapy use increased by 12% per year (OR 1.12, 95% CI 1.10–1.14, p&lt; 0.01), offset by decreasing prostatectomy use (12% per year, OR 0.88, 95% CI 0.87–0.89, p&lt; 0.01). Comparing BT to EBRT, the strongest predictors of receiving BT were geographic residence (OR 27.6, 95% CI: 20.3–37.6, p&lt; 0.01 between highest/lowest Local Health Integration Networks) and whether the first consulting radiation oncologist performed BT (OR 3.46, 95% CI: 3.15–3.80, p&lt; 0.01). Other significant factors predicting BT use vs. EBRT included lower age, lower PSA, lower Charlson comorbidity score and increasing neighborhood income quintile. Low-intermediate, high-intermediate and high-risk groups were predictive of receiving BT boost, whereas BT monotherapy was predominantly used in low-risk disease. Conclusions: Contrary to trends observed in other jurisdictions, utilization of prostate BT is increasing over time in Ontario. However, substantial variation in BT utilization was found, strongly driven by both geographic region and radiation oncologist BT practice patterns. To our knowledge, this is the first study to report increasing BT utilization in the era of dose-escalated EBRT, with Ontario potentially serving as a model to promote BT utilization elsewhere.

Population-Based Estimates of Health Care Utilization and Expenditures by Adults During the Last 2 Years of Life in Canada’s Single-Payer Health System

Measuring health care utilization and costs before death has the potential to initiate health care improvement. To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada's single-payer health system. This population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015. Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents' postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure. Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups. Among 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates. In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.

Primary care reform and funding equity for mental health disorders in Ontario: a retrospective observational population-based study.

Mental health disorders are associated with high morbidity and reduced life expectancy, and are largely managed in primary care. We sought to assess the equity of distribution of new alternative payment models and teams introduced under primary care reform in Ontario for patients with mental health disorders. We conducted a retrospective observational study using population-level administrative data for insured Ontario adults (age ≥ 18 yr) to identify all primary care payments to physicians that were allocated to individual patients in 2002/03 and 2011/12. We identified patients with mental health disorders using validated algorithms, and modelled the relations between per capita primary care costs and mental health disorders over time, stratified by type of mental health or substance use disorder and type of primary care payment. In an adjusted model, we adjusted for age, sex, rurality, neighbourhood income quintile, immigrant status, comorbidity and primary care model. For comparative purposes, we also examined the distribution of primary care payments for people with diabetes mellitus. Total per capita primary care payments increased more slowly over the study period for patients with mental health disorders (62.0%) than for the general population (88.3%). Total payments for patients with substance use disorders increased by 142.7%, largely owing to urine drug testing in opioid substitution clinics. Adjusted total payments for those with versus without mental health disorders decreased by 10% between 2002/03 and 2011/12, driven by lower alternative payments. Similar decreases, also driven by lower alternative payments, were found for all mental health disorder subgroups except substance use and for diabetes. Payment and team reforms were associated with inequitable resource allocation to people with mental health disorders. The findings suggest the need for monitoring reforms for their impact on high-needs populations and making appropriate adjustments.

Association of Immigrant and Refugee Status With Risk Factors for Exposure to Violent Assault Among Youths and Young Adults in Canada

Immigrant populations continue to grow across Western countries. Such populations may face vulnerabilities that contribute to the risk of experiencing violent injury. Youths are at disproportionate risk compared with other age groups, and such violence may be preventable with appropriately targeted injury prevention strategies. To examine the association of immigrant or refugee status and immigration-related factors with the experience of assault. This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal, single-payer health insurance plan. All youths and young adults aged 10 to 24 years (hereafter referred to as youths) residing in Ontario from January 1, 2008, to December 31, 2016, were eligible to participate. Data were analyzed from April 13, 2017, to January 6, 2020. The main exposure was immigrant status. Secondary exposures were immigration-related factors, including visa class, time since immigration, and region and country of origin. The main outcome consisted of violent injuries requiring acute care (emergency department visit or hospitalization) or causing death. Poisson regression models were used to estimate rate ratios for injuries. A total of 22 969 443 person-years were included in the analysis (51.3% male and 48.7% female participants). Compared with nonimmigrants, a greater proportion of immigrants lived in the lowest neighborhood income quintile (30.5% vs 18.2%) and urban areas (98.9% vs 87.7%). Among immigrants, 17.9% were refugees. Rates of violent injuries experienced were 549.0 (95% CI, 545.7-552.2) per 100 000 person-years in nonimmigrant youth, 225.0 (95% CI, 219.4-230.7) per 100 000 person-years in nonrefugee immigrant youth, and 525.4 (95% CI, 507.2-544.1) per 100 000 person-years in refugee immigrant youth. The rates of violent injury among nonrefugee and refugee immigrants were lower than among nonimmigrants (nonrefugee adjusted rate ratio [aRR], 0.41 [95% CI, 0.38-0.43]; refugee aRR, 0.82 [95% CI, 0.76-0.89]). Older age (oldest vs youngest aRR, 6.90 [95% CI, 6.53-7.29]), male sex (aRR, 2.60 [95% CI, 2.52-2.68]), and low neighborhood income (aRR, 2.42 [95% CI, 2.32-2.53]) were associated with violent injury risk. Rates of experiencing assault were lowest among South Asian (aRR, 0.33 [95% CI, 0.30-0.37]) and East Asian (aRR, 0.23 [95% CI, 0.19-0.26]) immigrants. Only Somali immigrants experienced higher assault rates (712.0 [95% CI, 639.3-805.3] per 100 000 person-years) compared with nonimmigrants. Most injuries (79.9%) were from being struck, followed by being cut (5.9%). The low rates of assault experienced by immigrants, including refugees, compared with nonimmigrants suggests that Canadian immigrant settlement supports and cultural factors may be protective against the risk of experiencing assault.

Evaluation of opioid discontinuation after non-orthopaedic surgery among chronic opioid users: a population-based cohort study

BackgroundMany patients use opioids chronically before surgery; it is unclear if surgery alters the likelihood of ongoing opioid consumption in these patients. MethodsWe performed a population-based matched cohort study of adults in Ontario, Canada undergoing one of 16 non-orthopaedic surgical procedures and who were chronically using opioids, defined as (1) an opioid prescription that overlapped the index date and (2) either a total of 120 or more cumulative calendar days of filled opioid prescriptions, or 10 or more prescriptions filled in the prior year. Each surgical patient was matched based on age, sex, Charlson comorbidity index, and daily preoperative opioid dose to three non-surgical patients who were also chronic opioid users. The primary outcome was time to opioid discontinuation. ResultsThe cohort included 4755 surgical and 14 265 matched non-surgical patients. After adjustment for sociodemographic characteristics and comorbidities, surgery was associated with an increased likelihood of opioid discontinuation (adjusted hazard ratio: 1.34, 95% confidence interval [CI]: 1.27, 1.42). Among surgical patients, factors associated with a reduced odds of discontinuation included a mean preoperative opioid dose above 90 morphine milligram equivalents (adjusted odds ratio [aOR]: 0.39; 95% CI: 0.32, 0.49) or filling a prescription for oxycodone (aOR: 0.73; 95% CI: 0.56, 0.98). Receipt of an in-patient Acute Pain Service consultation (aOR: 1.34; 95% CI: 1.06, 1.69) or residing in the highest neighbourhood income quintile (aOR: 1.35; 95% CI: 1.04, 1.79) were associated with a greater odds of opioid discontinuation. ConclusionsFor chronic opioid users, surgery was associated with an increased likelihood of discontinuation of opioids in the following year compared with non-surgical chronic opioid users.