Physician Billing Research Articles

Projected health and economic outcomes of extending public funding of pharmacy services to include administration of Pneu23 and Td/Tdap immunizations by pharmacy practitioners in New Brunswick.

Although legislation permits New Brunswick pharmacy professionals to administer a wide range of immunizations, public funding for these services is currently limited to immunizations against influenza and COVID-19 and was recently extended to include pneumococcal immunization (Pneu23) in individuals aged 65 years or older. We used administrative data to project health and economic outcomes associated with the current Pneu23 program and with extension of public funding to include: 1) younger adults aged 19 years or older in the Pneu23 program, and 2) tetanus boosters (Td/Tdap). Two model scenarios were compared: a Physician-Only model in which physicians remain the only practitioners to administer publicly funded Pneu23 and Td/Tdap, and a Blended model in which this service is also provided by pharmacy professionals. Immunization rates by practitioner type were projected based on physician billing data accessed via the New Brunswick Institute for Research, Data and Training in conjunction with trends observed with influenza immunization by pharmacists. These projections were used along with published data to estimate health and economic outcomes under each model. Public funding of Pneu23 (65+), Pneu23 (19+) and Td/Tdap (19+) administration by pharmacy professionals is projected to yield increased immunization rates and physician time savings compared with the Physician-Only model. Public funding of Pneu23 and Td/Tdap administration by pharmacy professionals in those aged ≥19 years would result in cost savings, owing primarily to productivity losses avoided in the working age population. Increased immunization rates, physician time savings and cost savings may be realized if public funding were extended to include administration of Pneu23 in younger adults and Td/Tdap, by pharmacy practitioners.

Abstract C098: "Am I at risk for cervical cancer?": Racial disparity implications of an unexpected relationship between chronic conditions and precancerous lesions

Abstract Objective: Cervical cancer is a highly preventable malignancy caused by HPV that begins with the development of precancerous lesions (high risk cervical intraepithelial neoplasia grades 2 or 3 - hrCIN). As cancer is a metabolic disease, individuals with metabolic conditions such as diabetes, high cholesterol (hcho) and high blood pressure (hbp) may be at higher risk of developing hrCIN. Given the higher prevalence among Black women, we sought to determine whether these metabolic conditions increase the risk of hrCIN differentially by race. Methods: We used data from hospital and physician billing claims for any CIN diagnosis occurring at the Virginia Commonwealth University Health System (VCUHS) from 01/01/2014 through 12/04/2021, along with respective clinical and sociodemographic characteristics at the time of diagnosis. We estimated the risk of high-grade dysplasia (CIN2+ versus CIN1) among women with various metabolic diseases, using logistic regression (LR) with a backward selection approach (removing terms with p ≥ 0.2 and adding those with p < 0.1) to identify most relevant confounding factors. Results: There were 2,761 women diagnosed with CIN 1, 2, 3, and unspecified dysplasia of the cervix uteri with respective prevalence of 30%, 45%, 11%, and 14%. The prevalence of hrCIN did not vary by race (48% versus 52% for non-Latina (nL)-whites versus nL-Blacks respectively). Of the variables included in the LR model (age, marital status, religion, preferred language, insurance status, Body Mass Index, HIV, HPV, presence of bacterial vaginosis, hypertension, cholesterol, diabetes, pulmonary conditions, arthritis, heart conditions, pregnancy status, parity, smoking, alcohol, and previous cancer diagnoses), only pregnancy status, diabetes, hypertension, cholesterol, insurance, language, pulmonary conditions, and HPV remained in the final LR model. We identified an interaction between hypertension and cholesterol (p=0.03) where the odds of a hrCIN among women with both, hypertension, and cholesterol, were more than twice compared to women with neither comorbidity (OR=2.2, 95%CI: 1.1, 4.3). Stratified by race, the elevated risk of hrCIN was only significant among nL-Black women (p=0.05, OR=2.9, 95%CI: 1.1, 8.6). Conclusions: Despite no apparent difference in the incidence of hrCIN by race in this dataset, our analysis revealed an excess risk of hrCIN that was only present for Black women with both hypertension and hypercholesterolemia. These comorbidities are both overrepresented in nL-Blacks and are associated with low grade systemic inflammation, which may promote HPV persistence and progression to hrCIN. If replicable, this association deserves further investigation to assess its biological underpinnings and potential as a point of intervention to reduce the risk of CIN progression and cervical cancer. Citation Format: Shreya R. Raman, Stephanie A. Sullivan, Robert A. Winn, Katherine Y. Tossas. "Am I at risk for cervical cancer?": Racial disparity implications of an unexpected relationship between chronic conditions and precancerous lesions [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C098.

Physician Practice in Ontario Nursing Homes: Defining Physician Commitment.

To characterize the practice profile of nursing home (NH) physicians in Ontario, Canada. Population-based cross-sectional study. A total of 1527 most responsible physicians (MRPs) across 626 NHs in Ontario, Canada, for the calendar year,2017. We examined physician services within all publicly regulated and funded NH facilities. Descriptive summaries were generated to characterize MRPs and their practice patterns by the physician's primary practice location, the NH facility size, and the proportion of physician billings that occurred within NHs. Community sizes were classified into quintiles based on population size and assigned as urban or rural. The number of ministry-designated NH beds were assessed by quintiles to examine physician services by facility size. We also assessed the proportion of physician billings within NHs by quintiles. MRPs tended to be older, male, and practice family medicine. The majority of MRPs practiced in communities with populations exceeding 100,000 residents, although physicians with greater NH billings tended to practice in rural locations. The mean number of NH residents that a physician was MRP for was positively associated with the community size. Physicians provided care for more NH residents than they were assigned most responsible. Fifty-one percent of physicians were MRP for 90% of all NH residents. Our work provides an exemplar for characterizing physician commitment in NHs, using 2 approaches, according to the NH specialist model. We demonstrated the medical practice characteristics, locations, and billing patterns of physicians within Ontario NHs. Future work can investigate the association between physician commitment and the quality of care provided to NH residents. A greater understanding of physician commitment may lead to the development of quality metrics based on physician practice patterns.

Abstract 14016: Marked Geographic Variation in Atrial Fibrillation Ablation Rates in a Universal Single Payer Health Care System

Introduction: Atrial fibrillation (AF) ablation is increasingly commonly performed for patients with symptomatic AF. In Canada, AF ablation occurs at specialized electrophysiology centers (“EP centers”), which are clustered in major urban centers. Hypothesis: People with AF who live closer to an EP center are more likely to undergo an AF ablation. Methods: Data was compiled from Ontario Health datasets (e.g. emergency department (ED) visits, hospital discharges, physician billing) and Canadian census data for people presenting to an ED in Ontario, Canada with a new diagnosis of AF between 2007-16. The primary outcome was ablation within one year of the index ED visit. Secondary outcomes include ablation at two years. Multivariate logistic regression was conducted to assess the relationship between distance to EP centers and likelihood of ablation. We also studied ablation frequency in relation to material deprivation (e.g. income, housing quality and education). Geospatial analyses were performed using QGIS. Results: Of the 135,681 people with newly diagnosed AF, 3911 (2.9%) had an ablation within one year of AF diagnosis and 5827 (4.3%) within two. There was a significant inverse relationship between a doubling of distance to the closest EP center and ablation within one year (OR: 0.93, 95% CI: 0.91-0.94), and two years (OR: 0.95, 95% CI: 0.94-0.97). Higher deprivation (measured in standard deviations from the mean) was associated with significantly less ablation at one year (OR: 0.89, 95% CI: 0.85-0.92). There was wide regional variation with relatively low rates near the largest urban center (Figure 1). Conclusions: Living further from an EP center and greater material deprivation are associated with lower AF ablation rates. Ablation rates vary by region, with the highest rates not consistently observed in areas most concentrated with EP centers. Figure 1. Age and sex adjusted AF ablation rates per 100,000 patients within a year of AF diagnosis in Ontario, Canada

Treatment pattern trends of medications for type 2 diabetes in British Columbia, Canada

IntroductionSeveral new oral drug classes for type 2 diabetes (T2DM) have been introduced in the last 20 years accompanied by developments in clinical evidence and guidelines. The uptake of new...

Impact of the COVID-19 Pandemic on Virtual Care: A Major Shift for Physicians and Patients.

To reduce the spread of COVID-19 in Canada, patients receiving physician services experienced a significant shift to virtual appointments by telephone, video conference and online messaging as many physician visits moved from in-person to virtual delivery. The Canadian Institute for Health Information's analysis of the physician billing data in five provinces (Ontario, Manitoba, Saskatchewan, Alberta and British Columbia) shows that during the first year of the pandemic in 2020, up to twice as many physicians provided care virtually compared to 2019. At the same time, the rate at which patients received virtual services quadrupled. Furthermore, data from the 2021 Commonwealth Fund (CMWF) survey of older adults show that almost twice as many Canadian seniors (71%) had a virtual appointment with a doctor or healthcare provider compared to seniors in other CMWF countries (39%). Going forward, virtual care remains a significant mode of delivery and has important implications for the future of patient care and the relationships between patients and providers.

Use of virtual care in ophthalmology in Ontario, Canada in 2020 during the COVID-19 pandemic

ObjectifExaminer l'utilisation des soins virtuels en ophtalmologie et les tendances à cet égard tout en explorant les facteurs connexes au sein d'un système de soins de santé universel pendant la pandémie de COVID-19 en 2020. NatureÉtude transversale. ParticipantsOntariens admissibles à l'Assurance-santé de l'Ontario. MéthodesNous avons eu recours aux données de facturation des médecins pour la période de 2017 à 2020 afin de comparer les soins virtuels aux soins en personne. Une analyse de régression logistique a servi à examiner les facteurs en lien avec le recours aux soins virtuels. RésultatsLa hausse des visites virtuelles en ophtalmologie s'est produite immédiatement après l'adoption de la directive gouvernementale visant à réduire les activités en clinique et la mise en place d'un nouveau code de facturation pour les visites virtuelles (17,6 %). Les visites virtuelles ont atteint un sommet 2 semaines plus tard (55,8 %) pour diminuer immédiatement une fois la directive annulée (24,2 %). Entre mars et décembre 2020, les visites virtuelles étaient plus fréquentes chez les femmes (11,6 %) que chez les hommes (10,3 %), ainsi que chez les patients de < 20 ans (16,4 %) et de 20 à 39 ans (12,3 %) que chez ceux de 40 à 64 ans (10,8 %) et de ≥ 65 ans (10,6 %). Le recours aux visites virtuelles était similaire chez les patients des quartiers défavorisés (10,9 %) et des autres quartiers (11,1 %). Le taux de consultation virtuelle a été le plus élevé chez les porteurs d'une infection aiguë (14,2 %) ou d'un diagnostic sans caractère d'urgence (16,2 %), et le plus bas chez les patients qui présentaient une rétinopathie (4,2 %). Les ophtalmologistes de sexe féminin (15,4 %) ont prodigué des soins virtuels plus fréquemment que leurs collègues masculins (9,9 %). Ce sont les ophtalmologistes de 60 à 69 ans (13,1 %) qui ont prodigué le plus de soins virtuels (< 40 ans: 11,3 %; 40 à 49 ans : 11,0 %; 50 à 59 ans : 10,0 % et ≥ 70 ans : 7,7 %). Plusieurs modèles de régression logistique ont donné des résultats similaires. ConclusionAprès une hausse significative pendant la période initiale de la pandémie, l'utilisation des soins virtuels en ophtalmologie a ensuite diminué. Le recours aux soins virtuels variait significativement en fonction des caractéristiques des patients et des ophtalmologistes.

S476 PPI Discontinuation Rates in Patients With Esophageal Strictures

Introduction: In March 2018, Canadian physicians received notification of new guidelines encouraging PPI deprescription in most patients with GERD.1 An adverse event from PPI discontinuation is rebound acid reflux leading to esophageal stricture. This study aims to quantify the proportion of patients with esophageal strictures requiring endoscopic dilation who had previously discontinued their PPI medication before and after implementation of these new guidelines. Methods: This retrospective cohort study analyzed patients who received an esophageal dilation between the years of 2015-2017 (group 1) and 2019-2021 (group 2). The outcome of interest was the rate of PPI discontinuation between the two groups. All patients from two gastroenterology practices who received esophageal dilations to treat symptomatic strictures during these years were identified for the study using physician billing codes. Information regarding demographics, medications, and previous GI diagnoses were collected using endoscopy reports and medication records from the local hospital medical database. We defined PPI discontinuation as either a 50% dose reduction, frequency reduction or complete medication discontinuation at the time of endoscopic dilation compared to the established PPI therapy from the previous 3 months or longer. The information was coded using a standardized data sheet and entered into SPSS for data analysis. Results: Data were collected from 223 esophageal dilations. The average patient age of the sample was 58.8 years old. The sample consisted of 124 males (56%) and 99 females (44%). Patients receiving dilations from group 1 (2015-17) had a PPI discontinuation rate of 6.5% (10/152 cases). Meanwhile, patients from group 2 (2019-21) had a PPI discontinuation rate of 24% (17/71 cases). These results were statistically significant (p<0.001) following Chi-Squared analysis (Table). Conclusion: There was a higher rate of PPI discontinuation in patients undergoing esophageal dilation after new PPI deprescription guidelines were sent to physicians. PPI deprescription recommendations may have unintended consequences. Further research is necessary to understand the risks and benefits of discontinuing PPI therapy. 1- https://tinyurl.com/2p8t9a7b Table 1. - Fisher Exact test: p value <0.001 Chi-Squared PPI Discontinued PPI Non-discontinued Total Group 1 10 142 152 Group 2 17 54 71 Total 27 196 223

How state surprise billing protections increased ED visits, 2007-2018: potential implications for the No Surprises Act.

The No Surprises Act took effect in 2022 and prevents patients from receiving unexpected emergency department (ED) out-of-network physician bills from in-network hospitals and restricts out-of-network co-payments to in-network co-payment levels. By studying similar state bans, we examine whether the large reduction in out-of-pocket payments under bans will have an unintended consequence of an increase in ED visits and spending. We examine 16 million nonelderly, fully funded, privately insured health maintenance organization (HMO) enrollees between 2007 and 2018 from 15 states with balance billing bans for HMO ED visits and 16 states without bans as the control group. Using MarketScan data, we conduct an event study analysis and a difference-in-difference analysis of the impact of state balance billing bans on the probability of an ED visit. We use a 2-part expenditure model to estimate the impact on spending. By analyzing 15 state-level bans, we find that the bans reduced spending per visit by 14% but spurred a demand response, an increase of 3 percentage points in ED visits, which wiped away the cost savings. Based on an ED severity index, these extra ED visits were 9% less urgent than prior to the bans. We predict that the federal ban will result in $5.1 billion in savings but 3.5 million more ED visits at $4.2 billion in extra spending per year, largely negating expected savings. Health plans must be prepared to manage this spike in ED visits as the No Surprises Act takes effect.

Local Prostate Radiation Therapy and Symptomatic Local Events in De Novo Metastatic Prostate Cancer

PurposeLocal prostate radiation therapy (LPRT) for low-burden metastatic prostate cancer (mPCa) improves overall survival and is the standard of care. The role of LPRT in reducing symptomatic local events (SLE) remains unclear. We aimed to identify SLE risk factors and to evaluate the association between LPRT and SLE in mPCa. Methods and MaterialsWe conducted a retrospective, population-based cohort study of patients initially diagnosed with mPCa between 2005 and 2016 in a cancer registry. Patient, tumor, and treatment characteristics were obtained from chart review and the cancer registry. The coprimary endpoints were genitourinary (GU) and gastrointestinal (GI) SLE, identified by physician billing claims between 2004 and 2017 for diagnostic or therapeutic procedures potentially related to GU and GI SLE. The effect of LPRT on SLE was evaluated using both recurrent event (Andersen-Gill model) and time-to-first-event sequential landmark analyses. Risk factors for SLE were assessed by multivariable Cox regression. LPRT was defined as ≥40 Gy within 1 year of diagnosis. Metastatic burden was defined per the STAMPEDE trial. ResultsOf 1363 patients, 46 (3.4%) received LPRT. Median follow-up was 27.3 and 28.9 months in the control and LPRT groups, respectively. LPRT was associated with less recurrent GU SLE (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.17-0.67; P = .002), upper tract obstruction (HR, 0.20; 95% CI, 0.05-0.84; P = .03), and cystoscopy (HR, 0.38; 95% CI, 0.15-0.96; P = .04). Metastatic burden was not associated with SLE. ConclusionsLPRT in mPCa was associated with less recurrent GU SLE, specifically for upper tract obstruction and cystoscopy.

Differences in Practice Patterns and Payments for Female and Male Dermatologists: A Canadian Population-Based Study Over 3 Decades.

Canada's fee-for-service physician reimbursement system, where a set rate is provided for each service, suggests that a physician sex pay gap should not exist. However, recent evidence has questioned this presumption. To characterize trends in demographics and billing, overall and by sex, for dermatologists compared to other medical and surgical specialty groups in Ontario, Canada. Using population-based data, analysis of physician billing and clinical activity from Ontario, Canada, over 27 years (1992-2018) was performed. Multilevel regression models were used to examine unadjusted and adjusted differences in payments between females and males over time, while controlling for age, distinct patients seen, patient visits, and full-time equivalent. A total of 22 389 physicians were included in the analyses, including 381 dermatologists. The proportion of female dermatologists increased from 32% in 1992 to 46% in 2018. Dermatologists' median Ontario Health Insurance Plan (OHIP) payments were $415 340 (IQR: 285 630-566 580) in 1992 compared to $296 750 (IQR: 164 480-493 180) in 2018. Male dermatologists' OHIP payments were 20% more than their female counterparts across the entire study period. After adjusting for practice volumes, there was no significant pay gap amongst female and male dermatologists (P = .42); however, the sex pay gap remained significant for the other specialty groups (P < .001). From 1992 to 2018, dermatologists on average saw 19% fewer distinct patients per year and 15% fewer visits per patient. The overall sex pay gap within medical dermatology can be attributed to differences in practice patterns, whereas the sex pay gap remained significant in the other specialty groups.

Commentary: From Mixtapes to Playlists - Evolving Options for Capturing Diagnoses in Canadian Physicians' Data.

Physician billing claims are rich sources of administrative health data. However, diagnostic codes in billing claims are drawn from the International Classification of Diseases, Ninth Revision (WHO & International Conference for the Ninth Revision of the International Classification of Diseases 1977), which has not been updated by the World Health Organization in three decades. With its updated and expanded content and its digital tooling, the International Classification of Diseases 11th Revision (ICD-11) (WHO n.d.a.) could be considered for this purpose. Primary care practitioners have always found the ICD inadequate for their needs. This may change with ICD-11, with which the International Classification of Primary Care (ICPC) (van Boven and Ten Napel 2021) is more closely aligned. ICD-11, ICPC and the Systematized Nomenclature of Medicine Clinical Terms present evolving options for capturing diagnoses in physician data.

Leaving the Walkman and ICD-9 Behind: Modernizing the Disease Classification System Used by Canadian Physicians.

The International Classification of Diseases, Ninth Revision (ICD-9) was released in the 1970s and adopted in Canada for physician billing claims in 1979 (CIHI n.d.b.; WHO & International Conference for the Ninth Revision of the International Classification of Diseases 1977). ICD-9 is no longer adequate for representing our modern healthcare environment and patient needs. We summarize the findings from a small survey of ICD-9 users across Canada – such as family physicians, researchers and decision makers – who describe the limitations of ICD-9 and the features that they would desire in a new or updated classification system.

The same, only different: Using physician billing data from four provincial payment systems to describe family physician practice patterns in Canada.

ObjectivesIn Canada physician payment systems and associated billing data vary across provinces. We used linked billing data to develop comparable measures of family physician (FP) service volume, continuity, and comprehensiveness in each of four provinces, with the goal of describing changing patterns over time, relevant to workforce planning policy. ApproachWe accessed linked population and physician registry data, vital statistics, physician billing data, hospital and emergency department records, and (where available) laboratory and prescription drug records in four Canadian provinces from 1996/7 to 2017/8. We tracked changes in primary care physician service volume (patient visits), continuity, and comprehensiveness over two decades, and explored the impacts of career stage and graduation cohort on patterns observed. We also quantified changes in the volume of services that required FP coordination, review, administration, and/or follow-up, reporting changes in service volume per-capita, per community-based family physician and per physician visit. ResultsVisit volume and continuity per provider fell over time in the four provinces examined. Visits increased with years in practice until mid-to-late-career and declined into end-of-career. We found no relationship between graduation cohort and practice volume, continuity, or comprehensiveness of care. Over this time period, the number of FPs per-capita has grown, but the number in comprehensive, community-based practice has remained constant. While primary care visits have declined, the number of prescriptions, lab tests, emergency department visits, and specialist visits per capita have all increased. When expressed per community-based FP, and particularly per community-based FP patient visit, the increases in workload range from 36.1% for lab tests to 55.0% for ED follow-up. Increases in service volume are greatest among patients ages 80 and older, a rapidly-growing population segment. ConclusionLinked data capturing changes in practice patterns and workload suggest that even with an increasing per-capita supply of family physicians, additional resources will be needed to ensure all patients can access comprehensive primary care. Information on the various roles family physicians fill and demographic change will strengthen workforce planning.

Disparities in adherence to diabetes screening guidelines among males and females in a universal care setting: A population-based study of 1,389,697 adults.

ObjectivesNational guidelines recommend that all adults over the age of 40 years undergo screening for diabetes at least once every 3-years. We examined the association between sex and adherence to diabetes screening after accounting for age, urban/rural residence and material deprivation. We also examined the subsequent incidence of prediabetes and diabetes in adherent and non-adherent individuals. ApproachOur study is based on a retrospective population-level inception cohort of adults aged 40 - 79 years without pre-existing diabetes or cardiovascular disease on April 1, 2013. Data on hospitalizations, emergency department visits, ambulatory clinic visits, physician billing claims, pharmaceutical claims, centralized laboratory data, vital statistics death registry, and census data at the neighbourhood level were linked at the patient level for years 2013 to 2020. Adherence during a 3-year screening period (2013 – 2016) and prediabetes and diabetes during a 4-year follow-up period were examined. Multivariate logistic regression was used to examine the adjusted association between sex and adherence. ResultsAmong 1,389,697 individuals (49.2% male, 50.8% female) adherence rates were 69.9% in males and 79.8% in females. Sex-differences in adherence were largest in younger individuals (58.0% and 72.6% and in males and females aged 40-44 years, respectively) and consistent across rural/urban residence and material deprivation categories. Females were more adherent (adjusted odds ratio 1.93; 95% confidence interval 1.90 to 1.97) than males. Among adherent males and females, 65.3% and 64.8% had at least one Haemoglobin A1C, respectively during the screening period. During the follow-up period, prediabetes and diabetes rates among males who were adherent were 25.9% and 5.2%, compared to 8.8% and 2.1% among non-adherent males; and 20.2% and 2.9% among adherent and 7.3% and 1.3% among non-adherent females. ConclusionsDespite lower rates of adherence to screening, males have higher rates of prediabetes and diabetes compared to females. Our study highlights the need to develop education campaigns and targeted interventions at the local and population level to raise awareness and improve diabetes screening rates in young people, especially males.

Community trial evaluating the integration of Indigenous healing practices and a harm reduction approach with principles of seeking safety in an Indigenous residential treatment program in northern Ontario

ObjectiveOur primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS.MethodsWe observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 – March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients’ health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40.ConclusionsOur results indicate that IHSS positively influenced program completion but had no significant effect on health service use.Trial registrationThis study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.

Are Women with Antecedent Low-Grade Cytology and

ObjectiveTo determine the baseline and cumulative risks of cervical intraepithelial lesion grade 3 (CIN3) and invasive cervical cancer in patients with <CIN2 colposcopy findings after a low-grade screening cytology finding (atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion [LSIL]). MethodsBy linking administrative databases, including cytology, pathology, cancer registries, and physician billing history, a population-based cohort study was performed on participants with <CIN2 initial colposcopy results after a low-grade antecedent cytology finding, between January 2012 and December 2013. Three and 5-year risks of CIN3 and invasive cervical cancer were generated using Kaplan-Meier survival analysis. ResultsAmong the 36 887 participants included in the study, CIN3 incidence based on referral cytology were as follows at 3 and 5 years, respectively: normal, 0.7% and 0.9%; ASCUS, 4.31% and 5.6%; and LSIL, 5.9% and 7.2%. Three- and 5-year incidence of invasive cancer were 0% and 0.02% for normal cytology, 0.08% and 0.11% for ASCUS, and 0.04% and 0.07% for LSIL, respectively. Stratifying risk by biopsy result at initial colposcopy, 3- and 5-year CIN3 incidences were 2.85% and 3.81% with a negative biopsy, 7.09% and 8.32% with an LSIL biopsy, and 4.11% and 5.2% when no biopsy was done, respectively. Three- and 5-year incidence of invasive cancer was 0% and 0.05% after a negative biopsy, 0% and 0% after LSIL biopsy, and 0.05% and 0.08% when no biopsy was done, respectively. ConclusionWhen initial colposcopy is done after a low-grade screening cytology result and <CIN2 is identified, the risk of CIN3 and invasive cancer is low, particularly when biopsies indicate LSIL. Surveillance strategies should balance the likelihood of detecting CIN3 with the potential harms over management with too frequent screening or colposcopic interventions in low-risk patients.

Quality of end-of-life care for women with gynecologic malignancies in Ontario, Canada: A 14-year population-based retrospective analysis (132)

Objectives: Tracking population-based quality indicators of supportive and aggressive end of life (EOL) care may provide insight into the success of EOL interventions and health resource utilization. We examined patterns of EOL care in patients with gynecologic cancers over 14 years in Ontario, Canada. Methods: We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2005 to 2018 using linked administrative healthcare data (Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan physician billing claims, homecare databases). Quality indices included emergency department (ED) use, admissions to hospital or intensive care unit (ICU), chemotherapy in the last 14 days of life, physician or palliative care home visits, and death in hospital, as well as previously defined aggregate measures of aggressive or supportive care. Descriptive statistics and crude incidence rates of each indicator were calculated. A multivariable logistic regression model was created to examine the relationship between sociodemographic and patient factors and receipt of aggressive and supportive care. Results: The cohort included 1 7,405 women; 51% died of ovarian cancer, 30% uterine cancer, 12% cervical cancer, and 6.5% vulvar or vaginal cancers (VVC). During the study period, death rates in hospitals decreased from 48% to 39%, while supportive care indices increased from 47% to 71%, and aggressive care indices remained stable (18%). Within the last 30 days of life, 53% were hospitalized, 5.6% were admitted to ICU, and 64% accessed palliative homecare, while within the last 14 days of life, 33% visited the ED, and 4.5% received chemotherapy. Patients with VVC demonstrated lower rates of both aggressive (11%) and supportive care (58%) compared to other cancer subtypes. On multivariable analyses, patients were significantly more likely to receive aggressive EOL care if they were <50 years of age, had a modified Deyo-Charlson Comorbidity Index score of 0, had uterine or ovarian cancer, or lived in a smaller community (<100,000) or a neighborhood in the lowest three income quintiles. Patients were less likely to receive supportive EOL care if they were ≥70 years of age, had a non-ovarian gynecologic malignancy, or lived in the lowest two income quintiles. Objectives: Tracking population-based quality indicators of supportive and aggressive end of life (EOL) care may provide insight into the success of EOL interventions and health resource utilization. We examined patterns of EOL care in patients with gynecologic cancers over 14 years in Ontario, Canada. Methods: We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2005 to 2018 using linked administrative healthcare data (Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan physician billing claims, homecare databases). Quality indices included emergency department (ED) use, admissions to hospital or intensive care unit (ICU), chemotherapy in the last 14 days of life, physician or palliative care home visits, and death in hospital, as well as previously defined aggregate measures of aggressive or supportive care. Descriptive statistics and crude incidence rates of each indicator were calculated. A multivariable logistic regression model was created to examine the relationship between sociodemographic and patient factors and receipt of aggressive and supportive care. Results: The cohort included 1 7,405 women; 51% died of ovarian cancer, 30% uterine cancer, 12% cervical cancer, and 6.5% vulvar or vaginal cancers (VVC). During the study period, death rates in hospitals decreased from 48% to 39%, while supportive care indices increased from 47% to 71%, and aggressive care indices remained stable (18%). Within the last 30 days of life, 53% were hospitalized, 5.6% were admitted to ICU, and 64% accessed palliative homecare, while within the last 14 days of life, 33% visited the ED, and 4.5% received chemotherapy. Patients with VVC demonstrated lower rates of both aggressive (11%) and supportive care (58%) compared to other cancer subtypes. On multivariable analyses, patients were significantly more likely to receive aggressive EOL care if they were <50 years of age, had a modified Deyo-Charlson Comorbidity Index score of 0, had uterine or ovarian cancer, or lived in a smaller community (<100,000) or a neighborhood in the lowest three income quintiles. Patients were less likely to receive supportive EOL care if they were ≥70 years of age, had a non-ovarian gynecologic malignancy, or lived in the lowest two income quintiles.

Physician home visits in Ontario: a cross-sectional analysis of patient characteristics and postvisit use of health care services.

Background:It is unknown how much of current physician home visit volume is driven by low-complexity or low-continuity visits. Our objectives were to measure physician home visit volumes and costs in Ontario from 2005/06 to 2018/19, and to compare patient characteristics and postvisit use of health care services across home visit types.Methods:This was a retrospective cross-sectional study using health administrative data. We examined annual physician home visit volumes and costs from 2005/06 to 2018/19 in Ontario, and characteristics and postvisit use of health care services of residents who received at least 1 home visit from any physician in 2014/15 to 2018/19. We categorized home visits as palliative, provided to a patient who also received home care services or “other,” and compared characteristics and outcomes between groups.Results:A total of 4 418 334 physician home visits were performed between 2005/06 and 2018/19. More than half (2 256 667 [51.1%]) were classified as “other” and accounted for 39.1% ($22 million) of total annual physician billing costs. From 2014/15 to 2018/19, of the 413 057 home visit patients, 240 933 (58.3%) were adults aged 65 or more, and 323 283 (78.3%) lived in large urban areas. Compared to the palliative care and home care groups, the “other” group was younger, had fewer comorbidities, and had lower rates of emergency department visits and hospital admissions in the 30 days after the visit.Interpretation:About half of physician home visits in 2014/15 to 2018/19 were to patients who were receiving neither palliative care nor home care, a group that was younger and healthier, and had low use of health care services after the visit. There is an opportunity to refine policy tools to target patients most likely to benefit from physician home visits.

Trends in opioid dispensing after common abdominal and orthopedic surgery procedures in British Columbia: a retrospective cohort analysis.

PurposePostdischarge opioid prescriptions are reportedly much higher in Canada than in other countries. To assess potentially contributing factors, we examined trends after abdominal and orthopedic surgeries in British Columbia (BC).MethodsUsing the BC Ministry of Health’s databases on physician billings, hospital discharge abstracts, and medication dispensations in community pharmacies for the period 2003–2016, we assembled a cohort of 263,056 patients who received laparoscopic appendectomy (LA, 11%), laparoscopic cholecystectomy (LC, 30%), open inguinal or femoral hernia repair (IHR, 20%), total hip arthroplasty (THA, 18%), or total knee arthroplasty (TKA, 22%). Adjusting for covariates using generalized linear modeling, we measured trends in percentages of patients dispensed opioids postdischarge (opioid rate) within 30 days after surgery, by surgery type, opioid type, prior use, surgeon, and trends in morphine milligram equivalents of first dispensations (MME) with 95% confidence intervals (CI).ResultsOpioid dispensation rates rose steadily. Mean annual increases were 1.7% in LA; 1.3% in LC; 0.8% in IHR; 0.9% in THA; and 0.8% in TKA. By 2016, rates were 69% in LA; 76% in LC; 81% in IHR; 88% in THA; and 94% in TKA. Codeine dispensations fell 2.4% (abdominal) and 3.1% (orthopedic) per year while tramadol dispensations increased 3.6% (abdominal) and 1.7% (orthopedic). Hydromorphone dispensations increased 2.9% per year (orthopedic); oxycodone was level at 22% between 2007 and 2014, but then fell. The mean MME rose 8 mg⋅yr-1 (95% CI, 7 to 9) (abdominal) and 61 mg⋅yr-1 (95% CI, 58 to 64) (orthopedic). Variation in rates was greater among abdominal than orthopedic surgeons.ConclusionRising opioid dispensation rates, together with shifts to prescribing higher MME opioids, doubled MME per patient in first dispensations postdischarge after abdominal or orthopedic surgery from 2003 to 2016 in BC.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12630-022-02272-7.