Ontario's Program Research Articles

The impact of the COVID-19 pandemic on the Ontario Cervical Screening Program, colposcopy and treatment services in Ontario, Canada: a population-based study.

ObjectiveTo describe the immediate impact of the COVID‐19 pandemic on cervical screening, colposcopy and treatment volumes in Ontario, Canada.DesignPopulation‐based retrospective observational study.SettingOntario, Canada.PopulationPeople with a cervix age of 21–69 years who completed at least one cervical screening cytology test, colposcopy or treatment procedure for cervical dysplasia between January 2019 and August 2020.MethodsAdministrative databases were used to compare cervical screening cytology, colposcopy and treatment procedure volumes before (historical comparator) and during the first 6 months of the COVID‐19 pandemic (March–August 2020).Main outcome measuresChanges in cervical screening cytology, colposcopy and treatment volumes; individuals with high‐grade cytology awaiting colposcopy.ResultsDuring the first 6 months of the COVID‐19 pandemic, the monthly average number of cervical screening cytology tests, colposcopies and treatments decreased by 63.8% (range: −92.3 to −41.0%), 39.7% (range: −75.1 to −14.3%) and 31.1% (range: −43.5 to −23.6%), respectively, when compared with the corresponding months in 2019. Between March and August 2020, on average 292 (−51.0%) fewer high‐grade cytological abnormalities were detected through screening each month. As of August 2020, 1159 (29.2%) individuals with high‐grade screening cytology were awaiting follow‐up colposcopy.ConclusionsThe COVID‐19 pandemic has had a substantial impact on key cervical screening and follow‐up services in Ontario. As the pandemic continues, ongoing monitoring of service utilisation to inform system response and recovery is required. Future efforts to understand the impact of COVID‐19‐related disruptions on cervical cancer outcomes will be needed.Tweetable abstractCOVID‐19 has had a substantial impact on cervical screening and follow‐up services in Ontario, Canada.

Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening.

Individuals living with low income are more likely to smoke, have a higher risk of lung cancer, and are less likely to participate in preventative healthcare (i.e., low-dose computed tomography (LDCT) for lung cancer screening), leading to equity concerns. To inform the delivery of an organized pilot lung cancer screening program in Ontario, we sought to contextualize the lived experiences of poverty and the choice to participate in lung cancer screening. At three Toronto academic primary-care clinics, high-risk screen-eligible patients who chose or declined LDCT screening were consented; sociodemographic data was collected. Qualitative interviews were conducted. Theoretical thematic analysis was used to organize, describe and interpret the data using the morphogenetic approach as a guiding theoretical lens. Eight participants chose to undergo screening; ten did not. From interviews, we identified three themes: Pathways of disadvantage (social trajectories of events that influence lung-cancer risk and health-seeking behaviour), lung-cancer risk and early detection (upstream factors that shape smoking behaviour and lung-cancer screening choices), and safe spaces of care (care that is free of bias, conflict, criticism, or potentially threatening actions, ideas or conversations). We illuminate how 'choice' is contextual to the availability of material resources such as income and housing, and how 'choice' is influenced by having access to spaces of care that are free of judgement and personal bias. Underserved populations will require multiprong interventions that work at the individual, system and structural level to reduce inequities in lung-cancer risk and access to healthcare services such as cancer screening.

Incidence of mesothelioma and asbestosis by occupation in a diverse workforce.

We sought to characterize detailed patterns of mesothelioma and asbestosis incidence in the workforce as part of an occupational disease surveillance program in Ontario, Canada. The Occupational Disease Surveillance System (ODSS) cohort was established using workers' compensation claims data and includes 2.18 million workers employed from 1983 to 2014. Workers were followed for mesothelioma and asbestosis diagnoses in Ontario Cancer Registry, physician, hospital, and ambulatory care records through 2016. Trends in incidence rates were estimated over the study period. Cox proportional hazard models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). A total of 854 mesothelioma and 737 asbestosis cases were diagnosed during follow-up. Compared with all other workers in the ODSS, those employed in construction trades occupations had the greatest adjusted incidence rate of both mesothelioma (223 cases; HR, 2.38; 95% CI: 2.03-2.78) and asbestosis (261 cases; HR, 3.64; 95% CI: 3.11-4.25). Rates were particularly elevated for insulators, pipefitters and plumbers, and carpenters. Workers in welding and flame cutting, boiler making, and mechanic and machinery repair occupations, as well as those in industrial chemical and primary metal manufacturing industries, had strongly elevated rates of both diseases. Rates were greater than anticipated for workers in electrical utility occupations and education and related services. Results substantiate the risk of mesothelioma and asbestosis in occupation and industry groups in the Ontario workforce with known or suspected asbestos exposure. Sustained efforts to prevent the occurrence of additional cases of disease in high-risk groups are warranted.

COVID-19 and school food: The impact of the early stages of the coronavirus pandemic on student nutrition programs in Ontario

This paper is an exploration of the impact of the early stages of the COVID-19 pandemic on emer­gency food supply to school-aged children in Ontario, Canada. Using surveys in the framework of a bounded qualitative case study, we investigate how Student Nutrition Program (SNP) support staff have responded to the changed circumstances of the pandemic. Results indicate that program support staff were able to shift the SNP’s focus from universal access in-school nutrition programs to targeted food security initiatives for families. This shift was possible due to the complex web of relationships within which SNPs in Ontario oper­ate. Additional data and findings are discussed in the article, relating to the prepandemic operation of SNPs, how programs have been affected, and the concerns of SNP support staff about future issues as the programs restart in the new school year under pandemic conditions.

Perforation and post-polypectomy bleeding complicating colonoscopy in a population-based screening program.

Background and study aims We aimed to estimate the rate of hospital admissions for perforation and for post-polypectomy bleeding, after outpatient colonoscopy following a first positive fecal occult blood test screen through the population-based ColonCancerCheck program in Ontario, Canada. Patients and methods We identified all individuals aged 50 to 74 years with a first positive CCC gFOBT screening result from 2008 to 2017 who underwent outpatient colonoscopy ≤ 6 months later and who did not receive a diagnosis of CRC ≤ 24 months later. We identified inpatient hospital admissions for colonic perforation ≤ 7 days after and for post-polypectomy bleeding ≤ 14 days following colonoscopy. Results Among 121,626 individuals who underwent colonoscopy, the rate of perforation was 0.6 per 1000 from 2008 to 2012 and 0.4 per 1000 from 2013 to 2017. The rate was elevated among those aged 70 to 74 years; those with comorbidities; when colonoscopy was performed by endoscopists other than gastroenterologists or endoscopists with low prior year volume; and when polypectomy was performed during colonoscopy. The rate of bleeding was 4.3 per 1000 and was elevated among those aged 70 to 74 years, those with comorbidity, and with complex polypectomy. Both outcomes were more common among those aged 70 to 74 years, those with a 5-year cumulative Charlson score ≥ 1, those with prior hospitalization for ischemic heart disease, and those with endoscopists whose prior year colonoscopy volume was in the three lower quartiles. Conclusions Colonic perforation and post-polypectomy bleeding, among participants of population-based colorectal screening programs who test positive in the absence of colorectal cancer, are infrequent but serious complications, which increase with participant age and comorbidity, and with endoscopist characteristics.

Reduction of Need for Treatment and Length of Hospital Stay Following Institution of a Neonatal Abstinence Syndrome Rooming-In Program in Ontario, Canada

PurposeTo assess the impact of a rooming-in program for babies at risk of Neonatal Abstinence Syndrome (NAS) in one community hospital centre, in Belleville, Ontario. Design and methodsThis retrospective chart review was conducted at Belleville General Hospital. The hospital developed a rooming-in program for newborns at risk of NAS in July 2015. Charts on all infants born to mothers using opioids in the 24 months prior to and after the implementation of our program, who met the inclusion criteria, were examined. ResultsThe study consisted of 15 babies in the Special Care Nursery (SCN) group and 19 babies in the rooming-in group. Rooming-in is associated with a reduction in the need for treatment with morphine [rooming-in group (1/19, 5.3%), SCN group (14/15, 93.3%), p < 0.01], shorter length of stay in hospital [rooming-in group (days = 5), SCN group (days = 20), p < 0.01], improved exclusive breast and/or breast milk-feeding rates [rooming-in group (17/19,89.5%), SCN group (1/15,6.7%), p < 0.01] and lower total hospital cost [rooming-in group ($6458.00), SCN group ($17,851.00), p < 0.01]. ConclusionOur study demonstrates that rooming-in programs for babies born to mothers using opioids has benefits in terms of quality of care and health care resource utilization. Practical implicationsThese findings show that rooming-in can be successfully implemented in a community hospital.

A Double Standard - Improving Ontario's Working at Heights Approved Program

In early 2021, the Ministry of Labour, Training and Skills Development of Ontario initiated consultations for its scheduled five-year review of the Working at Heights Standard. The Working at Heights Standard is one of the most important and safety sensitive of its kind, as falls from heights are the greatest cost to human life in the construction industry in Ontario. Today, an individual or organization, approved by the Chief Prevention Officer, may train both the Working at Heights and three year Refresher Approved Programs in Ontario. This is not the case for the fully separate approvals for the less safety sensitive Joint Health and Safety Committee Part I, Part II, and Refresher Standards. Those entering the Working at Heights Refresher program will take the theory and practical module of the training program over 3.5 hours, which emulates the work the worker has been doing for three years. While the initial Working at Heights program is sacrosanct, the three year refresher training is ripe for innovation. Under the current model entering review, the separations of standards for innovation is not possible. Refresher is a program being taken by those who already work at heights, and the ability is there, should the Ministry be willing, to find better ways of delivering more innovative, more cost effective, and more effective refresher training. First, we need a double standard.

A study protocol for a quasi-experimental 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

BackgroundIndigenous communities in Canada face significant challenges with intergenerational trauma, which manifests in substance use disorders. There is consensus that connecting treatment approaches to culture, land, community, and spiritual practices is a pathway to healing trauma and substance use disorders for Indigenous peoples. Indigenous residential addiction treatment programs have been established as the primary intervention to provide healing for Indigenous peoples with substance use disorders and intergenerational trauma. However, there is limited evidence demonstrating the effectiveness of these programs. In collaboration with the Benbowopka Treatment Centre, this paper describes a study protocol which aims to evaluate the effectiveness of blending Indigenous Healing Practices and Seeking Safety for the treatment of Indigenous patients with intergenerational trauma and substance use disorders.MethodsWe will conduct a pre/post Quasi Experimental Community trial, to compare historical treatment outcomes for patients following the implementation of Indigenous Healing and Seeking Safety. We will conduct quantitative and qualitative analyses to understand the differences before and after the intervention is implemented. The pre- Indigenous Healing and Seeking Safety intervention study window will span from 2013 to 2016; n = 343, and the post-Indigenous Healing and Seeking Safety intervention study window from 2018 to 2020; n > 300. All participants will be enrolled in the Benbowopka residential treatment for the first time during the study periods. All data will be anonymized at the time of data entry. Propensity matching will be undertaken for patient characteristics, including sex/gender, age, and substance use type.Results and conclusionsThe study findings could be used to inform intergenerational trauma and substance use disorders residential treatment programming for Indigenous communities across Canada. Our work will contribute to the field of community-based intergenerational trauma and substance use disorders programming by addressing objectives that consider: (a) the patient perspective, (b) the program perspective, and (c) the community perspective. The study findings may validate an innovative approach for evaluating the effectiveness of residential addiction treatment and particularly the effective and appropriate care for Indigenous patients with intergenerational trauma and substance use disorders.

Liver transplantation in adult polycystic liver disease: the Ontario experience

BackgroundLiver transplantation (LT) remains the curative treatment for symptomatic Polycystic Liver Disease (PCLD) patients and is associated with excellent survival rates. The aim of the study is to review the Ontario experience in LT for PCLD.MethodsA retrospective study was performed from pre-existing LT databases from the LT Units at Toronto General Hospital and London Health Sciences Center, which are the two LT programs in Ontario, Canada. This database contains demographic, clinical parameters and follow-up of all patients transplanted for PCLD. Data was extracted for patients who underwent LT between January 2000–April 2017 and included follow up until December 31st, 2018.ResultsA total of 3560 patients underwent LT, of whom 51 (1.4%) had PCLD and met inclusion criteria. 43 (84%) of these patients were female. The median physiologic Model for End Stage Liver Disease (MELD-Na) score at time of referral was 13 (IQR = 7–22), however all patients required MELD-Na exception points to receive LT. The median age of transplant was 62 years (IQR = 59–64) for male vs. 52 (IQR = 45–56) for female patients. 33 (65%) of our cohort had PCLD while 9 (17.5%) had ADPKD and 9 (17.5%) had both diseases. 39 (76%) had LT due to symptoms of mass effect, while 8 (16%) had portal hypertensive complications. After a median follow-up of 6.3 (IQR = 2.9–12.5) years, the probability of survival was 96% (95% CI: 90%, 100%). Log-rank test, comparing survival analysis between males and females did not show a statistically significant difference (p = 0.26).ConclusionMost patients underwent LT for PCLD due to symptoms of mass effect with women being more likely than men to undergo LT. LT for PCLD had excellent long-term survival.

ES12.02 Defining High Risk

ES12.02 Defining High Risk

ES12.01 Patient Perspective on Lung Cancer Screening and Health Disparities

Lung cancer is the leading cause of cancer deaths in much of the world. Over 80% of lung cancer deaths are caused by tobacco. Systematic reviews show smoking rates are higher in low socio-economic status individuals.(1) This is true even in low and middle income countries(2). In the United States Native Americans and Alaska Natives have the highest tobacco use; 32.3% of Native Americans/Alaska Natives use any tobacco product as compared to 21.9% of Whites. In Canada, the Intuit have the highest smoking rates; 74% of Intuits in Canada smoke as compared to 23% of non-Aboriginal individuals in Ontario.(3) Smoking rates in Australian Indigenous populations are about double those of Non-indigenous populations.(4) Indigenous/Native populations and Blacks are at higher risk of lung cancer than non-indigenous populations and Whites. They are diagnosed at a younger age and have higher lung cancer incidence and mortality rates. In the US, Black men have 15% higher lung cancer incidence rates and 19% higher mortality rates than whites. Overall US indigenous/native populations have 8.8% higher lung cancer incidence rates than non-Hispanic whites with local incidence rates up to 80% higher in Alaska Native, Southern and Northern Plain populations.(5) Similarly, in Australia indigenous populations have higher lung cancer incidence and mortality rates and a younger age at diagnosis. (4) In the Ontario province in Canada lung cancer incidence rates are 19% higher for indigenous men and 48% higher for indigenous women as compared to non-Indigenous men and women respectively. Mortality in indigenous men is 13% higher and 43% higher in women than non-indigenous men and women respectively.(6) Age and smoking history don’t capture everyone at equivalent risk. Blacks are less likely to meet current CT lung screening criteria in the US than whites. Aldrich et al. assessed eligibility for CT lung screening using 2013 USPSTF screening guidelines in the Southern Community Cohort.(7) In their sample of 48,364 individuals, 17% of Blacks were eligible for screening as compared to 31% of whites. In the subset diagnosed with lung cancer (n= 1269): 32% of Blacks would have been eligible for screening as compared to 56% of whites. The American Lung Association 2020 State of Lung Cancer Report shows US CT lung screening rates are still low. The national average is 5.7% with large state to state variation. Massachusetts has the highest screening rate at 18.5% and Utah the lowest at 1%. Significant challenges remain for patients, especially those in disadvantage populations. These include lack of access to care, lack of awareness of the option for screening, difficult to understand eligibility criteria, distrust of the medical community, stigma and implicit bias due to the close association with smoking, nihilism and low perceived risk of getting lung cancer. Disadvantaged populations experience double stigma; the stigma of their lung cancer and the stigma of their disadvantage. It’s imperative to address eligibility, awareness, and access to CT lung screening for Blacks, indigenous/native populations and other disadvantaged populations to avoid increasing the current mortality and morbidity disparity for these populations. Encouragingly, in the US, the USPSTF updated draft CT lung screening recommendations lower the age of eligibility from 55 to 50 and the smoking history from 30 to 20 pack years. This will help address the disparity in screening eligibility between Blacks and whites of equivalent risk. A better approach to screen those at highest equivalent risk is to use a lung cancer risk prediction model as part of eligibility criteria. Recommended interventions include: Implementation of outreach programs to raise awareness and to provide CT lung screening in underserved communities. A good example of this is the Crosbie et al. UK mobile van lung health check study (8) Develop relationships with national and local minority organizations and partner with native/indigenous community leaders Form multidisciplinary state/provincial/local CT lung screening coalitions and learning collaboratives. Share lessons learned. Include lung cancer risk prediction model risk score in eligibility criteria. Example approaches include the Cancer Care Ontario program in Canada and the International Lung Screening Trial. Education to address stigma and clinician implicit bias and nihilism. Position lung cancer screening as health choice, similar to mammography and colonoscopy, co-develop culturally tailored education materials, public health campaigns raising awareness about stigma and implicit bias including information on glamorization of smoking in the early days when many eligible for CT lung screening started smoking.

The relational dynamics of caregivers of patients with a left ventricular assist device for destination-therapy: A qualitative investigation

BackgroundCaregivers are critical to the recovery and management of patients with destination-therapy left ventricular assist devices (DT-LVADs). ObjectiveTo explore the needs and impacts of caregiving for patients with DT-LVAD relative to the various relationships caregivers navigate from the shared perspectives of patients, caregivers, and healthcare providers. MethodsQualitative descriptive secondary analysis. Patients with a DT-LVAD (n = 3), caregivers (n = 2), and healthcare providers (n = 13) from all DT-LVAD programs in Ontario, Canada were invited to participate in semi-structured interviews. We used thematic analysis to identify, analyze, organize, describe, and report caregiver-related themes. ResultsEighteen participants were interviewed. The needs and impact of caregiving for patients with DT-LVADs were characterized by connection with others (relational), and drastic and ongoing changes from normalcy within established and new relationships (dynamics). ConclusionsDT-LVAD caregivers’ unique needs may be a result of multi-leveled and compounding relational dynamics within and across established and new relationships. These could be considered to inform the content of targeted support strategies.

Access to bariatric surgery among older patients in a publicly funded regionalized care system.

Bariatric surgery in older patients is safe and effective. Current guidelines do not endorse age limits for surgery; however, older patients may encounter difficulties with access given perceived risks. This study compares the adjusted probability of failing to receive bariatric surgery between older (≥ 60years) and younger (< 60years) patients referred to a publicly funded program. This is a retrospective cohort study of adult patients referred to a bariatric surgery program in Ontario from 2010-2016. Ontario health administrative databases and the Ontario Bariatric Registry were used for the analysis. The primary outcome was receipt of bariatric surgery within 3years of referral. A multivariable logistic regression analysis was performed to determine the adjusted effect of older age (≥ 60years) on the probability of not receiving surgery. Sensitivity analysis was performed using only healthy patients. Among 19,510 patients referred to the program, 1,795 patients (9.2%) were ≥ 60years old, of which 60% received bariatric surgery within 3years compared to 90% in younger patients. The odds older patients do not receive surgery after adjustment were significantly higher compared to younger patients (OR 1.69 [1.52-1.88], P < .001). This effect persists even among a subgroup of older patients with a Charlson Comorbidity Index = 0 (OR 1.78 [1.56-2.04], P < .001). Age alone, rather than comorbidities had a more significant effect on the access to bariatric surgery in older patients. Given the demonstrated benefits of bariatric surgery in older populations, ensuring equity in access to bariatric surgery should be encouraged. Future research is required to explore the underlying reasons why older patients who could benefit from bariatric surgery may not have the opportunity.

Correlates of non-adherence to breast, cervical, and colorectal cancer screening among screen-eligible women: a population-based cohort study in Ontario, Canada.

Breast, cervical, and colorectal cancers are cancers that can be detected early through screening. Despite organized cancer screening programs in Ontario, Canada participation remains low among marginalized populations. Although extensive research has been done about factors contributing to under-screening by cancer site, the predictors of under/never screened conjointly for all three types of cancer remain unknown. Using provincial-level linked administrative data sets, we examined Ontario women who were screen-eligible for all three types of cancer over a 36-month period (i.e., April 2014-March 2017) and determined how many were up to date on 0, 1, 2, and all three types of screenings. Multivariate logistic regression was utilized to examine individual and structural predictors of screening with the group overdue for all screening being the reference group. Of the 1,204,551 screen-eligible women, 15% were overdue for all. Living in the lowest income neighborhoods (AOR 0.46 [95% CI 0.45-0.47]), being recent immigrants (AOR 0.54 [95% CI 0.53-0.55]), having no primary care provider (AOR 0.17 [95% CI 0.16-0.17]), and having no contact with health care services (AOR 0.09 [95% CI 0.09-0.09]) significantly increased the likelihood of being overdue for all versus no screening type. Considering that more than 15% of screen-eligible women in Ontario were overdue for all types of cancer screening, it is imperative to address structural barriers such as lack of a primary care provider. Innovative interventions like "one-stop shopping" where screening for different cancers can be offered at the same time could promote screening uptake.

A Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) in Patients With Chronic Kidney Disease: Clinical Research Protocol of a Cluster-Randomized Clinical Trial.

Background:Many patients with kidney failure will live longer and healthier lives if they receive a kidney transplant rather than dialysis. However, multiple barriers prevent patients from accessing this treatment option.Objective:To determine if a quality improvement intervention provided in chronic kidney disease (CKD) programs (vs. usual care) enables more patients with no recorded contraindications to kidney transplant to complete more steps toward receiving a kidney transplant.Design:This protocol describes a pragmatic 2-arm, parallel-group, open-label, registry-based, cluster-randomized clinical trial—the Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial.Setting:All 26 CKD programs in Ontario, Canada, with a trial start date of November 1, 2017. The original end date of March 31, 2021 (3.4 years) has been extended to December 31, 2021 (4.1 years) due to the COVID-19 pandemic.Participants:During the trial, the 26 CKD programs are expected to care for more than 10 000 adult patients with CKD (including patients approaching the need for dialysis and patients receiving dialysis) with no recorded contraindications to a kidney transplant.Intervention:Programs were randomly allocated to provide a quality improvement intervention or usual care. The intervention has 4 main components: (1) local quality improvement teams and administrative support; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders.Primary Outcome:The primary outcome is the number of key steps completed toward receiving a kidney transplant analyzed at the cluster level (CKD program). The following 4 unique steps per patient will be counted: (1) patient referred to a transplant center for evaluation, (2) at least one living kidney donor candidate contacts a transplant center for an intended recipient and completes a health history questionnaire to begin their evaluation, (3) patient added to the deceased donor transplant wait list, and (4) patient receives a kidney transplant from a living or deceased donor.Planned Primary Analysis:Study data will be obtained from Ontario’s linked administrative healthcare databases. An intent-to-treat analysis will be conducted comparing the primary outcome between randomized groups using a 2-stage approach. First stage: residuals are obtained from fitting a regression model to individual-level variables ignoring intervention and clustering effects. Second stage: residuals from the first stage are aggregated at the cluster level as the outcome.Limitations:It may not be possible to isolate independent effects of each intervention component, the usual care group could adopt intervention components leading to contamination bias, and the relatively small number of clusters could mean the 2 arms are not balanced on all baseline prognostic factors.Conclusions:The EnAKT LKD trial will provide high-quality evidence on whether a multi-component quality improvement intervention helps patients complete more steps toward receiving a kidney transplant.Trial registration:Clinicaltrials.gov; identifier: NCT03329521.

Home-Care Nurses' Experiences of Caring for Older Adults With Type 2 Diabetes Mellitus and Urinary Incontinence: An Interpretive Description Study.

IntroductionA third of older adults with diabetes receiving home-care services have daily urinary incontinence. Despite this high prevalence of urinary incontinence, the condition is typically not recognized as a complication and thereby not detected or treated. Diabetes and urinary incontinence in older adults are associated with poorer functional status and lower quality of life. Home-care nurses have the potential to play an important role in supporting older adults in the management of these conditions. However, very little is known about home-care nurses’ care of this population.ObjectiveThe objective of this study was to explore how nurses care for older home-care clients with diabetes and incontinence.MethodsThis was an interpretive description study informed by a model of clinical complexity, and part of a convergent, mixed methods research study. Fifteen nurse participants were recruited from home-care programs in southern Ontario, Canada to participate in qualitative interviews. An interpretive description analytical process was used that involved constant comparative analysis and attention to commonalities and variance.ResultsThe experiences of home-care nurses caring for this population is described in three themes and associated subthemes: (a) conducting a comprehensive nursing assessment with client and caregiver, (b) providing holistic treatment for multiple chronic conditions, and (c) collaborating with the interprofessional team. The provision of this care was hampered by a task-focused home-care system, limited opportunities to collaborate and communicate with other health-care providers, and the lack of health-care system integration between home care, primary care, and acute care.ConclusionThe results suggest that nursing interventions for older adults with diabetes and incontinence should not only consider disease management of the individual conditions but pay attention to the broader social determinants of health in the context of multiple chronic conditions. Efforts to enhance health-care system integration would facilitate the provision of person-centred home care.

Unblurring the Lines of Responsibility: The Puzzle of Veteran Service Provision and its Gendered Implications

The ever-increasing representation of women in the Canadian Armed Forces (CAF) has sparked discussion about the gendered implications of military-to-civilian transition. Women are now the fastest growing cohort of veterans in Canada and represent nearly 16% of the military. As the demographics of the military change in Canada and elsewhere, so too will the face of veterans. Despite the Government of Canada’s clear mandate to include gender-based analysis in all policies and programs, has this really been accomplished in the field of veteran service provision? We grapple with this challenge by problematizing the division of labour in veteran services and programs, examining whether programs have been responsive to gender mainstreaming commitments from the federal government. Finally, we demonstrate how a gender-based analysis can enhance services. We conduct a comprehensive environmental scan and create an original database for veteran services and programs in Ontario. A total of 211 individual programs and service offerings were examined and coded, with 5 found to integrate gender considerations into their program delivery. Our analysis is further supported by focus group data from 52 veterans. In addition to generating important recommendations for veteran service providers and employers tied to our data analysis, we also provide further best practices drawn from the experiences of two close allies, the United States, and Australia.

An exploratory analysis of the necessity and utility of trauma-informed practices in education

Traumatic experiences in children are pervasive, and trauma has been correlated with adverse academic outcomes, including school dropout. This research study aimed to answer the following question: According to selected educators in specialized programs in Ontario, in what ways are trauma-informed frameworks used to support the social–emotional and academic outcomes of learners? This qualitative research study employed semi-structured interviews with three trauma-informed educators. In brief, the educators reported that their learners face many barriers to their education, oftentimes including the traditional school system itself. Also, the educators all highlighted the importance of relationships, safe spaces, and sensitive responses to learner behaviors. Last, despite their promising reports on learner social–emotional functioning and academics, the educators are unsure whether these programs help to increase graduation rates.

Morbidity and mortality after major large bowel resection of non-malignant polyp among participants in a population-based screening program.

Background and aimsColonoscopy following positive fecal occult blood screening may detect non-malignant polyps deemed to require major large bowel resection. We aimed to estimate the major inpatient morbidity and mortality associated with major resection of non-malignant polyps detected at colonoscopy following positive guaiac fecal occult blood screening in Ontario's population-based colorectal screening program.MethodsWe identified those without a diagnosis of colorectal cancer in the Ontario Cancer Registry ≤24 months following the date of colonoscopy prompted by positive fecal occult blood screening between 2008 and 2017, who underwent a major large bowel resection ≤24 months after the colonoscopy, with a diagnosis code for non-malignant polyp, in the absence of a code for any other large bowel diagnosis. We extracted records of major inpatient complications and readmissions ≤30 days following resection. We computed mortality within 90 days following resection.ResultsFor those undergoing colonoscopy ≤6 months following positive guaiac fecal occult blood screening, 420/127,872 (0.03%) underwent major large bowel resection for a non-malignant polyp. In 50/420 (11.9%), the resection included one or more rectosigmoid or rectal polyps, with or without a colonic polyp. There were one or more major inpatient complications or readmissions within 30 days in 117/420 (27.9%). Death occurred within 90 days in 6/420 (1.4%).ConclusionsSerious inpatient complications and readmissions following major large bowel resection for non-malignant colorectal polyps are common, but mortality ≤90 days following resection is low. These outcomes should be considered as unintended adverse consequences of population-based colorectal screening programs.

Optimizing screening for depression, anxiety disorders, and post-traumatic stress disorder in inpatient addiction treatment: A preliminary investigation

ObjectiveSubstance use disorders (SUD) are frequently comorbid with other psychiatric conditions, but a comprehensive diagnostic assessment is often not feasible clinically. Efficient psychometrically-validated screening tools exist for commonly comorbid conditions, but cutoff accuracies have typically not been evaluated in addiction treatment settings. This study examined the performance of several widely-used screening measures in relation to diagnostic status from a clinical interview to identify and validate cutoff scores in an inpatient SUD treatment setting. MethodParticipants were 99 patients in a large residential SUD treatment program in Ontario, Canada. Participants completed a screening battery, including the Patient Health Questionnaire – 9 (PHQ-9), Generalized Anxiety Disorder – 7 (GAD-7), and Post-Traumatic Stress Disorder Checklist-5 (PCL-5), and underwent a semi-structured diagnostic clinical interview. Receiver operating characteristic curves were used to determine optimal cutoff scores on the screening tool against the interview-based diagnosis. ResultsArea under the curve (AUC) was statistically significant for all screens and were as follows: PHQ-9 = 0.70 (95% CI = 0.59–0.80), GAD-7 = 0.74 (95% CI = 0.63–0.84), and PCL-5 = 0.79 (95% CI = 0.66–0.91). The optimal accuracy cutoff scores based on sensitivity and specificity were: PHQ-9 ≥ 16, GAD-7 ≥ 9, the PCL-5 ≥ 42. ConclusionsIn general, the candidate screeners performed acceptably in this population. However, the optimal cutoff scores were notably higher than existing guidelines for depression and PTSD, potentially due to the general elevations in negative affectivity among individuals initiating SUD treatment. Further validation of these cutoff values is warranted. Public health significanceThis study provides modified screening cutoff scores for major depression, anxiety disorders, and post-traumatic stress disorder in addiction treatment settings.