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Background: Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life., Objective: To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults., Design: Population-based cohort study., Participants: All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada., Exposures: Chinese ethnicity., Main Measures: Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation., Key Results: The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38)., Conclusions: Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: The COVID-19 pandemic altered traffic patterns worldwide, potentially impacting pedestrian and bicyclists safety in urban areas. In Toronto, Canada, work from home policies, bicycle network expansion, and quiet streets were implemented to support walking and cycling. We examined pedestrian and bicyclist injury trends from 2012 to 2022, utilizing police-reported killed or severely injured (KSI), emergency department (ED) visits and hospitalization data., Methods: We used an interrupted time series design, with injury counts aggregated quarterly. We fit a negative binomial regression using a Bayesian modeling approach to data prior to the pandemic that included a secular time trend, quarterly seasonal indicator variables, and autoregressive terms. The differences between observed and expected injury counts based on pre-pandemic trends with 95% credible intervals (CIs) were computed., Results: There were 38% fewer pedestrian KSI (95%CI: 19%, 52%), 35% fewer ED visits (95%CI: 28%, 42%), and 19% fewer hospitalizations (95%CI: 2%, 32%) since the beginning of the COVID-19 pandemic. A reduction of 35% (95%CI: 7%, 54%) in KSI bicyclist injuries was observed, but However, ED visits and hospitalizations from bicycle-motor vehicle collisions were compatible with pre-pandemic trends. In contrast, for bicycle injuries not involving motor vehicles, large increases were observed for both ED visits, 73% (95% CI: 49%, 103%) and for hospitalization 108% (95% CI: 38%, 208%)., Conclusion: New road safety interventions during the pandemic may have improved road safety for vulnerable road users with respect to collisions with motor vehicles; however, further investigation into the risk factors for bicycle injuries not involving motor vehicles is required., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Pedestrian and cyclist injuries represent a preventable burden to Canadians. Police-reported collision data include information on where such collisions occur but under-report the number of collisions. The primary objective of this study was to compare the number of police-reported collisions with emergency department (ED) visits and hospitalisations in Toronto, Canada., Methods: Police-reported collisions were provided by Toronto Police Services (TPS). Data included the location of the collision, approximate victim age and whether the pedestrian or cyclist was killed or seriously injured. Health services data included ED visits in the National Ambulatory Care Reporting System and hospitalisations from the Discharge Abstract Database using ICD-10 codes for pedestrian and cycling injuries. Data were compared from 2016 to 2021., Results: Injuries reported in the health service data were higher than those reported in the TPS for cyclists and pedestrians. The discrepancy was the largest for cyclists treated in the ED, with TPS capturing 7.9% of all cycling injuries. Cyclist injuries not involving a motor vehicle have increased since the start of the pandemic (from 3629 in 2019 to 5459 in 2020 for ED visits and from 251 in 2019 to 430 for hospital admissions)., Implications: While police-reported data are important, it under-reports the burden. There have been increases in cyclist collisions not involving motor vehicles and decreases in pedestrian injuries since the start of the pandemic. The results suggest that using police data alone when planning for road safety is inadequate, and that linkage with other health service data is essential., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: This study examined treatment patterns, survival outcomes and healthcare costs related to hepatocellular carcinoma (HCC) in British Columbia., Methods: The study utilized data from two physician databases (HCC and MOTION) and the provincial British Columbia transplant database., Results: The analysis revealed diverse treatment approaches and identified the varying treatment journeys of patients. Liver transplant and systemic therapies demonstrated improved survival rates. However, there was a scarcity of Canadian-specific cost data., Conclusion: The research emphasizes the complexities of managing HCC and underscores the need for personalized treatment strategies to enhance patient outcomes. These findings contribute valuable insights into HCC management and provide a foundation for future studies and interventions aimed at optimizing care and resource allocation., Competing Interests: Competing interests disclosure The authors have no competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties., (© 2024 The Authors.)

Aims: Patients are at high risk of death or readmission following hospitalization for heart failure (HF). We tested the effect of a transitional care model that included month-long nurse-led home visits and long-term heart function clinic visits - with services titrated to estimated risk of clinical events - on 3-year outcomes following hospitalization., Methods and Results: In a pragmatic, stepped-wedge cluster randomized trial, 10 hospitals were randomized to the intervention versus usual care. The primary outcome was a composite of all-cause death, readmission, or emergency department (ED) visit. Secondary outcomes included components of the primary composite outcomes, HF readmissions and healthcare resource utilization. There were 2494 patients (50.4% female) with mean age of 77.7 years. The primary outcome was reached in 1040 (94.2%) patients in the intervention and 1314 (94.5%) in the usual care group at 3 years. The intervention did not reduce the risk of the primary composite outcome (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.81-1.05) nor the component outcomes overall, although numerically reduced the risk of ED visits in women but not men (HR 0.79, 95% CI 0.63-1.00 vs. HR 0.98, 95% CI 0.80-1.19; sex-treatment interaction p = 0.23). The uptake of guideline-directed medical therapy was no different with the intervention than with usual care, with the exception of sacubitril/valsartan, which increased with the intervention (3.3% vs 1.5%; relative risk 6.2, 95% CI 1.92-20.06)., Conclusions: More than 9 of 10 patients hospitalized for HF experienced all-cause death, readmission, or ED visit at 3 years. A transitional care model with services titrated to risk did not improve the composite of these endpoints, likely because there were no major differences in uptake of medical therapies between the groups., Clinical Trial Registration: ClinicalTrials.gov Identifier NCT02112227., (© 2024 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Home-based palliative programs rely on family caregivers, who often miss time from employment. This article identified changes in caregivers' labour force participation over the palliative trajectory., Methods: Family caregivers (n = 262) were interviewed biweekly to measure transitions across four employment categories., Results: More than half of the caregivers had one employment transition and 29% had three or more. The highest proportion of transitions occurred for caregivers who were employed part-time., Interpretation: Understanding these transitions is critical to the development of strategies tailored to caregivers to contain labour force losses and to support caregivers during a time of high caregiving demands., (Copyright © 2020 Longwoods Publishing.)

Background: Children using home mechanical ventilation (HMV) live at home with better quality of life, despite financial burden for their family. Previous studies of healthcare utilization and costs have not considered public and private expenditures, including family caregiver time. Our objective was to examine public and private healthcare utilization and costs for children using HMV, and variables associated with highest costs., Methods: Longitudinal, prospective, observational cost analysis study (2012-2014) collecting data on public and private (out-of-pocket, third-party insurance, and caregiving) costs every 2 weeks for 6 months using the Ambulatory Home Care Record. Functional Independence Measure (FIM), WeeFIM, and Caregiving Impact Scale (CIS) were measured at baseline and study completion. Regression modeling examined a priori selected variables associated with monthly costs using Andersen and Newman's framework for healthcare utilization, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($1CAD = $0.78USD)., Results: Forty two children and their caregivers were enrolled. Overall median (interquartile range) monthly healthcare cost was $12 131 ($8159-$15 958) comprising $9929 (89%) family caregiving hours, $996 (9%) publicly funded, and $252 (2%) out-of-pocket (<1% third-party insurance) costs. With higher FIM score (lower dependency), median costs were reduced by 4.5% (95% confidence interval: 8.3%-0.5%), adjusted for age, sex, tracheostomy, and daily ventilation duration. Note: since the three cost categories did not sum to the total statistically derived median cost, the percentage of each category used the sum of median public + caregiver lost time + private out-of-pocket + third-party insurance as the denominator., Conclusions: For HMV children, most healthcare costs were due to family caregiving costs. More dependent children incur highest costs. The financial burden to family caregivers is substantial and needs to considered in future policy decisions related to pediatric HMV., (© 2020 Wiley Periodicals LLC.)

Background and Aim: Atrial fibrillation is associated with increased risk of ischemic stroke and its global prevalence is increasing. We aimed to describe the contemporary temporal trends in hospital admissions, case fatality rate, as well as sex differences in atrial fibrillation-related stroke in Canada., Methods: We conducted a retrospective cohort study using Canadian national administrative data to identify admissions to hospital for stroke with comorbid atrial fibrillation between 1 April 2007 and 31 March 2016. We determined temporal trends in the crude and the age- and sex-standardized admission and case fatality rates. We also evaluated for any sex differences in these outcomes., Results: There were 222,100 admissions to hospital for ischemic (n = 182,990) or hemorrhagic (n = 39,110) stroke. Comorbid atrial fibrillation was present in 20.2% of admissions for ischemic strokes and 10.1% for hemorrhagic strokes. Over the study period, the age-sex adjusted proportion of admissions with atrial fibrillation increased from 16.3% to 20.5% (p = 0.02) for ischemic stroke and was stable for hemorrhagic stroke. In-hospital case fatality rate decreased for ischemic stroke with and without comorbid atrial fibrillation. Women aged 65 years and older with ischemic stroke were more likely to have comorbid atrial fibrillation compared to men, while this association was reversed in younger women. There were no sex differences in the case fatality rate for people with atrial fibrillation-related ischemic stroke., Conclusion: Atrial fibrillation is present in an increasing proportion of people hospitalized in Canada with ischemic stroke and disproportionately affects older women. Renewed focus is needed on atrial fibrillation-related stroke prevention with particular attention to sex disparities.

Background: Mycosis fungoides (MF) typically has a CD4 + CD8 - T-cell phenotype. Rare cases of CD4 - CD8 + , CD4 - CD8 - , or CD4 + CD8 + immunophenotypes have been described. Little is known about the impact of MF immunophenotypes on disease behavior., Methods: We conducted a retrospective cohort study to review all cases of MF from 2007 to 2017 from Sunnybrook Health Sciences Centre, Toronto, Canada. CD4 + CD8 - (Group 1) was compared to the three less common subtypes (Group 2) with respect to stage at diagnosis, progression, and transformation. Potential confounding factors (demographic, clinical, and laboratory parameters) were assessed., Results: A total of 160 patients with confirmed MF were analyzed, including 126 CD4 + CD8 - MF (79%), 26 CD4 - CD8 + MF (16%), six CD4 + CD8 + MF (4%), and two CD4 - CD8 - MF (1%). Both groups were similar with respect to demographics and laboratory parameters at the time of diagnosis. There was no difference between patients with late stage disease (10% vs. 9%) for groups 1 and 2, respectively (P = 0.901). There was no statistically significant difference either in 5-year progression (27.7% vs. 23.5%, P = 0.283) or transformation (16.2% vs. 17.3%, P = 0.350) estimates. We did find that atypical immunophenotypes presented with different clinical morphologies and were less likely to require systemic therapy., Conclusion: Our large cohort study indicates that atypical MF immunophenotypes do not seem to influence prognosis. Hypopigmented MF was more frequent in the CD4 - CD8 + group while folliculotropic MF was exclusively seen in the CD4 + CD8 - group. We believe that cases of CD8 + MF with aggressive behavior described in the literature represent misclassified primary cutaneous aggressive epidermotropic CD8 + T-cell lymphoma. The small number of patients included in the study is a limiting factor., (© 2019 The International Society of Dermatology.)

Background and Purpose- The purpose of this study was to assess recent trends in the admission and mortality rates for subarachnoid hemorrhage in Canada. Methods- This retrospective cross-sectional study was based on data retrieved from the Canadian Institute for Health Information for all patients diagnosed with subarachnoid hemorrhage in Canada between 2004 and 2015. Adjusted admission rate, in-hospital mortality rates, and discharge disposition were calculated. Results- A total of 19 765  patients were diagnosed with subarachnoid hemorrhage between 2004 and 2015. The mean age was 58.1 years, and 40.3% were men. The annual hospitalization rate was 6.34 per 100 000 person-years, declining by -0.67% annually. In-hospital mortality rate was 21.5%. Conclusions- The Canadian subarachnoid hemorrhage admission and mortality rates are lower than previously reported, with a declining trend.

Objectives: TNM stage is the preeminent cancer staging system and a fundamental determinant of disease prognosis. Our goal was to evaluate the predictive power of TNM stage for gastric adenocarcinoma (GAC), in a low-incidence country., Methods: A province-wide chart review of GAC patients diagnosed from April 1, 2005 to March 31, 2008 was conducted in Ontario and linked to routinely collected vital status data with a follow-up on March 31, 2012. TNM staging was classified using the sixth and seventh Union International for Cancer Control/American Joint Committee on Cancer editions. Kaplan-Meier and log-rank tests compared stage-stratified survival estimates. Discrimination was evaluated using Harrell's C statistic., Results: The cohort included 2366 patients. One- and 5-year survival was 43% and 17%. Using the sixth edition, 9% of patients had stage I disease, 5.4% stage II, 7.3% stage III, and 64% stage IV; 15% were not staged. Using the seventh edition, 9% were stage I, 7.7% stage II, 16% stage III, and 54% stage IV; 14% were not staged. Stage-stratified 5-year survival ranged from 68% to 7% with the sixth edition and from 70% to 4% with the seventh edition. Harrell's C statistic was 0.64 (0.63-0.65) for the broad sixth edition staging categories and 0.68 (0.67-0.69) for the broad seventh edition. Discriminative power was similar for the refined stage categories and across multiple subgroup analyses; it was best in non-metastatic patients., Conclusion: Existing staging systems for GAC used in North America predict individualized prognosis poorly. The creation of a more complex prediction tool is necessary to provide accurate and precise prognostication information to oncologists, patients, and their families.

Objectives: This study estimated the health impacts of neighbourhood socioeconomic position (SEP) among public housing residents. Because applicants to public housing were assigned to housing projects primarily based on factors other than personal choice, we capitalised on a quasirandom source of variation in neighbourhood of residence to obtain more valid estimates of the health impacts of neighbourhood SEP., Design: Quasiexperimental study., Setting: Greater Metropolitan Toronto area, Canada., Participants: Residents (24 019-28 858 adults age ≥30 years in 1994 for all outcomes except for asthma, for which the sample was expanded to 66 627 individuals age ≥4 years) of public housing on 1 January 1994., Outcome Measures: Incident hypertension, diabetes, asthma, and acute myocardial infarction (MI) and all-cause mortality between 1 January 1994 and 31 December 2006. We used multivariate Cox proportional hazards models to estimate hazard ratios (HRs) for the associations between the quartile of census tract-level SEP and the risk of diagnosis of each health outcome as well as death from any cause., Results: Living in a public housing project in the second highest neighbourhood SEP quartile (Q3) was associated with lower hazards of acute MI (HR=0.76, 95% CI 0.54 to 1.07; P=0.11), incident asthma (HR=0.80, 95% CI 0.67 to 0.96; P=0.02) and all-cause mortality (HR=0.86, 95% CI 0.73 to 1.01; P=0.06) compared to living in the lowest neighbourhood SEP quartile (Q1), although only the trend for incident asthma reached statistical significance (P for trend=0.04). By contrast, the associations corresponding to living in the highest versus lowest quartile of median household income (Q4 vs Q1) were neither consistent in direction nor significant. The inconsistent associations may partly be attributed to selection and status incongruity., Conclusion: This study provides new evidence compatible with protective influences of higher neighbourhood SEP on health outcomes, particularly asthma., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Accurate TNM stage information is essential for cancer health services research, but is often impractical and expensive to collect at the population-level. We evaluated algorithms using administrative healthcare data to identify patients with metastatic gastric cancer., Methods: A population-based cohort of gastric cancer patients diagnosed between 2005 and 2007 identified from the Ontario Cancer Registry were linked to routinely collected healthcare data. Reference standard data identifying metastatic disease were obtained from a province-wide chart review, according to the Collaborative Staging method. Algorithms to identify metastatic gastric cancer were created using administrative healthcare data from hospitalization, emergency department, and physician billing records. Time frames of data collection in the peri-diagnosis period, and the diagnosis codes used to identify metastatic disease were varied. Algorithm sensitivity, specificity, and accuracy were evaluated., Results: Of 2366 gastric cancer patients, included within the chart review, 54.3% had metastatic disease. Algorithm sensitivity ranged from 50.0- 90%, specificity ranged from 27.6 - 92.5%, and accuracy from 61.5 - 73.4%. Sensitivity and specificity were maximized when the most conservative list of diagnosis codes from hospitalization and outpatient records in the six months prior to and the six months following diagnosis were included., Conclusion: Algorithms identifying metastatic gastric cancer can be used for research purposes using administrative healthcare data, although they are imperfect measures. The properties of these algorithms may be generalizable to other high fatality cancers and other healthcare systems. This study provides further support for the collection of population-based, TNM stage data.

Background: Individuals using home mechanical ventilation (HMV) frequently choose to live at home for quality of life, despite financial burden. Previous studies of healthcare utilisation and costs do not consider public and private expenditures, including caregiver time., Objectives: To determine public and private healthcare utilisation and costs for HMV users living at home in two Canadian provinces, and examine factors associated with higher costs., Methods: Longitudinal, prospective observational cost analysis study (April 2012 to August 2015) collecting data on public and private (out-of-pocket, third-party insurance, caregiving) costs every 2 weeks for 6 months using the Ambulatory and Home Care Record. Functional Independence Measure (FIM) was used at baseline and study completion. Regression models examined variables associated with total monthly costs selected a priori using Andersen and Newman's framework for healthcare utilisation, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($C1=US$0.78=₤0.51=€0.71)., Results: We enrolled 134 HMV users; 95 with family caregivers. Overall median (IQR) monthly healthcare cost was $5275 ($2291-$10 181) with $2410 (58%) publicly funded; $1609 (39%) family caregiving; and $141 (3%) out-of-pocket (<1% third-party insurance). Median healthcare costs were $8733 ($5868-$15 274) for those invasively ventilated and $3925 ($1212-$7390) for non-invasive ventilation. Variables associated with highest monthly costs were amyotrophic lateral sclerosis (1.88, 95% CI 1.09 to 3.26, P<0.03) and lower FIM quintiles (higher dependency) (up to 6.98, 95% CI 3.88 to 12.55, P<0.0001) adjusting for age, sex, tracheostomy and ventilation duration., Conclusions: For HMV users, most healthcare costs were publicly supported or associated with family caregiving. Highest costs were incurred by the most dependent users. Understanding healthcare costs for HMV users will inform policy decisions to optimise resource allocation, helping individuals live at home while minimising caregiver burden., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Family caregivers of patients enrolled in home-based palliative care programmes provide unpaid care and assistance with daily activities to terminally ill family members. Caregivers often experience caregiver burden, which is an important predictor of anxiety and depression that can extend into bereavement. We conducted a longitudinal, prospective cohort study to comprehensively assess modifiable and non-modifiable patient and caregiver factors that account for caregiver burden over the palliative care trajectory. Caregivers (n = 327) of patients with malignant neoplasm were recruited from two dedicated home-based palliative care programmes in Southern Ontario, Canada from 1 July 2010 to 31 August 2012. Data were obtained from bi-weekly telephone interviews with caregivers from study admission until death, and from palliative care programme and home-care agency databases. Information collected comprised patient and caregiver demographics, utilisation of privately and publicly financed resources, patient clinical status and caregiver burden. The average age of the caregivers was 59.0 years (SD: 13.2), and almost 70% were female. Caregiver burden increased over time in a non-linear fashion from study admission to patient death. Increased monthly unpaid care-giving time costs, monthly public personal support worker costs, emergency department visits and low patient functional status were associated with higher caregiver burden. Greater use of hospice care was associated with lower burden. Female caregivers tended to report more burden compared to men as death approached, and burden was higher when patients were male. Low patient functional status was the strongest predictor of burden. Understanding the influence of modifiable and non-modifiable factors on the experience of burden over the palliative trajectory is essential for the development and targeting of programmes and policies to support family caregivers and reduce burden. Supporting caregivers can have benefits such as improved caregiver health outcomes, and enhancing their ability to meet care-giving demands, thereby potentially allowing for longer patient care in the home setting., (© 2015 John Wiley & Sons Ltd.)

Background: On-site attendance to prescheduled cardiac rehabilitation visits has been shown to be associated with improved outcomes following cardiac rehabilitation. The extent to which on-site programmatic attendance represents a healthy-adherer effect remains unknown., Methods: This retrospective cohort study consisted of 17,000 consecutively referred patients to a cardiac rehabilitation program in Ontario, Canada. On-site attendance at prescheduled visits was our primary exposure variable. The primary outcome was all-cause death or hospitalization at two years following the expected program completion date, irrespective of drop-out. Secondary outcomes included adherence to statins, health-seeking preventative health visits, and changes in clinical risk-profiles. Cox proportional hazards adjusted for baseline sociodemographic, clinical and comorbid characteristics., Results: Among the 12,440 patients who attended at least one prescheduled on-site visit, on-site attendance was inversely correlated with baseline smoking rates and body mass index at program entry. After adjustment for baseline factors, the risk of death or hospitalization progressively fell with incremental increases in on-site attendance (adjusted hazard ratio for each 10% increase in on-site attendance: 0.96; 95% confidence interval: 0.93-0.99, p = 0.007). Such associations were driven predominantly by differences in non-cardiovascular hospitalizations. Incremental increases in on-site attendance were associated with improvements in cardiopulmonary fitness and body mass index (both p < 0.001), better attendance of preventative care physician visits (p < 0.001) and higher medication adherence to statins (p = 0.007)., Conclusions: Associations between on-site attendance at cardiac rehabilitation and outcomes may represent a healthy-adherer effect. Future research must evaluate the clinical utility of on-site attendance as a behavioral health-adherence metric for cardiac rehabilitation monitoring and surveillance., (© The European Society of Cardiology 2014.)

Many cancer patients die in institutional settings despite their preference to die at home. A longitudinal, prospective cohort study was conducted to comprehensively assess the determinants of home death for patients receiving home-based palliative care. Data collected from biweekly telephone interviews with caregivers (n = 302) and program databases were entered into a multivariate logistic model. Patients with high nursing costs (odds ratio [OR]: 4.3; confidence interval [CI]: 1.8-10.2) and patients with high personal support worker costs (OR: 2.3; CI: 1.1-4.5) were more likely to die at home than those with low costs. Patients who lived alone were less likely to die at home than those who cohabitated (OR: 0.4; CI: 0.2-0.8), and those with a high propensity for a home-death preference were more likely to die at home than those with a low propensity (OR: 5.8; CI: 1.1-31.3). An understanding of the predictors of place of death may contribute to the development of effective interventions that support home death.

To characterise trends in live birth rates, adverse neonatal outcomes and socio-demographic characteristics of pregnant women with diagnosed HIV between the ages of 18 and 49 in Ontario, Canada from 1 April 2002 to 31 March 2010, we conducted a population-based study. Utilising linked administrative healthcare databases we used generalised estimating equations to characterise secular trends and examine the association between live births and socio-demographic characteristics, including age, region of birth and neighbourhood income quintile. Between 2002/2003 and 2009/2010, there were 551 live births during 15,610 person-years of follow-up. The proportion of HIV-positive mothers originally from Africa or the Caribbean increased from 26.7% to 51.6% over the study period. The risk of pre-term (risk ratio 2.13, 95% confidence interval 1.74 to 2.61) and small for gestational age births (risk ratio 1.53, 95% confidence interval 1.20 to 1.94) was higher in women with HIV compared with provincial estimates for these outcomes. Women with HIV have rates of pre-term and small for gestational age births that exceed provincial estimates for these outcomes. Further research is required to identify factors mediating these disparities that are amenable to pre-natal risk reduction initiatives., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: The use of thrombolysis in acute stroke is an important indicator of the quality of stroke care, because it requires health care providers to work collaboratively, rapidly and accurately to optimize patient outcomes. We sought to assess the quality of hyperacute stroke care in Canada using the rate of thrombolysis as the key indicator., Methods: We used national administrative data and a chart audit in a retrospective cohort design. We identified discharge diagnoses of stroke in the 10 Canadian provinces between 2008 and 2009. We drew a sample (over-weighted by population and hospital size) for a detailed chart review that was focused on identifying indicators of acute stroke care. We determined the proportions of thrombolysis use, complications and outcomes, adjusted for age and sex and stratified by type of hospital., Results: Our final audit sample included 9588 patient charts, representative of 88% of the 43 651 cases of stroke for which patients were admitted to hospital in Canada. A total of 5.4% (95% confidence interval [CI] 5.1-5.6) of patients with stroke and 6.1% (95% CI 5.8-6.4) of patients with ischemic stroke received thrombolysis. Comprehensive stroke centres used thrombolysis in about one-third of ischemic cases - double the rate seen in primary stroke centres. Often (35%-49% of the time), thrombolysis was not given owing to an interval of more than 4.5 hours between stroke onset and arrival at hospital., Interpretation: The use of thrombolysis for acute stroke in Canada remains low and is limited by delays in both the arrival of patients to hospital and the in-hospital processes of neuroimaging and thrombolysis administration. Our data show the critical need for concerted national efforts to improve education regarding the treatment of acute stroke and speed up stroke management in the hospital setting.

Background: We studied the relationships among psychiatrist supply, practice patterns, and access to psychiatrists in Ontario Local Health Integration Networks (LHINs) with differing levels of psychiatrist supply., Methods: We analyzed practice patterns of full-time psychiatrists (n = 1379) and postdischarge care to patients who had been admitted to hospital for psychiatric care, according to LHIN psychiatrist supply in 2009. We measured the characteristics of psychiatrists' patient panels, including sociodemographic characteristics, outpatient panel size, number of new patients, inpatient and outpatient visits per psychiatrist, and percentages of psychiatrists seeing fewer than 40 and fewer than 100 unique patients. Among patients admitted to hospital with schizophrenia, bipolar disorder, or major depression (n = 21,123), we measured rates of psychiatrist visits, readmissions, and visits to the emergency department within 30 and 180 days after discharge., Results: Psychiatrist supply varied from 7.2 per 100 000 residents in LHINs with below-average supply to 62.7 per 100 000 in the Toronto Central LHIN. Population-based outpatient and inpatient visit rates and psychiatric admission rates increased with LHIN psychiatrist supply. However, as the supply of psychiatrists increased, outpatient panel size for full-time psychiatrists decreased, with Toronto psychiatrists having 58% smaller outpatient panels and seeing 57% fewer new outpatients relative to LHINs with the lowest psychiatrist supply. Similar patterns were found for inpatient practice. Moreover, as supply increased, annual outpatient visit frequency increased: the average visit frequency was 7 visits per outpatient for Toronto psychiatrists and 3.9 visits per outpatient in low-supply LHINs. One-quarter of Toronto psychiatrists and 2% of psychiatrists in the lowest-supply LHINs saw their outpatients more than 16 times per year. Of full-time psychiatrists in Toronto, 10% saw fewer than 40 unique patients and 40% saw fewer than 100 unique patients annually; the corresponding proportions were 4% and 10%, respectively, in the lowest-supply LHINs. Overall, follow-up visits after psychiatric discharge were low, with slightly higher rates in LHINs with a high psychiatrist supply., Interpretation: Full-time psychiatrists who practised in Ontario LHINs with high psychiatrist supply saw fewer patients, but they saw those patients more frequently than was the case for psychiatrists in low-supply LHINs. Increasing the supply of psychiatrists while funding unlimited frequency and duration of psychotherapy care may not improve access for patients who need psychiatric services.

Objectives: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain (CP) in individuals on waitlists of Canadian multidisciplinary pain treatment facilities. This article focuses on sex differences. Objectives were to (1) determine the pain characteristics and related biopsychosocial factors that best differentiated women and men with CP; and (2) examine whether public and private costs associated with CP differed according to sex., Materials and Methods: Sample consisted of 441 women and 287 men who were evaluated using self-administered questionnaires and a structured interview protocol. A subsample (233 women and 137 men) recorded all pain-related expenditures in a comprehensive diary over 3 months., Results: Results revealed that the burden of illness associated with CP was comparable in both sexes for average and worst pain intensity, pain impact on daily living, quality of life, and psychological well-being. The same was true for pain-related costs. The results of a hierarchical logistic regression analysis, in which sex was treated as the dependent variable, showed that factors that differentiated men and women were: work status, certain circumstances surrounding pain onset, present pain intensity, intake of particular types of pain medication, use of certain pain management strategies, pain beliefs, and utilization of particular health care resources., Discussion: This study suggests that women and men who are referred to multidisciplinary pain treatment facilities do not differ significantly in terms of their pain-related experience. However, the aspects that differ may warrant further clinical attention when assessing and managing pain.

Objective: To obtain estimates of direct health care costs for prostate cancer (PC) from diagnosis to death to inform state transition models., Methods: A stratified random sample of PC patients residing in 3 geographically diverse regions of Ontario, Canada, and diagnosed in 1993-1994, 1997-1998, and 2001-2002, was selected from the Ontario Cancer Registry. We retrieved patients' pathology reports to identify referring physicians and contacted surviving patients and next of kin of deceased patients for informed consent. We reviewed clinic charts to obtain data required to allocate each patient's observation time to 11 PC-specific health states. We linked these data to health care administrative databases to calculate resource use and costs (Canadian dollars, 2008) per health state. A multivariable mixed-effects model determined predictors of costs., Results: The final sample numbered 829 patients. In the regression model, total direct costs increased with age, comorbidity, and Gleason score (all P < 0.0001). Radical prostatectomy was the most costly primary treatment health state ($4676 per 100 days). Radical prostatectomy, hormone-refractory metastatic disease ($6398 per 100 days), and final (predeath) ($13,739 per 100 days) health states were significantly more costly (P < 0.05) than nontreated nonmetastatic PC ($3440 per 100 days), whereas the postprostatectomy ($732 per 100 days) and postradiation ($1556 per 100 days) states cost significantly less (P < 0.0001)., Conclusions: This study used an innovative but labor-intensive approach linking chart and administrative data to estimate health care costs. Researchers should weigh the potential benefits of this method against what is involved in implementation. Modifications in methodology may achieve similar gains with less outlay in individual studies. However, we believe that this is a promising approach for researchers wishing to advance the quality of costing in state transition modeling.

Objective: This study examined factors associated with living setting of patients with acquired brain injury at discharge from inpatient rehabilitation., Design: Retrospective cohort design., Subjects/patients: Cohort of patients first identified in acute care with a diagnostic code of traumatic or non-traumatic brain injury who also subsequently received inpatient rehabilitation in Ontario, Canada for fiscal years 2003/2004 to 2005/2006., Methods: Using logistic regression, we examined predisposing, need and enabling factors associated with living settings at discharge from inpatient rehabilitation (home/other versus residential care). Acute care and inpatient rehabilitation data were used., Results: The majority of patients (83%) were discharged home after inpatient rehabilitation. Among ABI patients, those with longer lengths of stay and patients living alone and in non-home settings at admission were significantly more likely to be living in a residential care setting at discharge. Conversely, patients with higher total function scores from the FIMTM Instrument and those receiving informal support at discharge were significantly less likely to be living in a residential care setting at discharge., Conclusion: Our findings suggest that informal support influences service utilization and provide evidence for its importance at discharge with respect to living in the community. Prior living arrangement and functional outcome at discharge significantly predicted discharge destination. Improving physical function and providing needed supports at discharge may be factors important to reduce the demand for residential care facilities.

The objectives were to describe times to diagnosis and initiation of treatment in pediatric ALL in Ontario from 1997 to 2007, and to measure their impact on OS and EFS. In 1000 children, the median times to diagnosis and treatment were both 1 day (IQR = 1-2). Those who began treatment >3 days after diagnosis had inferior OS (AHR = 2.49; 95% CI = 1.40-4.43; p = 0.002), and inferior EFS (AHR = 1.73; 95% CI = 1.01-2.96; p = 0.047) compared to those who began treatment ≤ 3 days after diagnosis. There was no statistically significant relationship between time to diagnosis and survival. Longer time to treatment was associated with worse survival in pediatric ALL; reasons for this relationship may be multi-factorial., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: To examine service use by adults with serious mental illness (SMI) rostered in new primary care models: enhanced fee-for-service (FFS), blended-capitation (CAP) and team-based capitation (TBC) models with and without mental health workers (MHW) in Ontario., Methods: This cross-sectional study used administrative health service databases to compare use of mental health and general health services among persons with SMI enrolled in new models (n = 125,233)., Results: Relative to persons rostered in enhanced FFS, those in CAP and TBC had fewer mental health primary care visits (adjusted rate ratios and 95% confidence limits: CAP: 0.77 [0.74, 0.81]; TBC with MHW: 0.72 [0.68, 0.76]; TBC with no MHW: 0.81 [0.72, 0.93]). Compared to patients in enhanced FFS, those in TBC models also had more mental health hospital admissions (TBC with MHW: 1.12 [1.05, 1.20]; TBC with no MHW: 1.22 [1.05, 1.41]). Patterns of use of general services were similar., Conclusion: Further attention to financial incentives in capitation that influence care of persons with SMI is necessary to determine if they are aligned with aims of primary care reform., (Copyright © 2014 Longwoods Publishing.)

Objective: To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis., Background: Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death., Methods: This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication., Results: From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13)., Conclusions: These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.

With increasing emphasis on the provision of home-based palliative care in Canada, economic evaluation is warranted, given its tremendous demands on family caregivers. Despite this, very little is known about the economic outcomes associated with home-based unpaid care-giving at the end of life. The aims of this study were to (i) assess the magnitude and share of unpaid care costs in total healthcare costs for home-based palliative care patients, from a societal perspective and (ii) examine the sociodemographic and clinical factors that account for variations in this share. One hundred and sixty-nine caregivers of patients with a malignant neoplasm were interviewed from time of referral to a home-based palliative care programme provided by the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, Toronto, Canada, until death. Information regarding palliative care resource utilisation and costs, time devoted to care-giving and sociodemographic and clinical characteristics was collected between July 2005 and September 2007. Over the last 12 months of life, the average monthly cost was $14 924 (2011 CDN$) per patient. Unpaid care-giving costs were the largest component - $11 334, accounting for 77% of total palliative care expenses, followed by public costs ($3211; 21%) and out-of-pocket expenditures ($379; 2%). In all cost categories, monthly costs increased exponentially with proximity to death. Seemingly unrelated regression estimation suggested that the share of unpaid care costs of total costs was driven by patients' and caregivers' sociodemographic characteristics. Results suggest that overwhelming the proportion of palliative care costs is unpaid care-giving. This share of costs requires urgent attention to identify interventions aimed at alleviating the heavy financial burden and to ultimately ensure the viability of home-based palliative care in future., (© 2013 John Wiley & Sons Ltd.)

Background: Population-based estimates of HIV prevalence, rates of new HIV diagnoses, and mortality rates among persons with HIV who have entered care are needed to optimize health service delivery and to improve the health outcomes of these individuals. However, these data have been lacking for Ontario., Methods: Using a validated case-finding algorithm and linked administrative health care databases, we conducted a population-based study to determine the prevalence of HIV and rates of new HIV diagnoses among adults aged 18 years or older in Ontario between fiscal year 1996/1997 and fiscal year 2009/2010, as well as all-cause mortality rates among persons with HIV over the same period., Results: Between 1996/1997 and 2009/2010, the number of adults living with HIV increased by 98.6% (from 7608 to 15,107), and the age- and sex-standardized prevalence of HIV increased by 52.8% (from 92.8 to 141.8 per 100,000 population; p < 0.001). Women and individuals 50 years of age or older accounted for increasing proportions of persons with HIV, rising from 12.8% to 19.7% (p < 0.001) and from 10.4% to 29.9% (p < 0.001), respectively, over the study period. During the study period, age- and sex-standardized rates of new HIV diagnoses decreased by 32.5% (from 12.3 to 8.3 per 100,000 population; p < 0.001) and mortality rates among adults with HIV decreased by 71.9% (from 5.7 to 1.6 per 100 adults with HIV; p < 0.001)., Interpretation: The prevalence of HIV infection in Ontario increased considerably between 1996/1997 and 2009/2010, with a greater relative burden falling on women and individuals aged 50 years of age or older. These trends may be due to the decreased rate of new diagnoses among younger men. All-cause mortality rates declined among persons with HIV who entered care.

Background: Acquired brain injury (ABI), which includes traumatic (TBI) and non-traumatic brain injury (nTBI), is a leading cause of death and disability worldwide. The objective of this study was to examine the trends, characteristics, cause of brain injury, and discharge destination of hospitalized older adults aged 65 years and older with an ABI diagnosis in a population with universal access to hospital care. The profile of characteristics of patients with TBI and nTBI causes of injury was also compared., Methods: A population based retrospective cohort study design with healthcare administrative databases was used. Data on acute care admissions were obtained from the Discharge Abstract Database and patients were identified using the International Classification of Diseases - Version 10 codes for Ontario, Canada from April 1, 2003 to March 31, 2010. Older adults were examined in three age groups - 65 to 74, 75 to 84, and 85+ years., Results: From 2003/04 to 2009/10, there were 14,518 episodes of acute care associated with a TBI code and 51, 233 episodes with a nTBI code. Overall, the rate of hospitalized TBI and nTBI episodes increased with older age groups. From 2007/08 to 2009/10, the percentage of patients that stayed in acute care for 12 days or more and the percentage of patients with delayed discharge from acute care increased with age. The most common cause of TBI was falls while the most common type of nTBI was brain tumours. The percentage of patients discharged to long term care and complex continuing care increased with age and the percentage discharged home decreased with age. In-hospital mortality also increased with age. Older adults with TBI and nTBI differed significantly in demographic and clinical characteristics and discharge destination from acute care., Conclusions: This study showed an increased rate of acute care admissions for both TBI and nTBI with age. It also provided additional support for falls prevention strategies to prevent injury leading to cognitive disability with costly human and economic consequences. Implications for increased numbers of people with ABI are discussed.

This study examined a population-based profile of older adults with acquired brain injury, and their functional outcomes, in in-patient rehabilitation. Older adults aged 65 and older admitted to in-patient rehabilitation from acute care with traumatic brain injury (TBI) (n = 1214) or non-traumatic brain injury (nTBI) (n = 1,530) from 2003/04 to 2009/10 in Ontario were identified. Demographic and clinical characteristics and the total function score from the FIM(™) Instrument were examined. The Discharge Abstract Database and National Rehabilitation Reporting System were used. Results indicated that older adults with TBI had significantly higher total function scores than those with nTBI at admission and at discharge (p < .001). However, both groups made significant (p < .001) and similar gains (p > .05) in total function scores. We conclude that older adults with TBI and nTBI make similar in-patient rehabilitation gains. Lower initial functional ability of nTBI patients on admission and patients' different clinical profiles have implications for clinical care and resources.

Introduction: The increasing attention on home-based service provision for end-of-life care has resulted in greater financial demands being placed on family caregivers. The purpose of this study was to assess publicly financed costs within a home-based setting from a societal perspective., Methods: A prospective cohort study design was employed. In all, 129 caregivers of palliative care patients were interviewed biweekly for a total of 667 interviews. Multiple regression analysis (log-linear regression and seemingly unrelated regression [SUR]) was conducted., Results: While publicly financed costs accounted for 20 percent of the full economic costs and increased with proximity to death, 76.7 percent of costs were borne by patients' caregivers in the form of unpaid caregiving. The share of publicly financed healthcare costs was driven by patients' and caregivers' sociodemographic and clinical characteristics., Conclusion: These findings warrant affording greater attention to policies and interventions intended to reduce the economic burden on palliative patients and their caregivers.

Helicobacter pylori (H. pylori) infection can be significantly reduced by immunization in mice. Th17 cells play an essential role in the protective immune response. Th1 immunity has also been demonstrated to play a role in the protective immune response and can compensate in the absence of IL-17. To further address the potential of Th1 immunity, we investigated the efficacy of immunization in mice deficient in IL-23p19, a cytokine that promotes Th17 cell development. We also examined the course of Helicobacter infection in unimmunized mice treated with Th1 promoting cytokine IL-12. C57BL/6, IL-12 p35 KO, and IL-23 p19 KO mice were immunized and challenged with H. pylori. Protective immunity was evaluated by CFU determination and QPCR on gastric biopsies. Gastric and splenic IL-17 and IFNγ levels were determined by PCR or by ELISA. Balb/c mice were infected with H. felis and treated with IL-12 therapy and the resulting gastric bacterial load and inflammatory response were assessed by histologic evaluation. Vaccine induced reductions in bacterial load that were comparable to wild type mice were observed in both IL-12 p35 and IL-23 p19 KO mice. In the absence of IL-23 p19, IL-17 levels remained low but IFNγ levels increased significantly in both immunized challenged and unimmunized/challenged mice. Additionally, treatment of H. felis-infected Balb/c mice with IL-12 resulted in increased gastric inflammation and the eradication of bacteria in most mice. These data suggest that Th1 immunity can compensate for the lack of IL-23 mediated Th17 responses, and that protective Th1 immunity can be induced in the absence of immunization through cytokine therapy of the infected host.

Objective: To examine the impact of anxiety disorders comorbid to bipolar disorder (BD) in a large, nationally representative sample, to describe the sociodemographic and clinical profiles of Canadians living with BD and with or without comorbid anxiety disorders, to identify the characteristics uniquely associated with comorbid anxiety, and to examine treatment patterns., Method: We analyzed data from the Canadian Community Health Survey: Mental Health and Well-Being, conducted among 38 492 Canadians. People meeting the criteria for BD (n = 808) were compared based on the presence or absence of an assessed anxiety disorder (that is, social phobia, panic disorder, and agoraphobia)., Results: People with BD and a comorbid anxiety disorder fare worse in terms of BD relapses, suicidality, and sleep disturbance, and are more likely to be taking psychiatric medication. They have more impairment in their work and social functioning and rate their health and life satisfaction lower. Despite the greater severity, they are not receiving additional psychological treatment, they feel they are not receiving the treatment they need, and they report more barriers to treatment., Conclusions: This study confirms the critical impact of comorbid anxiety on the course of BD in a large, nationally representative sample and reveals that the psychological treatment needs of this population are not being met. Clinical and research implications are discussed.

Background: A limited understanding of satisfaction with home-based palliative care currently exists., Aim: This study measured family caregivers' satisfaction with home-based physician and nursing palliative care services, and explored predictors of satisfaction, across the palliative care trajectory., Design: A longitudinal, cohort design was used. Family caregivers were interviewed by telephone by-weekly from palliative care admission until death. Satisfaction was assessed using the Quality of End-of-Life care and Satisfaction with Treatment (QUEST) questionnaire. Multiple logistic regression models were used to determine the extent to which demographic, quality of care, and service related variables predicted satisfaction., Setting/participants: Family caregivers (N=104) of palliative care patients., Results: Each of the nine quality of care parameters were consistently found to be significant predictors of overall satisfaction with palliative care., Conclusions: The results may inform key health policy issues. Specifically, knowledge of how quality of care parameters predict family caregivers' satisfaction over the course of the palliative care trajectory may aid managers responsible for resource allocation and the determination of home care standards.

Background: Cardiac rehabilitation (CR) is associated with mortality and morbidity benefits. Treatment adherence rates of 20% to 60% for patients with diabetes and obesity undermines CR effectiveness. Identification of factors that account for poorer adherence to CR in these populations is needed., Methods: Data from 12 003 CR patients from 1995 to 2010 were analyzed. Differences in characteristics were compared between groups of patients classified by the presence or absence of diabetes mellitus and obesity. Sequential logistic regression was conducted to examine the extent to which biopsychosocial factors account for the higher likelihood of CR non-adherence., Results: The proportion of CR non-adherence was 44% for patients without obesity or diabetes, 52% for patients with diabetes and no obesity, 56% for patients with obesity and no diabetes and 59% for patients with diabetes and obesity. After adjustment for all baseline factors, the presence of obesity or diabetes remained associated with an increased risk of CR nonadherence compared to no obesity or no diabetes (diabetes only [odds ratio (OR) 1.22; 95% confidence interval (CI) 1.08-1.38; p=0.001]; obesity only [OR 1.19; 95% CI 1.04-1.36; p=0.01]). The presence of both diabetes and obesity and their relationship to CR nonadherence is not significant (OR 1.14, 95% CI 0.947-1.37; p=0.16) after adjusting for body fat percentage and waist circumference., Conclusions: Diabetes and obesity were independent determinants of CR program nonadherence. The influence of having both diabetes and obesity was moderated by waist circumference and body fat percentage. Patients with diabetes mellitus, obesity or both may require greater attention and consideration with respect to CR delivery., (Copyright © 2013 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Despite evidence in favour of early cholecystectomy for most patients with acute cholecystitis, variation in practice has been reported across hospitals worldwide. We sought to characterize the extent and potential sources of variation in the performance of early cholecystectomy for acute cholecystitis within a large regional health care system., Methods: We used a population-based retrospective cohort design. The cohort was limited to adults with a first episode of acute cholecystitis, admitted through the emergency department. Patients were identified using administrative databases comprising all emergency department visits and hospital admissions in Ontario from 2004 to 2010. Patient and hospital characteristics associated with early cholecystectomy (within 7 d of emergency department presentation) were identified using multilevel logistic regression., Results: We identified 24 437 patients admitted to 106 hospitals with a first episode of acute cholecystitis. Most (58%, n = 14 286) underwent early cholecystectomy. Rates of early cholecystectomy varied widely across hospitals (median 51%, interquartile range [IQR] 25%-72%), even among healthy patients aged 18-49 years with uncomplicated cholecystitis (median 74%, IQR 41%-88%). Multivariable multilevel analysis showed that hospitals in the lowest quartile for volume of acute cholecystitis admissions had the lowest adjusted odds of early cholecystectomy (odds ratio 0.53, 95% confidence interval 0.35-0.78) and that hospital effects accounted for half (27%) of the explained variation (53%) in early cholecystectomy., Interpretation: Across the hospitals of a regional health care system, similar patients with acute cholecystitis did not receive comparable care. Hospital-specific initiatives should be considered to facilitate early cholecystectomy for patients with acute cholecystitis.

Background: Large multispecialty physician group practices, with a central role for primary care practitioners, have been shown to achieve high-quality, low-cost care for patients with chronic disease. We assessed the extent to which informal multispecialty physician networks in Ontario could be identified by using health administrative data to exploit natural linkages among patients, physicians, and hospitals based on existing patient flow., Methods: We linked each Ontario resident to his or her usual provider of primary care over the period from fiscal year 2008/2009 to fiscal year 2010/2011. We linked each specialist to the hospital where he or she performed the most inpatient services. We linked each primary care physician to the hospital where most of his or her ambulatory patients were admitted for non-maternal medical care. Each resident was then linked to the same hospital as his or her usual provider of primary care. We computed "loyalty" as the proportion of care to network residents provided by physicians and hospitals within their network. Smaller clusters were aggregated to create networks based on a minimum population size, distance, and loyalty. Networks were not constrained geographically., Results: We identified 78 multispecialty physician networks, comprising 12,410 primary care physicians, 14,687 specialists, and 175 acute care hospitals serving a total of 12,917,178 people. Median network size was 134,723 residents, 125 primary care physicians, and 143 specialists. Virtually all eligible residents were linked to a usual provider of primary care and to a network. Most specialists (93.5%) and primary care physicians (98.2%) were linked to a hospital. Median network physician loyalty was 68.4% for all physician visits and 81.1% for primary care visits. Median non-maternal admission loyalty was 67.4%. Urban networks had lower loyalties and were less self-contained but had more health care resources., Interpretation: We demonstrated the feasibility of identifying informal multispecialty physician networks in Ontario on the basis of patterns of health care-seeking behaviour. Networks were reasonably self-contained, in that individual residents received most of their care from providers within their respective networks. Formal constitution of networks could foster accountability for efficient, integrated care through care management tools and quality improvement, the ideas behind "accountable care organizations."

Background: Health system restructuring coupled with the preference of patients to be cared for at home has altered the setting for the provision of palliative care. Accordingly, there has been emphasis on the provision of home-based palliative care by multidisciplinary teams of health care providers. Evidence suggests that these teams are better able to identify and deal with the needs of patients and their family members. Currently there is a lack of literature examining the predictors of palliative care service use for various professional service categories., Objective: The purpose of this study was to examine the predictors of the propensity and intensity of five main health service categories in the last three months of life for home-based palliative care patients., Design: This was a prospective cohort study. The predictors of service use were assessed using a two-part model, which treats the decision to use a service (propensity) and the amount of service use (intensity) as two distinct processes. Propensity was modeled using a logistic regression and intensity was modeled using ordinary least squares regression., Results: The results indicate that each service category emerged with a different set of predictor variables. Common predictors of health service use across service categories were patient age and functional status. The results suggest that a consistent set of predictors across service categories does not exist, and thus the determinants of access to each service category are unique., Conclusion: These findings will help case managers, health administrators, and policy decision makers better allocate human resources to palliative patients.

Background: Current data on the clinical course of patients with acute cholecystitis managed with percutaneous cholecystostomy (PC) are limited by small sample size and imperfect follow-up. We present the characteristics and clinical course of a population-based cohort with acute cholecystitis managed with PC., Methods: We designed a retrospective cohort study using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region with a population of more than 13 million. From all adults with a first emergency admission for acute cholecystitis from 2004 to 2011, those managed with PC were included in the cohort. The cumulative incidences of subsequent cholecystectomy and death were calculated, considering death a competing risk to cholecystectomy. Polytomous logistic regression was then used to examine differences in patient characteristics across outcome status at 1 year: cholecystectomy, dead without cholecystectomy, or alive without cholecystectomy. Moreover, the risk of a gallstone-related ED visit or hospital admission after discharge was estimated using the Kaplan-Meier method., Results: Of 27,718 patients with acute cholecystitis, 890 (3.3%) underwent PC. The cohort was elderly with a mean (SD) age of 75 (14) years, and 14% were in the intensive care unit on the day of PC. In-hospital mortality was 5%. By 1 year after PC, only 40% had undergone cholecystectomy, while an additional 18% had died without cholecystectomy. The risk of a gallstone-related ED visit or hospital admission was 49% by 1 year after discharge., Conclusion: While PC is often performed with the intent of delayed cholecystectomy, less than half of patients actually go on to surgery. High mortality and likely ongoing contraindications to surgery preclude intervention in most patients, although the risk of gallstone-related ED visit or hospital admission remains high. Further prospective investigation is warranted to clarify the potential mortality and quality-of-life gains from elective cholecystectomy following PC., Level of Evidence: Prognostic study, level III.

Objective: To explore whether a discrepancy between the availability of trauma services (potential access) and trauma center utilization rates (realized access) exists, with the aim of informing strategies to improve access., Background: Lack of access to trauma center care has frequently been attributed to the geographic distribution of trauma centers. Alternatively, impeded access to trauma center care might be due to suboptimal triage practices in the setting of appropriate resources., Methods: Population-based retrospective cohort study of severely injured adult patients (2002-2010). Potential access to trauma center care was evaluated using network-based spatial analysis of census data and was defined as residing within 1 hour of a trauma center. Realized access to trauma center care was evaluated using population-based data sources and was defined as direct transport from the scene of injury to a trauma center. Concordance between potential and realized access (high, moderate, or low) was evaluated at the county level., Results: Of the population in the study region, 7,340,711 persons (60%) had potential access to trauma center care; persons in 11 counties (22%) had high potential access. Of 26,861 severely injured patients, 10,237 (38%) had realized access to trauma center care; patients in only 4 counties (8%) had high realized access. The concordance between potential and realized access was moderate (weighted κ = 0.49); 63% of counties (n = 7) with high potential access performed worse than expected and had moderate or low realized access., Conclusions: There is limited concordance between potential and realized access. Regions with high potential access had low realized access, and vice versa. This evaluation suggests that strategies to improve access must be based on understanding the distribution of centers and the triage practices used to access trauma care.

Background: Randomized trials and expert opinion support early laparoscopic cholecystectomy for most patients with acute cholecystitis (AC); however, practice patterns remain variable worldwide, and delayed cholecystectomy remains a common practice. We therefore present a population-based analysis of the clinical course of patients with AC discharged without cholecystectomy., Methods: Using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region encompassing 13 million persons, we identified adults with a first emergency admission for uncomplicated AC during the period of 2004 to 2011. In those discharged without cholecystectomy, the probability of a subsequent gallstone-related event (gallstone-related ED visit or hospital admission) was evaluated using Kaplan-Meier methods. The association of patient characteristics with time to first gallstone-related event after discharge was explored through multivariable time to event analysis., Results: Of 25,397 patients with AC, 10,304 (41%) did not undergo cholecystectomy on first admission. The probability of a gallstone-related event by 6 weeks, 12 weeks, and 1 year after discharge was 14%, 19%, and 29% respectively. Of these events, 30% were for biliary tract obstruction or pancreatitis. When controlling for sex, income, and comorbidity level, the risk of a gallstone-related event was highest for patients 18 years to 34 years old., Conclusion: For patients who do not undergo cholecystectomy on first admission for AC, the probability of a gallstone-related ED visit or hospital admission within 12 weeks of discharge is 19%. The increased risk in younger patients reinforces the value of early cholecystectomy in the nonelderly., Level of Evidence: Prognostic study, level III; therapeutic study, level IV.

Background: Cardiovascular disease (CVD) is a leading cause of hospitalizations, death, and health care costs. Although studies have shown that modifying CVD risk factors at the patient level improves patient prognosis, the effect of community-wide interventions at the population level has been uncertain., Objective: To evaluate the resource use and cost consequences of a community-wide Cardiovascular Health Awareness Program (CHAP)., Methods: Thirty-nine medium-sized communities in Ontario, Canada, participated in a community cluster randomized controlled trial stratified by population size and geographic location. All community-dwelling elderly residents (>65 years) in each community were included. Family physicians, pharmacists, community nurses, local organizations, and volunteers in the intervention communities implemented the program. Rates and costs of CVD hospitalizations, all hospitalizations, emergency department visits, physician visits, and prescription medication use in the year before and after the intervention were compared for the 19 control and 20 CHAP communities by using province-wide linked administrative databases. The cost of implementing and administrating CHAP in each community was combined with total community health care cost to determine the net cost effect., Results: CHAP was associated with a reduction in CVD hospitalization costs. There were no differences in utilization rates or costs for overall hospitalizations, in visits to emergency rooms, physicians, or specialists, or in the use of prescription medications. Results were robust over a range of cost assumptions., Conclusions: A community-wide CVD awareness program can be implemented and can reduce CVD-related hospitalization costs at the level of the community without a corresponding increase in overall health care costs., (Copyright © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Background: Among people living with HIV infection in the era of combination antiretroviral therapy (cART), admission to hospital may indicate inadequate community-based care. As such, population-based assessments of the utilization of inpatient services represent a necessary component of evaluating the quality of HIV-related care., Methods: We used a validated algorithm to search Ontario's administrative health care databases for all persons living with HIV infection aged 18 years or older between 1992/93 and 2008/09. We then conducted a population-based study using time-series and longitudinal analyses to first quantify the immediate effect of cART on hospital admission rates and then analyze recent trends (for 2002/03 to 2008/09) in rates of total and HIV-related admissions., Results: The introduction of cART in 1996/97 was associated with more pronounced reductions in the rate of hospital admissions among men than among women (for total admissions, -89.9 v. -60.5 per 1000 persons living with HIV infection, p = 0.003; for HIV-related admissions, -56.9 v. -36.3 per 1000 persons living with HIV infection, p < 0.001). Between 2002/03 and 2008/09, higher rates of total hospital admissions were associated with female sex (adjusted relative rate [RR] 1.15, 95% confidence interval [CI] 1.05-1.27) and low socio-economic status (adjusted RR 1.21, 95% CI 1.14-1.29). Higher rates of HIV-related hospital admission were associated with low socio-economic status (adjusted RR 1.30, 95% CI 1.17-1.45). Recent immigrants had lower rates of both total admissions (adjusted RR 0.70, 95% CI 0.61-0.80) and HIV-related admissions (adjusted RR 0.77, 95% CI 0.61-0.96)., Interpretation: We observed important socio-economic- and sex-related disparities in rates of hospital admission among people with HIV living in Ontario, Canada.

Background: More than a third of patients with severe injury who receive initial care at nontrauma centers (NTCs) are not transferred to trauma center care. In those who are transferred, significant delays have been described. The availability of specialists, imaging modalities, or critical care resources might significantly affect transfer practices., Methods: We undertook a population-based retrospective cohort study of adult patients with severe injury who were transported from the scene to an NTC. NTCs were characterized based on the availability of general and orthopedic surgeons, computed tomographic scanners, intensive care units, and emergency department staffing. NTCs that had all of the resources were characterized as resource rich, while those with none were characterized as resource limited. We evaluated the relationships between NTC resources and the likelihood and timeliness of interfacility transfer through the use of hierarchical regression modeling., Results: We identified 15,906 patients with severe injury across 192 NTCs (22% were resource limited, 57% were resource intermediate, and 21% were resource rich). Patients at resource rich centers, as compared with those at resource limited centers, were less likely to be transferred (27% vs. 50%, p < 0.001). This association persisted after adjustment for confounders (odds ratio, 0.66; 95% confidence interval, 0.47-0.92). Among patients who were transferred, median emergency department length of stay (ED-LOS) was 3.5 hours (interquartile range, 1.7-4.6 hours). However, ED-LOS varied significantly because resource rich centers had a greater proportion of patients experiencing prolonged ED-LOS when compared with resource limited centers (31% vs. 15%, p < 0.001). This association also persisted on multivariable analysis (odds ratio, 2.02; 95% confidence interval, 1.19-3.43)., Conclusion: Severely injured patients who received initial care in resource rich NTCs were less likely to be transferred to a trauma center compared with resource limited NTCs. Significant delays in the transfer process were identified. However, patients transferred from resource rich centers were more likely to experience prolonged ED-LOS compared with resource limited NTCs., Level of Evidence: Epidemiologic study, level II.

Background: Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada., Methods: A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective., Results: Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65% of the total treatment cost in the first year overwhelming all other cost components., Conclusions: The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.

Background: Disparities in access to services across genders have been reported in many healthcare settings. The extent to which this occurs in the case of emergency surgical care is unknown. We set out to evaluate whether gender is a determinant of access to trauma center care, particularly in the setting where trauma triage guidelines are strong facilitators to ensure that access is determined by physiologic status and injury characteristics., Methods: Population-based retrospective cohort analysis of severely injured (Injury Severity Score >15) adults surviving to reach hospital. Differential in access to trauma center care was evaluated for females compared with males. Secondary analyses evaluated gender-based differences in direct transport from the scene and transfer from nontrauma centers. The adjusted odd of trauma center care was determined using logistic regression models. Separate models were used to stratify patients based on age, mechanism, and injury severity., Results: We identified 26,861 severely injured patients; 35% were women. A smaller proportion of females received trauma center care compared with males (49% vs 62%; P < .0001), an association that persisted after adjustment for confounders (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.79-0.96). Emergency medical service personnel were less likely to transport females from the field to a trauma center compared with males (OR, 0.88; 95% CI, 0.81-0.97). Similarly, physicians were less likely to transfer females to trauma centers compared with males (OR, 0.85; 95% CI, 0.73-0.99)., Conclusion: Severely injured women were less likely to be directed to a trauma center across 2 types of providers. The reasons for this differential in access might be related to perceived difference in injury severity, likelihood of benefiting from trauma center care, or subconscious gender bias., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Helicobacter pylori (H. pylori) is a bacterial pathogen that resides at the gastric mucosa and has a world-wide prevalence of over 50%. Infection usually lasts for the life of the host, and although all infected individuals will develop histologic gastritis only a subset will develop symptomatic gastritis, peptic ulcer disease, gastric MALT lymphoma, or gastric adenocarcinoma. The bacterial and host factors that determine clinical outcome and influence the development of widely varying diseases have not been elucidated. We compared disease in Helicobacter-infected severe combined immunodeficient (SCID) mice on different genetic backgrounds with their corresponding immunocompetent partners to determine if the genetics of the host significantly impacts the innate inflammatory outcome, independent of variations in bacterial virulence factors. BALB/c SCID and C57BL/6 SCID mice developed equivalent histologic gastritis by 8 weeks of infection. Immunocompetent BALB/c mice and C57BL/6 mice developed significantly lower or higher degrees of inflammation respectively. Innate inflammation in immunodeficient mice on the C57BL/6 background remained low even in the absence of the regulatory cytokine IL-10. These results demonstrate that adaptive immunity is not required for the generation of low level inflammation in response to Helicobacter infection and that the degree of inflammation is consistent among different genetic backgrounds. Additionally, this inflammation is limited even in the absence of regulatory T cells.

Background: By ensuring timely access to trauma center (TC) care, well-organized trauma systems have the potential to significantly reduce injury-related mortality. However, undertriage continues to be a significant problem in many regional trauma systems. Taking a novel, population-based approach, we estimated the potential detrimental impact of undertriage to a non-TC (NTC) within a regional system., Methods: We performed a population-based, retrospective cohort study of TC effectiveness in a region with urban, suburban, and rural areas. Data were derived from administrative databases capturing all emergency department deaths and admissions in the region. Adult motor vehicle collision occupants presenting to any emergency department in the study region were included (2002-2010). Data were limited to patients with severe injury. The exposure of interest was initial triage destination (TC or NTC), regardless of later transfer to TC. Mortality was compared across groups, using an instrumental variable analysis to adjust for confounding., Results: Among 6,341 motor vehicle collision occupants, 45% (n = 2,857) were triaged from the scene of injury to a TC. Among patients transported from the scene to a NTC, 57% (n = 2,003) were transferred to a TC within 24 hours of initial evaluation. Compared with patients triaged to a NTC, adjusted mortality was lower among patients triaged directly to a TC, both at 24 hours (odds ratio: 0.58, 95% confidence interval: 0.41-0.84) and at 48 hours (odds ratio: 0.68, 95% confidence interval: 0.48-0.96). A trend toward reduced mortality with TC triage was also observed at 7 and 30 days., Conclusions: Our data are population-based evidence of the early benefits of direct triage to TC. Although many surviving patients are later transferred to a TC, initial triage to a NTC is associated with at least a 30% increase in mortality in the first 48 hours after injury., Level of Evidence: Therapeutic study, level IV., (Copyright © 2012 by Lippincott Williams & Wilkins.)

Alternate-level-of-care (ALC) days represent hospital beds that are taken up by patients who would more appropriately be cared for in other settings. ALC days have been found to be costly and may result in worse functional outcomes, reduced motor skills and longer lengths of stay in rehabilitation. This study examines the factors that are associated with acute care ALC days among patients with acquired brain injury (ABI). We used the Discharge Abstract Database to identify patients with ABI using International Classification of Disease-10 codes. From fiscal years 2007/08 to 2009/10, 17.5% of patients with traumatic and 14% of patients with non-traumatic brain injury had at least one ALC day. Significant predictors include having a psychiatric co-morbidity, increasing age and length of stay in acute care. These findings can inform planning for care of people with ABI in a publicly funded healthcare system.

Background: The aim of this paper is to examine factors associated with discharge destination after acquired brain injury in a publicly insured population using the Anderson Behavioral Model as a framework., Methods: We utilized a retrospective cohort design. Inpatient data from provincial acute care records from fiscal years 2003/4 to 2006/7 with a diagnostic code of traumatic brain injury (TBI) and non-traumatic brain injury (nTBI) in Ontario, Canada were obtained for the study. Using multinomial logistic regression models, we examined predisposing, need and enabling factors from inpatient records in relation to major discharge outcomes such as discharge to home, inpatient rehabilitation and other institutionalized care., Results: Multinomial logistic regression revealed that need factors were strongly correlated with discharge destinations overall. Higher scores on the Charlson Comorbidity Index were associated with discharge to other institutionalized care in the nTBI population. Length of stay and special care days were identified as markers for severity and were both strongly positively correlated with discharge to other institutionalized care and inpatient rehabilitation, compared to discharge home, in both nTBI and TBI populations. Injury by motor vehicle collisions was found to be positively correlated with discharge to inpatient rehabilitation and other institutionalized care for patients with TBI. Controlling for need factors, rural location was associated with discharge to home versus inpatient rehabilitation., Conclusions: These findings show that need factors (Charlson Comorbidity Index, length of stay, and number of special care days) are most significant in terms of discharge destination. However, there is evidence that other factors such as rural location and access to supplemental insurance (e.g., through motor vehicle insurance) may influence discharge destination outcomes as well. These findings should be considered in creating more equitable access to healthcare services across the continuum of care.