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To investigate the incidence of and factors associated with SARS–CoV‐2 testing and infection in immune‐mediated inflammatory disease (IMID) patients versus matched non‐IMID comparators from the general population. We conducted a population‐based, matched cohort study among adult residents from Ontario, Canada, from January 2020 to December 2020. We created cohorts for the following IMIDs: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases, multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica, and vasculitis. Each patient was matched with 5 patients without IMIDs based on sociodemographic factors. We estimated the incidence of SARS–CoV‐2 testing and infection in IMID patients and non‐IMID patients. Multivariable logistic regressions assessed odds of SARS–CoV‐2 infection. We studied 493,499 patients with IMIDs and 2,466,946 patients without IMIDs. Patients with IMIDs were more likely to have at least 1 SARS–CoV‐2 test versus patients without IMIDs (27.4% versus 22.7%), but the proportion testing positive for SARS–CoV‐2 was identical (0.9% in both groups). Overall, IMID patients had 20% higher odds of being tested for SARS–CoV‐2 (odds ratio 1.20 [95% confidence interval 1.19–1.21]). The odds of SARS–CoV‐2 infection varied across IMID groups but was not significantly elevated for most IMID groups compared with non‐IMID comparators. The odds of SARS–CoV‐2 infection was lower in IBD and MS and marginally higher in RA and iritis. Patients across all IMIDs were more likely to be tested for SARS–CoV‐2 versus those without IMIDs. The risk of SARS–CoV‐2 infection varied across disease subgroups.

ObjectiveTo examine the association between rheumatologist access, early treatment, and ongoing care of older-onset rheumatoid arthritis (RA) and healthcare utilization and costs following diagnosis.MethodsWe analyzed data from a population-based inception cohort of individuals aged > 65 years with RA in Ontario, Canada, diagnosed between 2002 and 2014 with follow-up to 2019. We assessed 4 performance measures in the first 4 years following diagnosis, including access to rheumatology care, yearly follow-up, timely treatment, and ongoing treatment with a disease-modifying antirheumatic drug. We examined annual healthcare utilization, mean direct healthcare costs, and whether the performance measures were associated with costs in year 5.ResultsA total of 13,293 individuals met inclusion criteria. The mean age was 73.7 (SD 5.7) years and 68% were female. Total mean direct healthcare cost per individual increased annually and was CAD $13,929 in year 5. All 4 performance measures were met for 35% of individuals. In multivariable analyses, costs for not meeting access to rheumatology care and timely treatment performance measures were 20% (95% CI 8-32) and 6% (95% CI 1-12) higher, respectively, than where those measures were met. The main driver of cost savings among individuals meeting all 4 performance measures were from lower complex continuing care, home care, and long-term care costs, as well as fewer hospitalizations and emergency visits.ConclusionAccess to rheumatologists for RA diagnosis, timely treatment, and ongoing care are associated with lower total healthcare costs at 5 years. Investments in improving access to care may be associated with long-term health system savings.

ObjectiveTo investigate coronavirus disease 2019 (COVID-19) hospitalization risk in patients with immune-mediated inflammatory diseases (IMIDs) compared with matched non-IMID comparators from the general population.MethodsWe conducted a population-based, matched cohort study using health administrative data from January to July 2020 in Ontario, Canada. Cohorts for each of the following IMIDs were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis (PsA), ankylosing spondylitis, systemic autoimmune rheumatic diseases (SARDs), multiple sclerosis (MS), iritis, inflammatory bowel disease, polymyalgia rheumatica, and vasculitis. Each patient was matched with 5 non-IMID comparators based on sociodemographic factors. We compared the cumulative incidence of hospitalizations for COVID-19 and their outcomes between IMID and non-IMID patients.ResultsA total of 493,499 patients with IMID (417 hospitalizations) and 2,466,946 non-IMID comparators (1519 hospitalizations) were assessed. The odds of being hospitalized for COVID-19 were significantly higher in patients with IMIDs compared with their matched non-IMID comparators (matched unadjusted odds ratio [OR] 1.37, adjusted OR 1.23). Significantly higher risk of hospitalizations was found in patients with iritis (OR 1.46), MS (OR 1.83), PsA (OR 2.20), RA (OR 1.42), SARDs (OR 1.47), and vasculitis (OR 2.07). COVID-19 hospitalizations were associated with older age, male sex, long-term care residence, multimorbidity, and lower income. The odds of complicated hospitalizations were 21% higher among all IMID vs matched non-IMID patients, but this association was attenuated after adjusting for demographic factors and comorbidities.ConclusionPatients with IMIDs were at higher risk of being hospitalized with COVID-19. This risk was explained in part by their comorbidities.

BACKGROUND:A small number of people with chronic obstructive pulmonary disease (COPD) receive pulmonary function testing around the time of diagnosis. Because omitting testing increases misdiagnosis, we sought to determine whether health outcomes differed between patients whose COPD was diagnosed with or without pulmonary function testing.METHODS:We conducted a longitudinal population study of patients with physician-diagnosed COPD from 2005 to 2012 using health administrative data from Ontario, Canada. We assessed whether having pulmonary function testing around the time of diagnosis was associated with the composite outcome of admission to hospital for COPD or all-cause death, using adjusted survival analysis.RESULTS:Chronic obstructive pulmonary disease was diagnosed in 68 898 patients during the study period; 41.2% of patients received peridiagnostic pulmonary function testing. In adjusted analysis, patients who underwent testing were less likely to die or be admitted to hospital for COPD (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.89–0.94) and were more likely to be prescribed an inhaled long-acting bronchodilator than patients who did not undergo testing. Subgroup analysis suggested that the association of testing and outcomes was confined to patients with COPD diagnosed in the ambulatory care setting (adjusted HR 0.80, 95% CI 0.76–0.84).INTERPRETATION:Confirmation of a COPD diagnosis using pulmonary function testing is associated with a decreased risk of death and admission to hospital for COPD. In ambulatory patients, this effect may be from increased use of appropriate COPD medications. The findings of this study validate current guideline recommendations that encourage pulmonary function testing for diagnosis in all patients with suspected COPD.

The diagnosis of COPD is made by objectively demonstrating nonreversible airflow obstruction of the lungs. Despite this, rates of pulmonary function testing (PFT) for diagnosis remain low. It is still not known why testing is underused.

IMPORTANCE Chronic obstructive pulmonary disease (COPD) is a common and deadly disease. Long-acting inhaled β-agonists and anticholinergics, first-line medications for COPD, have been associated with increased risk of cardiovascular outcomes. When choosing between the medications, patients and physicians would benefit from knowing which has the least risk. OBJECTIVE To assess the association of these classes of medications with the risk of hospitalizations and emergency department visits for cardiovascular events. DESIGN We conducted a nested case-control analysis of a retrospective cohort study. We compared the risk of events between patients newly prescribed inhaled long-acting β-agonists and anticholinergics, after matching and adjusting for prognostic factors. SETTING Health care databases from Ontario, the largest province of Canada, with a multicultural population of approximately 13 million. PARTICIPANTS All individuals 66 years or older meeting a validated case definition of COPD, based on health administrative data, and treated for COPD from September 1, 2003, through March 31, 2009. EXPOSURE New use of an inhaled long-acting β-agonist or long-acting anticholinergic. MAIN OUTCOME AND MEASURES An emergency department visit or a hospitalization for a cardiovascular event. RESULTS Of 191 005 eligible patients, 53 532 (28.0%) had a hospitalization or an emergency department visit for a cardiovascular event. Newly prescribed long-acting inhaled β-agonists and anticholinergics were associated with a higher risk of an event compared with nonuse of those medications (respective adjusted odds ratios, 1.31 [95% CI, 1.12-1.52; P < .001] and 1.14 [1.01-1.28; P = .03]). We found no significant difference in events between the 2 medications (adjusted odds ratio of long-acting inhaled β-agonists compared with anticholinergics, 1.15 [95% CI, 0.95-1.38; P = .16]). CONCLUSIONS AND RELEVANCE Among older individuals with COPD, new use of long-acting β-agonists and anticholinergics is associated with similar increased risks of cardiovascular events. Close monitoring of COPD patients requiring long-acting bronchodilators is needed regardless of drug class.

The rates of total joint arthroplasty (TJA) of the hip and knee have increased in North America over the last decade. While initially designed for elderly patients (70 years of age), several reports suggest that an increasing number of younger patients are undergoing joint replacements. This suggests that more people are meeting the indication for TJA earlier in their lives. Alternatively, it might indicate a broadening of the indications for TJA.

Studies of total joint arthroplasty (TJA) have not evaluated the costs and outcomes in the context of expected arthritis worsening.

Traumatic brain injury (TBI) is a leading cause of death and disability in developed countries. We document trends in TBI-related hospitalizations in Ontario, Canada, between April 1992 and March 2002, focusing on relationships between inpatient hospitalization rates, age, sex, cause of injury, severity level, and in-hospital mortality.

Chronic stable angina (CSA) is a major debilitating health problem in Canada. A paucity of relevant cardiovascular data sets has precluded a detailed examination of the impact of interventions on CSA-related costs and its broader economic burden.

This article surveyed the processes and policies underlying the routine collection of clinical data in acute care hospitals in Ontario, Canada. Although there is evidence of a small shortfall in the availability of human resources, most health records departments employ experienced staff with health records certification. However, there is much more important variation in the documented and undocumented processes used to generate routinely collected clinical data. Current guidelines and coding schedules are helpful but insufficient to guide the production of good quality data. The variations in the processes used to produce clinical data have important implications for the management, reimbursement, and planning of healthcare. This is particularly critical at a time when hospitals and other stakeholders, such as governments, are relying more and more on accurate, reliable, and comparable data.

Thrombosis is the primary cause of access failure in polytetrafluoroethylene grafts and arteriovenous fistulas. It can lead to significant patient and access morbidity and mortality, and is difficult to prevent medically. Intervention is largely limited to maximizing access patency by detecting culprit lesions early and intervening with angioplasty or surgical revision. The most efficacious monitoring strategy is undetermined.

Explanations for regional variation in the use of many medical and surgical treatments is controversial.

Background: In the era of chemo-immunotherapy, risk factors associated with survival in patients with diffuse large B-cell lymphoma (DLBCL) are largely limited to biologic characteristics of disease. Laboratory based studies have postulated that statins (through inhibition of the geranylgeranylation pathways) can induce apoptosis in DLBCL cells; pre-clinical data suggests an anti-cancer potential for metformin (through inhibition of cancer cell growth by activation of AMPK and inhibition of mTOR pathways) and cox-2 inhibitors (anti-proliferative effects through blockade of PI3K pathway, inhibition of angiogenesis and proliferation by blocking eicosanoid receptors). To date, these potential in-vitro benefits have not been demonstrated consistently in "real world" studies. Our objective was to assess the impact of medicines with a biologic potential on lymphoma outcome in the era of rituximab. Methods: We performed a retrospective population-based study of adults =66 years diagnosed with DLBCL or transformed lymphoma treated in Ontario, Canada. Administrative databases held at ICES were used to assess the impact of select medications on patient outcomes. All patients treated, with curative intent, with a rituximab containing regimen between January 2005 and December 2015 were included. A 1-year lookback of medication exposure prior to commencing rituximab was used. Cox regression analyses were performed to determine the relationship between medication exposure and lymphoma outcomes. Additional analyses were completed to control for known confounders of survival, including the number of comorbid conditions. Results: A total cohort of 4913 patients were treated with a rituximab containing regimen, most frequently R-CHOP, during the study timeframe. Median age was 75 years (IQR 70-80); 51% were male. The median number of cycles of chemotherapy was 6 (IQR 3-6). The median number of comorbidities was 11 (IQR 9-14). Sixty-nine percent had a high comorbidity score (=10); 26.4% moderate (6-9); and 4.7% low (0-5). Where mortality data was available, 52.1% of the cohort died at a median of 1 year, of whom 67% died due to DLBCL. In the year prior to commencing lymphoma therapy 45.7% received statin therapy; 16.3% metformin; and 25.0% cox-2 inhibitor. In the univariate analysis, statin exposure (HR 0.88; 0.8 - 0.97) was associated with improved survival, but exposure to cox-2 inhibitor (HR 0.82; 0.65 - 1.04) and metformin (HR 1.11; 0.98 - 1.26) had a no impact, during this timeframe. Adjusting for time varying exposure and demographic variables including socio-economic factors and comorbidities, we demonstrated that additional exposure to statin and cox-2 inhibitors in the 365 days prior to commencing lymphoma therapy was associated with a survival advantage, when compared to those who were never exposed. Statin exposure for 30 days (HR 0.97 [0.96-0.98]), 180 days (HR 0.84 [0.80-0.89]) and 365 days (HR 0.71 [0.63-0.79]) and cox-2 inhibitor exposure for 30 days (HR 0.95 [0.95-0.98]), 180 days (HR 0.76 [0.66-0.86]) and 365 days (HR 0.57 [0.43-0.74]) were independently associated with improved survival. In contrast metformin exposure had no impact on survival in this cohort. Patients with moderate (HR 1.69; 1.25 - 2.29) and high comorbidity scores (HR 3.16; 2.36 - 4.21) had significantly higher risk of mortality (p<0.0001). Increasing age (p<0.001; HR 1.05 [1.05-1.06]) and male sex (p=0.003; HR 1.13 [1.04-1.23]) were also associated with increased mortality.

Background: In the era of chemo-immunotherapy, risk factors associated with survival in patients with diffuse large B-cell lymphoma (DLBCL) are largely limited to biologic characteristics of disease. Laboratory based studies have postulated that statins (through inhibition of the geranylgeranylation pathways) can induce apoptosis in DLBCL cells; pre-clinical data suggests an anti-cancer potential for metformin (through inhibition of cancer cell growth by activation of AMPK and inhibition of mTOR pathways) and cox-2 inhibitors (anti-proliferative effects through blockade of PI3K pathway, inhibition of angiogenesis and proliferation by blocking eicosanoid receptors). To date, these potential in-vitro benefits have not been demonstrated consistently in “real world” studies. Our objective was to assess the impact of medicines with a biologic potential on lymphoma outcome in the era of rituximab.

Introduction

No relevant conflicts of interest to declare.

Buckstein: Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Despite advances in treatment for diffuse large B cell lymphoma (DLBCL), approximately one third of patients will relapse, with known risk factors largely limited to the biology of the disease. Recently, patient selection bias has been highlighted as a concern in patients enrolled in DLBCL trials, as the need to categorize patients by cell-of-origin necessitates a prolonged screening period that might exclude patients with a need for urgent treatment and thus more aggressive biology (Maurer et al., JCO 2018). Whether an abbreviated diagnosis to treatment interval represents a surrogate for more aggressive disease and adverse prognosis is unclear in a “real-world” setting. We evaluated the time from diagnosis to treatment (and other pre-treatment time intervals) and additional socioeconomic and system-based variables and their impact on lymphoma outcomes.

Despite advances in the management of patients with hematologic malignancies, a significant proportion of patients will still die of their disease. Current quality indicators at the end of life (EOL) focus on whether patients receive aggressive interventions, including chemotherapy in the last days of life. However, frail patients and caregivers themselves have recently highlighted that “time spent at home” represents the most important measure of EOL quality care (Groff et al., NEJM 2016). This potential patient-determined quality indicator has not been previously studied in patients with hematologic malignancies.

ObjectivesTo identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified.DesignPropensity score matched cohort study.SettingOntario, CanadaParticipants37 881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery.Main outcome measureThe rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery.ResultsMultivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v1.3%, P=0.006; NNH 172) and revision (1.5% v1.0%, P=0.03; NNH 204).ConclusionsIn a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.

ObjectiveTo examine whether total joint arthroplasty of the hip and knee reduces the risk for serious cardiovascular events in patients with moderate-severe osteoarthritis.DesignPropensity score matched landmark analysis.SettingOntario, Canada.Participants2200 adults with hip or knee osteoarthritis aged 55 or more at recruitment (1996-98) and followed prospectively until death or 2011.Main outcome measureRates of serious cardiovascular events for those who received a primary total joint arthroplasty compared with those did not within an exposure period of three years after baseline assessment.ResultsThe propensity score matched cohort consisted of 153 matched pairs of participants with moderate-severe arthritis. Over a median follow-up period of seven years after the landmark date (start of the study), matched participants who underwent a total joint arthroplasty during the exposure period were significantly less likely than those who did not to experience a cardiovascular event (hazards ratio 0.56, 95% confidence interval 0.43 to 0.74, P<0.001). Within seven years of the exposure period the absolute risk reduction was 12.4% (95% confidence interval 1.7% to 23.1%) and number needed to treat was 8 (95% confidence interval 4 to 57 patients).ConclusionsUsing a propensity matched landmark analysis in a population cohort with advanced hip or knee osteoarthritis, this study found a cardioprotective benefit of primary elective total joint arthroplasty.