Search

Background Income disparities may affect patients’ care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited. Objective To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities. Design Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial. Participants Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals. Main Measures The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted. Key Results Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0–3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health. Conclusions There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Admitting hospitalized patients to off-service wards ("bedspacing") is common and may affect quality of care and patient outcomes.To compare in-hospital mortality, 30-day readmission to general internal medicine (GIM), and hospital length-of-stay among GIM patients admitted to GIM wards or bedspaced to off-service wards.Retrospective cohort study including all emergency department admissions to GIM between 2015 and 2017 at six hospitals in Ontario, Canada. We compared patients admitted to GIM wards with those who were bedspaced, using multivariable regression models and propensity score matching to control for patient and situational factors.Among 40,440 GIM admissions, 10,745 (26.6%) were bedspaced to non-GIM wards and 29,695 (73.4%) were assigned to GIM wards. After multivariable adjustment, bedspacing was associated with no significant difference in mortality (adjusted hazard ratio 0.95, 95% confidence interval [CI]: 0.86-1.05, p = .304), slightly shorter median hospital length-of-stay (-0.10 days, 95% CI:-0.20 to -0.001, p = .047) and lower 30-day readmission to GIM (adjusted OR 0.89, 95% CI: 0.83-0.95, p = .001). Results were consistent when examining each hospital individually and outcomes did not significantly differ between medical or surgical off-service wards. Sensitivity analyses focused on the highest risk patients did not exclude the possibility of harm associated with bedspacing, although adverse outcomes were not significantly greater.Overall, bedspacing was associated with no significant difference in mortality, slightly shorter hospital length-of-stay, and fewer 30-day readmissions to GIM, although potential harms in high-risk patients remain uncertain. Given that hospital capacity issues are likely to persist, future research should aim to understand how bedspacing can be achieved safely at all hospitals, perhaps by strengthening the selection of low-risk patients.

Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation.We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay.A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas (People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies.

Background: Heart failure (HF) affects many patients who are older and frail, presenting multiple physical barriers to accessing specialty care in a traditional ambulatory clinic model. Here, we present an assisted virtual care model in which a home visiting nurse facilitated video visits with a HF cardiologist to follow homebound, frail, and older patients with HF. Methods: This is a pragmatic, quasi-experimental, pre–post, single-centre study. It included homebound, frail, and older patients with HF from 2015 to 2019 who were followed for 1 year; in-person clinic visits were completely replaced by nurse-facilitated virtual video visits. Outcomes evaluated included annualized hospitalization rate, number of hospitalization days, and number of emergency department visits. Results: A total of 49 patients were included, with a median age of 86 (83-93) years, and were followed for 1 year after enrollment. Among patients enrolled, HF with preserved ejection fraction was the most common subtype (57%). Compared to the year prior to enrollment, patients had a lower mortality-adjusted all-cause annualized hospitalization rate in the year following enrollment (2.57 vs 1.78, P < 0.0001). Compared to the year prior, the number of mortality-adjusted all-cause hospitalization days was significantly lower in the year following enrollment (27.2 vs 21.4, P < 0.0001). There was a reduction in the number of all-cause annualized emergency department visits (3.10 vs 2.27, P = 0.003). Conclusions: Nurse-assisted virtual visits may be a preferable strategy for homebound, frail, and older patients with HF to receive longitudinal care. This approach may represent a plausible strategy to care for other patients with significant barriers to accessing specialized cardiac care. Résumé: Contexte: L’insuffisance cardiaque (IC) touche de nombreux patients âgés et fragiles, et dresse maints obstacles physiques à l’accès aux soins spécialisés au sein d’un modèle classique de soins cliniques ambulatoires. Dans le présent article, nous exposons un modèle de soins virtuels assistés où une infirmière visiteuse assure par vidéoconsultation, avec un cardiologue, le suivi de patients âgés et fragiles atteints d’IC confinés à la maison. Méthodologie: Une étude monocentrique et pragmatique, quasi expérimentale de type « avant-après », a été menée de 2015 à 2019 auprès de patients âgés et fragiles atteints d’IC confinés à la maison. Les patients ont été suivis durant un an; les consultations en personne ont été entièrement remplacées par des vidéoconsultations effectuées par une infirmière. Les paramètres évalués comprenaient le taux annualisé d’hospitalisation, le nombre de jours d’hospitalisation et le nombre de consultations aux urgences. Résultats: Au total, 49 patients dont l’âge médian était de 86 ans (83-93 ans) ont été suivis durant un an à compter de leur admission à l’étude. L’IC à fraction d’éjection préservée était le sous-type d’IC le plus fréquent (57 %) chez les patients participant à l’étude. Par comparaison à l’année précédente, le taux annualisé d’hospitalisation toutes causes confondues ajusté en fonction de la mortalité a été plus faible chez les patients au cours de l’année où ils ont été suivis dans le cadre de l’étude (2,57 vs 1,78, P < 0,0001). Toujours par comparaison à l’année précédente, le nombre de jours d’hospitalisation toutes causes confondues ajusté en fonction de la mortalité a été significativement inférieur chez les patients au cours de l’année où ils ont été suivis dans le cadre de l’étude (27,2 vs 21,4, P < 0,0001). Le nombre annualisé de consultations aux urgences toutes causes confondues a quant à lui diminué (3,10 vs 2,27, P = 0,003). Conclusions: Les consultations virtuelles assistées par une infirmière peuvent constituer une stratégie à privilégier dans la prestation de soins longitudinaux à des patients âgés et fragiles atteints d’IC qui sont confinés à la maison. Cette approche pourrait représenter une stratégie plausible pour prodiguer des soins à d’autres patients qui sont confrontés à d’importants obstacles limitant leur accès à des soins spécialisés en cardiologie.

BackgroundNeonatal care for preterm babies is prolonged and expensive. Our aim was to analyze and report costs associated with common preterm diagnoses during NICU stay.MethodsWe analyzed data from the Ontario healthcare data service. Diagnoses were collated by discharge ICD codes, and categorized by gestational age. We calculated typical non parametric statistics, and for each diagnosis we calculated median shifts and generalized linear mode.ResultsWe included data on 12,660 infants between 23 and 30 weeks gestation in 2005-2017. Calculated cost increment with diagnosis were: Intestinal obstruction: $94,738.08 (95%CI: $70,093.3, $117,294.2), Ventriculoperitoneal shunt: $86,456.60 (95%CI: $60,773.7, $111,552.2), Chronic Lung Disease $77,497.70 (95%CI: $74,937.2, $80,012.8), Intestinal perforation $57,997.15 (95%CI:$45,324.7, $70,652.6), Retinopathy of Prematurity: $55,761.80 (95%CI: $53,916.2, $57,620.1), Patent Ductus Arteriosus $53,453.70 (95%CI: $51,206.9, $55692.7, Post-haemorrhagic ventriculomegaly $41,822.50 (95%CI: $34,590.4, $48,872.4), Necrotizing Enterocolitis $39,785 (95%CI: $35,728.9, $43,879), Meningitis $38,871.85 (95%CI: $25,272.7, $52,224.4), Late onset sepsis $32,954.20 (95%CI: $30,403.7, 35.515), Feeding difficulties $24,820.90 (95%CI: $22,553.3, $27,064.7), Pneumonia $23,781.70 (95%CI: $18,623.8, $28,881.6), Grade >2 Intraventricular Haemorrhage $14,777.38 (95%CI: $9,821.7, $20,085.2). Adjusted generalized linear model of diagnoses as coefficients for cost confirmed significance and robustness of the model.ConclusionCost of care for preterm infant is expensive, and significantly increases with prematurity complication. Interventions to reduce those complications may enable resource allocation and better understanding of the needs of the neonatal health services.

ImportanceThere is an urgent need for evidence to inform preoperative risk assessment for the millions of people who have had SARS-CoV-2 infection and are awaiting elective surgery, which is critical to surgical care planning and informed consent.ObjectiveTo assess the association of prior SARS-CoV-2 infection with death, major adverse cardiovascular events, and rehospitalization after elective major noncardiac surgery.Design, Setting, and ParticipantsThis population-based cohort study included adults who had received a polymerase chain reaction test for SARS-CoV-2 infection within 6 months prior to elective major noncardiac surgery in Ontario, Canada, between April 2020 and October 2021, with 30 days follow-up.ExposuresPositive SARS-CoV-2 polymerase chain reaction test result.Main Outcomes and MeasuresThe main outcome was the composite of death, major adverse cardiovascular events, and all-cause rehospitalization within 30 days after surgery.ResultsOf 71 144 patients who underwent elective major noncardiac surgery (median age, 66 years [IQR, 57-73 years]; 59.8% female), 960 had prior SARS-CoV-2 infection (1.3%) and 70 184 had negative test results (98.7%). Prior infection was not associated with the composite risk of death, major adverse cardiovascular events, and rehospitalization within 30 days of elective major noncardiac surgery (5.3% absolute event rate [n = 3770]; 960 patients with a positive test result; adjusted relative risk [aRR], 0.91; 95% CI, 0.68-1.21). There was also no association between prior infection with SARS-CoV-2 and postoperative outcomes when the time between infection and surgery was less than 4 weeks (aRR, 1.15; 95% CI, 0.64-2.09) or less than 7 weeks (aRR, 0.95; 95% CI, 0.56-1.61) and among those who were previously vaccinated (aRR, 0.81; 95% CI, 0.52-1.26).Conclusions and RelevanceIn this study, prior infection with SARS-CoV-2 was not associated with death, major adverse cardiovascular events, or rehospitalization following elective major noncardiac surgery, although low event rates and wide 95% CIs do not preclude a potentially meaningful increase in overall risk.

ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use post-hospitalization.For sedative-naïve older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt?Population-based cohort study of ICU survivors ≥66 years who had not filled sedative prescriptions ≤6 months pre-hospitalization (sedative-naïve) in Ontario, Canada (2003 - 2019). Using multilevel logistic regression, we described demographic, clinical, and hospital characteristics and their association with new sedative prescription ≤7 days of discharge. We quantified variation between hospitals using the adjusted median odds ratio (aMOR). Factors associated with persistent prescriptions (≤6 months) were examined with multivariable proportional hazards model.250,428 patients were included (mean age 76, 61% male). 15,277 (6.1%) filled a new sedative prescription with variation across hospitals (2% (95% CI 1-3) to 44% (3-57)); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (aOR 4.00, 3.72-4.31); receipt of inpatient geriatric (aOR 1.95, 1.80-2.10) or psychiatry (aOR 2.76, 2.62-2.91) consultation, invasive ventilation (aOR 1.59, 1.53-1.66), and ICU length of stay ≥7 days (aOR 1.50, 1.42-1.58). The residual heterogeneity between hospitals (aMOR 1.43, 1.35-1.49) had a stronger association with new sedative prescriptions than Charlson comorbidity score or sepsis. Factors associated with persistent sedative use were similar with the addition of females (sHR 1.07, 1.02-1.13) and pre-existing polypharmacy (sHR 0.88, 0.80-0.93).One in 15 sedative-naïve older adult ICU survivors filled a new sedative ≤7 days of discharge, of whom more than half filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.

The World Health Organization (WHO) has recognized antimicrobial resistance (AMR) as a top threat to global health. However, the public has an incomplete understanding of AMR and its consequences.The aim of this study was to explore patients' understanding, perspective and health outcome expectations for antibiotic therapy within an inpatient internal medicine population.A mixed methods study, combining a cross-sectional survey with qualitative methods. Fourteen questions (10 paper survey and four open ended interview questions) were used, and were completed by the participant in one sitting. Participants were recruited from General Internal Medicine units at two academic hospitals in Canada (convenience sample).Thirty participants were included. Out of a scale of 1-100%, participants indicated moderate concern (mean of 40%) about getting an infection that could not be cured by antibiotics. The majority agreed that they trusted their healthcare team to decide on appropriate antibiotic therapy (mean of 81%). The participants strongly agreed (mean of 90%) that it was important to understand the rationale for their antibiotic therapyThe study results showed varying levels of patients' antibiotic knowledge and large gaps in awareness related to AMR. Exploring the role and workflow of interdisciplinary healthcare professionals may be a potential strategy to minimize patients' knowledge gap related to antimicrobial therapy and AMR.

To determine whether attendance at an acute kidney injury (AKI) follow-up clinic is associated with reduced major adverse kidney events.Propensity-Matched Cohort study.Patients hospitalized with AKI in Ontario, Canada, from February 1, 2013, to September 30, 2017, at a single clinical center discharged not dependent on dialysis.Standardized assessment by a nephrologist.Time to a major adverse kidney event, defined as death, initiation of maintenance dialysis, or incident/progressive chronic kidney disease.Propensity-scores were used to match each patient who attended an AKI follow-up clinic to four patients who received standard care. Cox proportional hazard models were fit to assess the association between the care within an AKI follow-up clinic and outcomes. To avoid immortal time bias, we randomly assigned index dates to the comparator group.We matched 164 patients from the AKI follow-up clinic to 656 patients who received standard care. Over a mean (SD) follow-up of 2.2 (1.3) years, care in the AKI follow-up clinic was not associated with a reduction in major adverse kidney events relative to standard care (22.1 versus 24.7 events per 100 patient-years, HR 0.91, 95% CI 0.75-1.11). The AKI follow-up clinic was associated with a lower risk of all-cause mortality (HR 0.71, 95% CI 0.55-0.91). Patients ≥66 years who attended the AKI follow-up clinic were more likely to receive beta-blockers (HR 1.34, 95% CI 1.02-1.77) and statins (HR 1.35, 95% CI 1.05-1.74), but not angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (HR 1.21, 95% CI 0.94-1.56).Single-center study and residual confounding.Specialized post-discharge follow-up for AKI survivors was not associated with a lower risk of major adverse kidney events but was associated with a lower risk of death and increased prescriptions for some cardioprotective medications.

Background Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents. Methods We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter. Results Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference −2.65%, 95% confidence interval [CI]: −4.93 to −.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports. Conclusions Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466.

Background Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation. Research Question What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD? Study Design and Methods A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort. Results Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P Interpretation In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.

An important potential unintended consequence of the growth of surgical subspecialization is the narrowing of surgical practice among comprehensive ophthalmologists. We investigated trends in the narrowing of surgical practice and the exclusive provision of cataract surgery.Population-based, retrospective study.All ophthalmologists and all ophthalmologic surgical patients in Ontario from 1994 to 2016.We linked several health care databases to evaluate the proportion of ophthalmologists who exclusively provided cataract surgery (and no other ophthalmologic surgery) and the proportion who provided other types of ophthalmologic surgical care. To further investigate surgical focus, we evaluated the proportion of surgical cases within each surgical area for each ophthalmologist.Between 1994 and 2016, the proportion of ophthalmologists who exclusively provided cataract surgery rose from 10.0% to 34.9% (p0.0001). In contrast, the proportions of ophthalmologists providing other types of subspecialized surgical care were stable over the study period. Cataract surgeons showed high degrees of focus with a median percentage of surgical cases approaching 100% in all years. Among exclusive cataract surgeons, the median annual cataract case volume increased from 138 (interquartile range: 87-214) to 529 (interquartile range: 346-643) between 1994 and 2009 (p0.0001) and then plateaued.Between 1994 and 2016, exclusive cataract surgical focus among ophthalmologists in Ontario rose dramatically from 1 in 10 to 1 in 3 surgeons. This evolution was similar among recent graduates and established ophthalmologists. Our data may have important implications for policies regarding surgeon human resources as well as residency and fellowship training programs.

Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre–post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre–post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre–post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.

Background:Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited.Objective:To support nursing home providers with the selection and adoption of ASP interventions.Design and Setting:A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting.Participants:A 16-member multidisciplinary panel of experts and resident representatives.Results:From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions.Conclusions:Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.

Background Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested 3 behavioral nudging techniques delivered by email to improve report opening. Methods We conducted a pragmatic randomized controlled trial among Ontario long-term care prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions. Results The trial included 421 physicians caring for >28 000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio [OR], 1.51 [95% confidence interval {CI}, 1.10–2.07], P = .011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR [aOR], 1.74 [95% CI, 1.24–2.45], P = .0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR, 1.62 [95% CI, 1.06–2.47], P = .026; aOR, 2.16 [95% CI, 1.33–3.50], P = .0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR, 1.28 [95% CI, 1.14–1.43], P Conclusions Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback. Clinical Trials Registration NCT04187742.

Identifying characteristics of disciplined surgeons is important for public safety. A database of all physicians disciplined by a Canadian provincial medical regulatory authority (College of Physicians and Surgeons) between 2000 and 2017 was constructed, and comparisons between surgeons and other physicians were undertaken. Of 1100 disciplined physicians, 174 (15.8 %) were surgeons. Obstetrics and gynecology was the specialty with the most disciplined surgeons (57 of 174 [32.8%]), followed by general surgery (48 of 174 [27.6%]). The overall disciplinary rate for surgeons was higher than for other physicians (12.59, 95 % confidence interval [CI] 10.69-14.83 v. 9.85, 95 % CI 8.88-10.94 cases per 10 000 physician-years

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

Background More than 50% of Canadian adult patients wait longer than four weeks to see a specialist after referral from primary care. Access to accurate wait time information may help primary care physicians choose the timeliest specialist to address a patient’s specific needs. We conducted a mixed-methods study to assess if primary to specialist care wait times can be extracted from electronic medical records (EMR), analyzed the wait time information, and used focus groups and interviews to assess the potential clinical utility of the wait time information. Methods Two family practices were recruited to examine primary care physician to specialist wait times between January 2016 and December 2017, using EMR data. The primary outcome was the median wait time from physician referral to specialist appointment for each specialty service. Secondary outcomes included the physician and patient characteristics associated with wait times as well as qualitative analyses of physician interviews about the resulting wait time reports. Results Wait time data can be extracted from the primary care EMR and converted to a report format for family physicians and specialists to review. After data cleaning, there were 7141 referrals included from 4967 unique patients. The 5 most common specialties referred to were Dermatology, Gastroenterology, Ear Nose and Throat, Obstetrics and Gynecology and Urology. Half of the patients were seen by a specialist within 42 days, 75% seen within 80 days and all patients within 760 days. There were significant differences in wait times by specialty, for younger patients, and those with urgently labelled medical situations. Overall, wait time reports were perceived by clinicians to be important since they could help family physicians decide how to triage referrals and might lead to system improvements. Conclusions Wait time information from primary to specialist care can aid in decision-making around specialist referrals, identify bottlenecks, and help with system planning. This mixed method study is a starting point to review the importance of providing wait time data for both family physicians, specialists and local health systems. Future work can be directed towards developing wait time reporting functionality and evaluating if wait time information will help increase system efficiency and/or improve provider and patient satisfaction.

OBJECTIVES Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs. DESIGN We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist. SETTING Critical care units. PATIENTS OR SUBJECTS Critical care patients. INTERVENTIONS Identified studies with cost-effectiveness analyses. MEASUREMENTS AND MAIN RESULTS We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]). CONCLUSIONS Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.

We implemented twice-weekly academic detailing rounds in 2015 as an antimicrobial stewardship (AMS) intervention in solid organ transplant (SOT) patients, led by an AMS pharmacist and a transplant infectious diseases physician. They reviewed SOT patients’ antimicrobials and made recommendations to prescribers on antimicrobial regimens, diagnostics investigations, and appropriate referrals for transplant infectious diseases consultation. To determine the impact of the intervention, we adjudicated antimicrobials prescriptions using established AMS principles, and compared the proportion of AMS-concordance regimens pre-intervention (2013) with post-intervention (2016) via 4-point-prevalence surveys conducted in each period. All admitted SOT patients who were receiving antimicrobial treatment on survey days were included. Primary outcome was the percentage of antimicrobial regimen adjudicated as AMS concordant. Secondary outcomes were percentage of AMS concordance in patients consulted by transplant infectious diseases; categories of AMS discordance; antimicrobial consumption in defined daily dose/100 patient-days (DDD/100PD); antimicrobial cost in CAD$/PD; and C. difficile infections. Balancing measures were length of stay, 30-day readmission, and in-hospital mortality. We compared outcomes using χ2 test or t-test; significant difference was defined as p

Background and objectivesRecent years have seen increasing calls for more proactive use of patient complaints to develop effective system-wide changes, analogous to the intended functions of incident reporting and root cause analysis (RCA) to improve patient safety. Given recent questions regarding the impact of RCAs on patient safety, we sought to explore the degree to which current patient complaints processes generate solutions to recurring quality problems.Design/settingQualitative analysis of semistructured interviews with 21 patient relations personnel (PRP), nursing and physician leaders at three teaching hospitals (Toronto, Canada).ResultsChallenges to using the patient complaints process to drive hospital-wide improvement included: (1) Complaints often reflect recalcitrant system-wide issues (eg, wait times) or well-known problems which require intensive efforts to address (eg, poor communication). (2) The use of weak change strategies (eg, one-off educational sessions). (3) The handling of complaints by unit managers so they never reach the patient relations office. PRP identified giving patients a voice as their primary goal. Yet their daily work, which they described as ‘putting out fires’, focused primarily on placating patients in order to resolve complaints as quickly as possible, which may in effect suppress the patient voice.ConclusionsUsing patient complaints to drive improvement faces many of the challenges affecting incident reporting and RCA. The emphasis on ‘putting out fires’ may further detract from efforts to improve care for future patients. Systemically incorporating patients’ voices in clinical operations, as with co-design and other forms of authentic patient engagement, may hold greater promise for meaningful improvements in the patient experience than do RCA-like analyses of patient complaints.

Purpose Tamsulosin is associated with intraoperative floppy iris syndrome (IFIS), an important risk factor for complications during cataract surgery. Significant efforts have been made to increase awareness of the risks associated with tamsulosin, and educational initiatives have fostered the uptake of technical adjustments to decrease adverse event rates among tamsulosin-exposed patients. However, the effectiveness of these efforts at the population level has not been studied. Design Population-based study to evaluate cataract surgical adverse event rates over time among patients exposed to tamsulosin and those not exposed to this drug. Participants All male patients 66 years of age and older undergoing cataract surgery in Ontario, Canada, between January 1, 2003, and December 31, 2013, were included in the study. Methods Linked healthcare databases were used to study the evolution in the risk of cataract surgical adverse events over time among tamsulosin-exposed and non–tamsulosin-exposed patients adjusting for patient-, surgeon-, and institution-level covariates. The study timeframe incorporated periods before and after the first reports of tamsulosin-associated IFIS. Main Outcome Measures Four important cataract surgical adverse events were evaluated: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Results Among patients exposed to tamsulosin, the risk of surgical adverse events decreased over time (odds ratio, 0.95 per year; 95% confidence interval, 0.91–0.99 per year). This trend was observed across patient age strata. Among patients not recently exposed to tamsulosin, the risk of surgical adverse events also decreased over time (odds ratio, 0.96 per year; 95% confidence interval, 0.95–0.98 per year). Conclusions The risk of cataract surgical complications among both tamsulosin-exposed and non–tamsulosin-exposed patients declined between 2003 and 2013. Tamsulosin remains an important risk factor for cataract surgical adverse events, and ongoing efforts will be needed to develop and disseminate surgical approaches that mitigate the risks posed by tamsulosin.

OBJECTIVES Antimicrobial stewardship is advocated to reduce antimicrobial resistance in ICUs by reducing unnecessary antimicrobial consumption. Evidence has been limited to short, single-center studies. We evaluated whether antimicrobial stewardship in ICUs could reduce antimicrobial consumption and costs. DESIGN We conducted a phased, multisite cohort study of a quality improvement initiative. SETTING Antimicrobial stewardship was implemented in four academic ICUs in Toronto, Canada beginning in February 2009 and ending in July 2012. PATIENTS All patients admitted to each ICU from January 1, 2007, to December 31, 2015, were included. INTERVENTIONS Antimicrobial stewardship was delivered using in-person coaching by pharmacists and physicians three to five times weekly, and supplemented with unit-based performance reports. Total monthly antimicrobial consumption (measured by defined daily doses/100 patient-days) and costs (Canadian dollars/100 patient-days) before and after antimicrobial stewardship implementation were measured. MEASUREMENTS AND MAIN RESULTS A total of 239,123 patient-days (57,195 patients) were analyzed, with 148,832 patient-days following introduction of antimicrobial stewardship. Antibacterial use decreased from 120.90 to 110.50 defined daily dose/100 patient-days following introduction of antimicrobial stewardship (adjusted intervention effect -12.12 defined daily dose/100 patient-days; 95% CI, -16.75 to -7.49; p < 0.001) and total antifungal use decreased from 30.53 to 27.37 defined daily doses/100 patient-days (adjusted intervention effect -3.16 defined daily dose/100 patient-days; 95% CI, -8.33 to 0.04; p = 0.05). Monthly antimicrobial costs decreased from $3195.56 to $1998.59 (adjusted intervention effect -$642.35; 95% CI, -$905.85 to -$378.84; p < 0.001) and total antifungal costs were unchanged from $1771.86 to $2027.54 (adjusted intervention effect -$355.27; 95% CI, -$837.88 to $127.33; p = 0.15). Mortality remained unchanged, with no consistent effects on antimicrobial resistance and candidemia. CONCLUSIONS Antimicrobial stewardship in ICUs with coaching plus audit and feedback is associated with sustained improvements in antimicrobial consumption and cost. ICUs with high antimicrobial consumption or expenditure should consider implementing antimicrobial stewardship programs.

BACKGROUND: Guidance from randomized clinical trials about the ongoing benefits of statin therapies in residents of long-term care facilities is lacking. We sought to examine the effect of statin dose on 1-year survival and admission to hospital for cardiovascular events in this setting. METHODS: We conducted a retrospective cohort study using population-based administrative data from Ontario, Canada. We identified 21 808 residents in long-term care facilities who were 76 years of age and older and were prevalent statin users on the date of a full clinical assessment between April 2013 and March 2014, and categorized residents as intensive- or moderate-dose users. Treatment groups were matched on age, sex, admission to hospital for atherosclerotic cardiovascular disease, resident frailty and propensity score. Differences in 1-year survival and admission to hospital for cardiovascular events were measured using Cox proportional and subdistribution hazard models, respectively. RESULTS: Using propensity-score matching, we included 4577 well-balanced pairs of residents who were taking intensive- and moderate-dose statins. After 1 year, there were 1210 (26.4%) deaths and 524 (11.5%) admissions to hospital for cardiovascular events among residents using moderate-dose statins compared with 1173 (25.6%) deaths and 522 (11.4%) admissions to hospital for cardiovascular events among those taking intensive-dose statins. We found no significant association between prevalent use of intensive-dose statins and 1-year survival (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.90 to 1.05) or 1-year admission to hospital for cardiovascular events (HR 0.99, 95% CI 0.88 to 1.12) compared with use of moderate-dose statins. INTERPRETATION: The rates of mortality and admission to hospital for cardiovascular events at 1 year were similar between residents in long-term care taking intensive-dose statins compared with those taking moderate-dose statins. This lack of benefit should be considered when prescribing statins to vulnerable residents of long-term care facilities who are at potentially increased risk of statin-related adverse events.

Background Patients who receive palliative care are less likely to die in hospital. Objective To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. Research design Population-based decedent cohort study using linked health administrative data in Ontario, Canada. Subjects A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. Exposure Physician annual rate of referral to palliative care (high, average, low). Measures Odds of death in hospital versus home, adjusted for patient characteristics. Results There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. Conclusions and relevance An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Objective: To estimate the bias associated with specific nonrandomized study attributes among studies comparing transcatheter aortic valve implantation with surgical aortic valve replacement for the treatment of severe aortic stenosis.Data sources and study selection: We searched 7 databases from inception to June 2017: Medline, Medline In-Process/ePubs, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included all RCTs and nonrandomized studies that reported outcomes of interest.Data extraction and synthesis: We categorized studies according to study design, and evaluated 41 nonrandomized study attributes as potential sources of bias. We calculated odds ratios (OR) and other effect measures with 95% confidence intervals (CI) using random effects models.Main outcomes: One month postoperative mortality, and length of stay. Bias was defined as the difference in estimates of treatment effects between nonrandomized studies and high quality (low risk of bias) RCTs, which were considered to provide “gold standard” estimates.Results: We included 6 RCTs and 87 nonrandomized studies. Surgical risk scores were similar for comparison groups in RCTs, but were higher for patients having transcatheter aortic valve implantation in nonrandomized studies. Nonrandomized studies underestimated the benefit of transcatheter aortic valve implantation compared with RCTs. For example, nonrandomized studies without adjustment estimated a higher risk of postoperative mortality for transcatheter aortic valve implantation compared with surgical aortic valve replacement (OR 1.43 [95% CI, 1.26 to 1.62]) than high quality RCTs (OR 0.78 [95% CI, 0.54 to 1.11). Nonrandomized studies using propensity score matching (OR 1.13 [95% CI, 0.85 to 1.52]) and regression modelling (OR 0.68 [95% CI, 0.57 to 0.81]) to adjust results estimated treatment effects closer to high quality RCTs. Nonrandomized studies describing losses to follow-up estimated treatment effects that were significantly closer to high quality RCT than nonrandomized studies that did not.Conclusion: Studies with different attributes produce different estimates of treatment effects. Study design attributes related to the completeness of follow-up may explain biased treatment estimates in nonrandomized studies, as in the case of aortic valve replacement where high-risk patients were preferentially selected for the newer (transcatheter) procedure.

INTRODUCTION Several differences have been reported between male and female patients with stroke in clinical and sociodemographic features, treatment, and outcomes. Potential effects in the inpatient rehabilitation population are unclear. OBJECTIVE To evaluate the differences between male and female patients in discharge functional status, length of stay, and discharge home after inpatient rehabilitation for stroke. DESIGN Retrospective, population-based cohort study. SETTING Inpatient rehabilitation centers in Ontario, Canada. PARTICIPANTS Male (N = 10,684) and female (N = 9459) patients discharged from acute care between September 1, 2012 and August 31, 2017, with a diagnosis of stroke and subsequently admitted to inpatient rehabilitation. EXPOSURE VARIABLE Female sex. MAIN OUTCOME MEASURES Discharge Functional Independence Measure (FIM) score, length of stay, and discharge home. RESULTS Female patients had a lower functional status at discharge (mean FIM score 94.1 vs. 97.8, p

As Ontario expands access to the COVID-19 vaccine beyond the Phase 1 priority populations, strategic planning and execution of mass vaccine rollout will have a significant impact on the health and safety of Ontario’s 14.5 million residents. There are six key elements of Israel’s successful COVID-19 vaccine campaign that can be readily applied to Ontario to expedite and expand the province’s vaccine rollout strategy: a simple vaccine prioritization process; modification to the transport, storage, and distribution of the vaccines; effective communication to promote vaccine confidence; decentralization of vaccination sites; centralized organization through Health Maintenance Organizations (HMOs) using a fully integrated information technology (IT) system in a universal health care system; and the engagement of community-based personnel, infrastructure, and resources.

BACKGROUND: Neonatal intensive care is expensive and prolonged. Extremely preterm infants are routinely supported. The costs for this practice at the age of borderline viability are of interest to clinicians and policymakers. METHODS: We analyzed data from the Canadian national administrative database on total cost and length of hospital care from a public payor perspective for 23–28-week premature infants from 2011 to 2015. We also compared total and daily costs for 23–25-week newborns. Each comparison evaluated the total cohort and infants who lived more than 3 days. We used non-parametric tests, correlation tests, and generalized linear models for cost difference analysis, adjusting for survival, length of stay, and year. RESULTS: We analyzed 6,932 infants’ cost records. For all infants, median length of hospital stay was 41 days (IQR, 1–77 days). For infants who survived the first 3 days, median length of stay was 61 days (IQR, 34–90 days). The median total cost was $66,669 (IQR, $4,920–$125,550). For infants who survived the first 3 days, median total cost was $91,137 (IQR, $56,596–$188,757). For infants who survived the first 3 days, median total costs were $147,835 (IQR, $44,711–$233,847) for 23-week infants, $154,736 (IQR, $61,160–$248,290) for 24-week infants, and $130,317 (IQR, $79,737–$229,058) for 25-week infants. These amounts did not differ (P>0.7). CONCLUSIONS: Total and daily costs of neonatal intensive care are high. Total cost was not different between surviving 23–25-week infants. These findings highlight the need for a funding strategy for the routine support of these fragile infants.

IMPORTANCE: The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear. OBJECTIVE: To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020. STUDY SELECTION: Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES: Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points). RESULTS: Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I(2) = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I(2) = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), −0.12; [95% CI, −0.20 to −0.03]; I(2) = 0%; Edmonton Symptom Assessment Scale score mean difference, −1.6 [95% CI, −2.6 to −0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, −0.24 to 0.61]; I(2) = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, −6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, −0.09 to 0.23]; I(2) = 68%). CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

BackgroundRegional variation in cost of neonatal intensive care for extremely preterm infant is not documented. We sought to evaluate regional variation that may lead to benchmarking and cost saving.MethodsAn analysis of a Canadian national costing data from the payor perspective. We included all liveborn 23–28-week preterm infants in 2011–2015. We calculated variation in costs between provinces using non-parametric tests and a generalized linear model to evaluate cost variation after adjustment for gestational age, survival, and length of stay.ResultsWe analysed 6932 infant records. The median total cost for all infants was $66,668 (Inter-Quartile Range (IQR): $4920–$125,551). Medians for the regions varied more than two-fold and ranged from $48,144 in Ontario to $122,526 in Saskatchewan. Median cost for infants who survived the first 3 days of life was $91,000 (IQR: $56,500–$188,757). Median daily cost for all infants was $1940 (IQR: $1518–$2619). Regional variation was significant after adjusting for survival more than 3 days, length of stay, gestational age, and year (pseudo-R2 = 0.9,p ConclusionCosts of neonatal intensive care are high. There is large regional variation that persists after adjustment for length of stay and survival. Our results can be used for benchmarking and as a target for focused cost optimization, savings, and investment in healthcare.

Background Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process. Methods Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations. Results Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant. Conclusions This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.

Objectives:Antibiotics are commonly used in intensive care units (ICUs), yet differences in antibiotic use across ICUs are unknown. Herein, we studied antibiotic use across ICUs and examined factors that contributed to variation.Methods:We conducted a retrospective cohort study using data from Ontario’s Critical Care Information System (CCIS), which included 201 adult ICUs and 2,013,397 patient days from January 2012 to June 2016. Antibiotic use was measured in days of therapy (DOT) per 1,000 patient days. ICU factors included ability to provide ventilator support (level 3) or not (level 2), ICU type (medical-surgical or other), and academic status. Patient factors included severity of illness using multiple-organ dysfunction score (MODS), ventilatory support, and central venous catheter (CVC) use. We analyzed the effect of these factors on variation in antibiotic use.Results:Overall, 269,351 patients (56%) received antibiotics during their ICU stay. The mean antibiotic use was 624 (range 3–1460) DOT per 1,000 patient days. Antibiotic use was significantly higher in medical-surgical ICUs compared to other ICUs (697 vs 410 DOT per 1,000 patient days; P < .0001) and in level 3 ICUs compared to level 2 ICUs (751 vs 513 DOT per 1,000 patient days; P < .0001). Higher antibiotic use was associated with higher severity of illness and intensity of treatment. ICU and patient factors explained 47% of the variation in antibiotic use across ICUs.Conclusions:Antibiotic use varies widely across ICUs, which is partially associated with ICUs and patient characteristics. These differences highlight the importance of antimicrobial stewardship to ensure appropriate use of antibiotics in ICU patients.

Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population‐based cohort study using linked health administrative data in Ontario, Canada of 74 986 community‐dwelling adults with heart failure who died between 2010 and 2015. Seventy‐five percent of community‐dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI , 2.03–2.20]; P CI , 9.34–15.11]; P CI , 6.41–10.27]; P Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end‐of‐life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end‐of‐life care in people dying with chronic noncancer illness.

Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation.What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD?A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort.Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P .001] and 1.62 [95% CI, 1.39, 1.90; P .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group.In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.

Objectives We aimed to evaluate the personal, professional, and psychological impact of the COVID-19 pandemic on hospital workers and their perceptions about mitigating strategies. Design Cross-sectional web-based survey consisting of (1) a survey of the personal and professional impact of the COVID-19 pandemic and potential mitigation strategies, and (2) two validated psychological instruments (Kessler Psychological Distress Scale [K10] and Impact of Events Scale Revised [IES-R]). Regression analyses were conducted to identify the predictors of workplace stress, psychological distress, and post-traumatic stress. Setting and participants Hospital workers employed at 4 teaching and 8 non-teaching hospitals in Ontario, Canada during the COVID-19 pandemic. Results Among 1875 respondents (84% female, 49% frontline workers), 72% feared falling ill, 64% felt their job placed them at great risk of COVID-19 exposure, and 48% felt little control over the risk of infection. Respondents perceived that others avoided them (61%), reported increased workplace stress (80%), workload (66%) and responsibilities (59%), and 44% considered leaving their job. The psychological questionnaires revealed that 25% had at least some psychological distress on the K10, 50% had IES-R scores suggesting clinical concern for post-traumatic stress, and 38% fulfilled criteria for at least one psychological diagnosis. Female gender and feeling at increased risk due to PPE predicted all adverse psychological outcomes. Respondents favoured clear hospital communication (59%), knowing their voice is heard (55%), expressions of appreciation from leadership (55%), having COVID-19 protocols (52%), and food and beverages provided by the hospital (50%). Conclusions Hospital work during the COVID-19 pandemic has had important personal, professional, and psychological impacts. Respondents identified opportunities to better address information, training, and support needs.

Background Most dementia care occurs in the community with support from informal caregivers who are often distressed. Dementia caregiver distress is known to be hazardous to the caregiver's health, but the impact on the dementia care recipient is not well known. Methods We searched the Medline, Embase, PsycINFO, CINAHL, and Cochrane databases from inception until June 2017 for studies investigating the association of informal caregiver distress with health outcomes of community-dwelling dementia care recipients. The search results were screened and then data abstracted, and the risk of bias was appraised independently by pairs of reviewers. Results We included 81 original investigations (n = 43 761 caregivers and dementia care recipients). Sixty-six studies (81.5%) were observational or cross-sectional in design, and 47 studies (58%) had a low risk of bias. There was considerable clinical and methodological heterogeneity precluding quantitative synthesis. Dementia care recipients (n = 21 881) had a mean age of 78.2 years (SD ± 3.8 y), half (50.0%) were women, and two-thirds (66.1%) had Alzheimer's disease. The dementia caregivers (n = 21 880) had a mean age of 62.5 years (SD ± 23.3), three-quarters (74.1%) were women, and one-half (50.5%) were spouses of the dementia care recipient. Twenty-two unique dementia care recipient outcomes were studied including cognition, mood, quality of life, function, healthcare utilization, and costs. Overall, informal caregiver distress is commonly associated with the institutionalization of the dementia care recipient, worsening behavioral and psychological symptoms of dementia, and experiencing elder abuse. Conclusion Informal caregiving is a cornerstone of dementia care, and distress related to this role is associated with worsening of several dementia care recipient health outcomes. It is important that clinicians and researchers worldwide consider the broader consequences of caregiver distress. J Am Geriatr Soc 67:609-617, 2019.

Background: Staphylococcus aureus bacteremia (SAB) results in high morbidity and mortality. Infectious diseases (ID) consultation for SAB has been associated with improved process measures and outcomes in SAB. Recent guidelines have been implemented to include ID consultation in the management of positive SAB culture. We sought to determine whether a policy of mandatory ID consultation for SAB would improve management and mortality. Methods: We conducted a retrospective quasi-experimental study of patients with SAB at three academic hospitals comparing adherence to process measures, and mortality as a secondary measure, before and after implementation of a hospital policy of mandatory ID consultation for all cases of SAB. Results: ID consultation was performed in 239/411 (58%) patients in the pre-intervention period and 196/205 (96%) patients in the post-intervention period (p < 0.0001). Compared with pre-intervention, mandatory consultation was associated with better adherence to quality process measures including echocardiography (319/411 (78%) versus 186/205 (91%) p < 0.0001), subsequent blood culture within 2–4 days (174/411 (42%) versus 143/205 (70%) p < 0.0001) and avoidance of vancomycin as definitive antibiotic therapy for methicillin-susceptible S. aureus (MSSA) (54/347 (16%) versus 13/177 (7%) p = 0.0082). In-hospital mortality rate was 94/411 (23%) in the pre-intervention group and 33/205 (16%) in the post-intervention group. The unadjusted sub-distribution hazard ratio (sHR) for in-hospital mortality in the postintervention period was 0.67 (95% CI 0.45 to 0.99, p = 0.0447). After adjusting for significant prognostic factors, post-intervention in-hospital mortality had an sHR of 0.79 (95% CI 0.52 to 1.20, p = 0.2686). Conclusions: A policy of mandatory ID consultation for patients with SAB was easily implemented leading to consultation in nearly all SAB patients and improved adherence to standard of care process measures. In-hospital mortality did not improve significantly after adjusting for patient characteristics. Our study provides the framework to support this easily implemented institutional policy in academic hospitals.

Purpose To determine whether patients with severe acute kidney injury who receive dialysis (AKI-D) experience better outcomes at centres that care for more patients with AKI-D. Materials and methods Linked administrative datasets where used to perform a retrospective cohort study of all critically ill patients in Ontario, Canada, who had a first episode of AKI-D between 2002 and 2011. Centre volume for a given year, was designated by calculating the mean number of patients treated with acute dialysis at that centre during that year and the one preceding it. Patients treated at that centre were then assigned to a centre volume quartile for that year. Results We identified 19,658 critically ill patients with AKI-D treated at 54 Ontario hospitals. Mortality and dialysis dependence at 90-days were 46% and 31%, respectively. Centre volume was not associated with mortality at 90 days (with quartile 1 as the reference, adjusted odds ratio (aOR) 1.16 (95% CI, 0.87 - 1.54) in quartile 2, aOR 1.17 (95% CI, 0.91 - 1.50) in quartile 3, and aOR 1.06 (95% CI, 0.81 - 1.41) in quartile 4). Conclusions There are no Centre volume survival associations in the management of AKI-D despite high mortality and dependence rate.

Objectives To evaluate whether risk of fall‐related injuries differs between nursing home (NH) residents newly dispensed low‐dose trazodone and those newly dispensed benzodiazepines. Design Retrospective, matched cohort study in linked, population‐based administrative data. Matching was based on propensity score ( ± 0.2 standard deviations of the score as a caliper), age ( ± 1 year), sex, frailty status, and history of dementia. The derived propensity score included demographic characteristics, clinical comorbidities, cognitive and functional status, and risk factors for falls. Setting All NHs in Ontario, Canada. Participants Propensity score–matched pairs of residents aged 66 and older who received a full clinical assessment between April 1, 2010, and March 31, 2015 (N=7,791). Measurements Hospitalization (emergency department visit or acute care admission) for a fall‐related injury within 90 days of exposure. Subdistribution hazard functions accounted for competing risk of death. Sensitivity analyses were used to examine falls resulting in hip or wrist fracture only, as well as different lengths of follow‐up at 30, 60, and 180 days. Results Cumulative incidence of a fall‐related injury in the 90 days after index was 5.7% for low‐dose trazodone users and 6.0% for benzodiazepine users (between‐group change=–0.29, 95% confidence interval (CI)=–1.02–0.44]; hazard ratio=0.94, 95% CI=0.83–1.08). Findings were consistent across sensitivity analyses. Conclusion New use of low‐dose trazodone was no safer with respect to a risk of a fall‐related injury than new use of benzodiazepines. Additional studies to compare the effectiveness and risks of low‐dose trazodone with those of a variety of psychotropic drug therapies are required in light of increasing trends in the use of trazodone in NHs.

Objectives To examine dose‐related prescribing and short‐term serious events associated with initiation of cholinesterase inhibitor (ChEI) therapy. Design Retrospective, population‐based cohort study. Setting Ontario, Canada. Participants Women (n=47,829) and men (n=32,503) aged 66 and older who initiated a ChEI between April 1, 2010, and June 30, 2016. Measurements All‐cause serious events (emergency department (ED) visits, inpatient hospitalizations, death) within 30 days of ChEI initiation. Multivariable Cox proportional hazards models were used to estimate adjusted rates of serious events. Results Overall, 4.8% of older adults were dispensed a lower‐than‐recommended ChEI starting dose, 87.9% a recommended dose, and 7.3% a higher‐than‐recommended starting dose. Eight thousand six hundred seventy‐one (10.8%) individuals experienced a serious event within 30 days of initiating therapy, primarily ED visits (8,540, 10.6%). Relative to those initiated on a recommended starting dose, those initiated on a higher dose had a significantly increased rate of serious events (women adjusted hazard ratio (aHR) 1.50, 95% confidence interval (CI) =1.38–1.63; men aHR 1.31, 95% CI=1.19–1.45). Similar patterns were found for ED visits and inpatient hospitalizations but not death. The relative effect of higher‐than‐recommended starting dose dispensed vs. recommended starting dose dispensed was greater in women than it was in men: the number needed to harm was 22 (95% confidence interval (CI)=18–29) for women and 36 (95% CI= 26–61) for men. Conclusion Serious events immediately after initiation of ChEIs were associated with starting ChEI dose. This association was stronger in women.

Laparoscopic adjustable gastric band (LAGB) placement remains a common bariatric procedure. While LAGB procedure is performed within private clinics in most Canadian provinces, public health care is often utilized for LAGB-related reoperations. We identified 642 gastric band removal procedures performed in Ontario from 2011 to 2014 using population-level administrative data. The number of procedures performed increased annually from 101 in 2011 to 220 in 2014. Notably, 54.7% of the patients required laparotomy, and 17.6% of patients underwent a subsequent bariatric surgery. Our findings demonstrated that LAGB placement in private clinics resulted in a large number of band removal procedures performed within the public system. This represents a significant public health concern that may result in significant health care utilization and patient morbidity.

Purpose A mapping review to quantify representation of vulnerable populations, who suffer from disparity and often inequitable healthcare, in quality improvement (QI) research. Data sources Studies published in 2004-2014 inclusive from Medline, Embase and Cochrane databases for English language research with the terms 'quality improvement' or 'quality control' or 'QI' and 'plan-do-study-act' or 'PDSA' in the years 2004-2014 inclusively. Study selection Published clinical research that was a QI-themed, as identified by its declared search terms, MESH terms, abstract or title. Data extraction Three reviewers identified the eligible studies independently. Excluded were publications that were not trials, evaluations or analyses. Results of data synthesis Of 2039 results, 1660 were eligible for inclusion. There were 586 (33.5%) publications that targeted a specific vulnerable population: children (184, 10.54%), mental health patients (125, 7.16%), the elderly (100, 5.73%), women (57, 3.27%), the poor (30, 1.72%), rural residents (29, 1.66%), visible minorities (27, 1.55%), the terminally ill (17, 0.97%), adolescents (16, 0.92%) and prisoners (1 study). Seventy-four articles targeted two or more vulnerable populations, and 11 targeted three population categories. On average, there were 158 QI research studies published per year, increasing from 69 in 2004 to 396 in 2014 (R2 = 0.7, P < 0.001). The relative representation of vulnerable populations had a mean of 33.58% and was stable over the time period (standard deviation (SD) = 5.9%, R2 = 0.001). Seven countries contributed to over 85% of the publications targeting vulnerable populations, with the USA contributing 62% of the studies. Conclusions Over 11 years, there has been a marked increase in QI publications. Roughly one-third of all published QI research is on vulnerable populations, a stable proportion over time. Nevertheless, some vulnerable populations are under-represented. Increased education, resources and attention are encouraged to improve the health of vulnerable populations through focused QI initiatives.