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BackgroundThere is an increasing prevalence of multiple conditions (multimorbidity) and multiple medications (polypharmacy) across many populations. Previous literature has focused on the prevalence and impact of these health states separately, but there is a need to better understand their co-occurrence.Methods and findingsThis study reported on multimorbidity and polypharmacy among middle-aged and older adults in two national datasets: the Canadian Longitudinal Study on Aging (CLSA) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Using consistent methodology, we conducted a cross-sectional analysis of CLSA participants and CPCSSN patients aged 45 to 85 years as of 2015. When multimorbidity was defined as two or more conditions, the prevalence was 66.7% and 52.0% in the CLSA and CPCSSN cohorts, respectively. The prevalence of polypharmacy was 14.9% in the CLSA cohort and 22.6% in the CPCSSN cohort when defined as five or more medications. Using the same cut-points, the co-occurrence of multimorbidity and polypharmacy was similar between the two cohorts (CLSA: 14.3%; CPCSSN: 13.5%). Approximately 20% of older adults (65 to 85 years) were living with both multimorbidity and polypharmacy (CLSA: 21.4%; CPCSSN: 18.3%), as compared to almost 10% of middle-aged adults (45 to 64 years) living with this co-occurrence (CLSA: 9.2%; CPCSSN: 9.9%). Across both cohorts and age groups, females had consistently higher estimates of multimorbidity, polypharmacy and the co-occurrence of multimorbidity and polypharmacy.ConclusionsThis study found that multimorbidity and polypharmacy are not interchangeable in understanding population health needs. Approximately one in five older adults in the CLSA and CPCSSN cohorts were living with both multimorbidity and polypharmacy, double the proportion in the younger cohorts. This has implications for future research, as well as health policy and clinical practice, that aim to reduce the occurrence and impact of multimorbidity and unnecessary polypharmacy to enhance the well-being of aging populations.

Objective: The COVID-19 pandemic highlighted and exacerbated health inequities worldwide. While several studies have examined the impact of individual social factors on COVID infection, our objective was to examine how interactions of social factors were associated with the risk of testing positive for SARS-CoV-2 during the first two years of the pandemic. Study design and setting: We conducted an observational cohort study using linked health administrative data for Ontarians tested for SARS-CoV-2 between January 1st, 2020, and December 31st, 2021. We constructed multivariable models to examine the association between SARS-CoV-2 positivity and key variables including immigration status (immigrants vs. other Ontarians), and neighbourhood variables for household size, income, essential worker status, and visible minority status. We report main and interaction effects using odds ratios and predicted probabilities, with age and sex controlled in all models. Results: Of 6,575,523 Ontarians in the cohort, 88.5 % tested negative, and 11.5 % tested positive for SARS-CoV-2. In all models, immigrants and those living in neighbourhoods with large average household sizes had greater odds of testing positive for SARS-CoV-2. The strength of these associations increased with increasing levels of neighbourhood marginalization for income, essential worker proportion and visible minority proportion. We observed little change in the probability of testing positive across neighbourhood income quintiles among other Ontarians who live in neighbourhoods with smaller households, but a large change in probability among other Ontarians who live in neighbourhoods with larger households. Conclusion: Our study found that SARS-CoV-2 positivity was greater among people with certain combinations of social factors, but in all cases the probability of testing positive was consistently greater for immigrants than for other Ontarians. Examining interactions of social factors can provide a more nuanced and more comprehensive understanding of health inequity than examining factors separately.

Abstract Background Advance care planning (ACP) is a process which enables patients to communicate wishes, values, fears, and preferences for future medical care. Despite patient interest in ACP, the frequency of discussions remains low. Barriers to ACP may be mitigated by involving non-physician clinic staff, preparing patients ahead of visits, and using tools to structure visits. An ACP care pathway incorporating these principles was implemented in longitudinal generalist outpatient care, including primary care/family medicine and general internal medicine, in two Canadian provinces. This study aims to understand clinician experiences implementing the pathway. Methods The pathway was implemented in one family practice in Alberta, two family practices in British Columbia (BC), and one BC internal medicine outpatient clinic. Physicians and allied health professionals delivered structured pathway visits based on the Serious Illness Conversation Guide. Twelve physicians and one social worker participated in interviews or focus groups at the end of the study period. Qualitative data were coded inductively using an iterative approach, with regular meetings between coders. Results Clinicians described experiences with the ACP care pathway, impact at the clinician level, and impact at the patient level. Within each domain, clinicians described barriers and facilitators experienced during implementation. Clinicians also reflected candidly about potential for future implementation and the sustainability of the pathway. Conclusions While the pathway was implemented slightly differently between provinces, core experiences were that implementation of the pathway, and integration with current practice, were feasible. Across settings, similar themes recurred regarding usefulness of the pathway structure and its tools, impact on clinician confidence and interactions with patients, teamwork and task delegation, compatibility with existing workflow, and patient preparation and readiness. Clinicians were supportive of ACP and of the pathway. Trial registration The study was prospectively registered with clinicaltrials.gov (NCT03508557). Registered April 25, 2018. https://classic.clinicaltrials.gov/ct2/show/NCT03508557 .

Background: Nephrologists routinely provide end-of-life care for patients with kidney failure (KF) on maintenance dialysis. Involvement of primary care and palliative care physicians may enhance this experience. Objective: The objective was to describe outpatient care patterns in the last year of life and the end-of-life acute care utilization for patients with KF on maintenance dialysis. Design: Retrospective cohort study using population-level health administrative data. Setting & Participants: Outpatient and inpatient care during the last year of life among patients who died between 2017 and 2019, receiving maintenance dialysis in Ontario, Canada. Measurements: The primary exposure is patterns of physician specialties providing outpatient care in the last year of life. Outcomes include outpatient encounters in the last year of life, acute care visitation in the last month of life, and place of death. Methods: We reported the count and percentage of categorical outcomes and the median (interquartile range) for numeric outcomes. We produced time series plots of the mean monthly percentage of encounters to different specialties stratified by physician specialty patterns. We evaluated differences in outcomes by physician specialty patterns using analysis of variance (ANOVA) and Pearson’s chi-square tests ( P < .05, two-tailed). Results: Among 6866 patients, the median age at death was 73, 36.1% were female, and 87.8% resided in urban regions. Three patterns emerged: a primary care, nephrology, and palliative care triad (25.5%); a primary care and nephrology dyad (59.3%); and a non-primary care pattern (15.2%). Palliative care involvement is concentrated near death. Of all, 81.4% spent at least 1 day in hospital or emergency department in the last month, but those with primary care, palliative care, and nephrology involvement had the fewest acute care deaths (65.8%). Limitations: Outpatient care patterns were defined using physician billing codes, potentially missing care from other providers. Conclusions: Nephrology and primary care predominantly manage outpatient care in the last year of life for patients with KF on maintenance dialysis, with consistent acute care use across care patterns except for the place of death. Future research should explore associations between patterns of care and end-of-life outcomes to identify the most optimal model of care for patients with KF on maintenance dialysis.

Abstract Background Advance care planning (ACP) is a process intended to help ensure people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness. Barriers to implementing ACP in primary care settings exist. Community-led ACP initiatives exist in British Columbia to engage the public directly. These initiatives may help prepare people for conversations with their primary care providers. The objectives of this study were to elicit primary care providers’ perceptions of the utility and desired content of community-led ACP activities and suggestions for integrating community-led ACP activities with primary care. Methods We conducted an online cross-sectional survey of primary care providers practicing in British Columbia, Canada in 2021. Both quantitative and qualitative survey questions addressed ACP engagement in practice, the perceived role and desired outcomes of community-led ACP activities, and ways to integrate community-led ACP activities with primary care. Results Eighty-one providers responded. Over 80% perceived a moderate or greater potential impact of community-led ACP activities. The most common reasons for not referring a patient to a community-led ACP activity were lack of awareness of the option locally (62.1%) and in general (44.8%). Respondents wanted their patients to reflect on their values, wishes and preferences for care, to have at least thought about their goals of care and to have chosen a substitute decision maker in the community. They indicated a desire for a summary of their patient’s participation and a follow-up discussion with them about their ACP. They suggested ways to integrate referral to programs into existing health care system structures. Conclusions Community-led ACP activities were perceived to be useful to engage and prepare patients to continue ACP discussions with clinicians. Efforts should be made to establish and integrate community-based ACP initiatives within existing primary care systems to ensure awareness and uptake.

Objective The objective was to analyse how the pandemic affected primary care access and comprehensiveness in chronic disease management by comparing primary care patterns before and during the early COVID-19 pandemic.Design We conducted a quasi-experimental pre–post design cohort study and reported indicators for the 21 months before and after the onset of the COVID-19 pandemic.Setting We used electronic medical record data from primary care clinics enrolled in the Canadian Primary Care Sentinel Surveillance Network from 1 January 2018 to 31 December 2021.Population The study population included patients (n=919 928) aged 18 years or older with at least one primary care contact from 12 March 2018 to 12 March 2020, in Canada.Outcome measures The study indicators included three indicators measuring access to primary care (encounters, blood pressure measurements and lab tests) and three for comprehensiveness (diagnoses, non-COVID-19 vaccines administered and referrals).Results 67.3% of the cohort was aged ≥40 years, 56.4% were female and 53.5% were from Ontario, Canada. Fewer patients received an encounter during the pandemic (91.5% to 81.5%), while the median (IQR) number of encounters remained the same (5 (2–1)) for those with access. Fewer patients received a blood pressure measurement (47.9% to 31.8%), and patients received fewer measurements during the pandemic (2 (1–4) to 1 (0–2)).Conclusions Encounters with primary care remained consistent during the pandemic, but in-person care, such as lab tests and blood pressure measurements, decreased. In-person care indicators followed temporally to national COVID-19 case counts during the pandemic.

ObjectiveGestational diabetes mellitus (GDM) is a common medical complication of pregnancy that leads to adverse outcomes for both infants and pregnant people. Early detection and treatment can mitigate these negative outcomes. The COVID-19 pandemic strained healthcare and laboratory services, including GDM screening programs. Adapted GDM screening guidelines were introduced in many jurisdictions. This study examined changes in uptake, modality, and experiences of GDM screening in Ontario, Canada during the COVID-19 pandemic.MethodsThis convergent mixed-method study involved a population-based retrospective cohort analysis of Ontario-based health administrative data to describe and compare gestational diabetes screening rates among 85,228 individuals with live, in-hospital births between January 1-March 31 before (2019) and during the COVID-19 pandemic (2021 and 2022). Descriptive analyses were conducted for GDM screening pathways aligning with usual and pandemic-adapted screening guidance. Qualitative descriptive interviews were conducted about experiences and decision-making of GDM screening with 43 Ontario residents who gave birth between May 2020 and December 2021. Data were integrated during the design and interpretation phases.ResultsThere were small but significant increases in GDM screening during the pandemic; likelihood of screening completion using any modality increased in 2021 and 2022 compared to 2019. Testing modality shifted; the alternate screening strategies introduced during COVID-19 were adopted by clinicians. Interview participants perceived GDM screening to be important and obligatory but accompanied by a degree of stress about potential COVID-19 exposure.ConclusionDespite health system challenges experienced in Ontario during the COVID-19 pandemic, GDM screening rates increased in the study population, demonstrating the success of adapted GDM screening guidelines. Decisions about screening modalities were driven by clinician expertise, and interview participants were satisfied to provide informed consent to these recommendations.

PurposePathological angiogenesis and vascular instability are observed in diabetic retinopathy (DR), diabetic macular edema (DME), and wet age-related macular degeneration (wAMD). Many receptor tyrosine kinases (RTKs) including vascular endothelial growth factor receptors (VEGFRs) contribute to angiogenesis, whereas the RTK TIE2 is important for vascular stability. Pan-VEGFR tyrosine kinase inhibitors (TKIs) such as vorolanib, sunitinib, and axitinib are of therapeutic interest over current antibody treatments that target only one or two ligands. This study compared the anti-angiogenic potential of these TKIs.MethodsA kinase HotSpot™ assay was conducted to identify TKIs inhibiting RTKs associated with angiogenesis and vascular stability. Half-maximal inhibitory concentration (IC50) for VEGFRs and TIE2 was determined for each TKI. In vitro angiogenesis inhibition was investigated using a human umbilical vein endothelial cell sprouting assay, and in vivo angiogenesis was studied using the chorioallantoic membrane assay. Melanin binding was assessed using a melanin-binding assay. Computer modeling was conducted to understand the TIE2-axitinib complex as well as interactions between vorolanib and VEGFRs.ResultsVorolanib, sunitinib, and axitinib inhibited RTKs of interest in angiogenesis and exhibited pan-VEGFR inhibition. HotSpot™ assay and TIE2 IC50 values showed that only axitinib potently inhibited TIE2 (up to 89%). All three TKIs effectively inhibited angiogenesis in vitro. In vivo, TKIs were more effective at inhibiting VEGF-induced angiogenesis than the anti-VEGF antibody bevacizumab. Of the three TKIs, only sunitinib bound melanin. TKIs differ in their classification and binding to VEGFRs, which is important because type II inhibitors have greater selectivity than type I TKIs.ConclusionsVorolanib, sunitinib, and axitinib exhibited pan-VEGFR inhibition and inhibited RTKs associated with pathological angiogenesis. Of the three TKIs, only axitinib potently inhibited TIE2 which is an undesired trait as TIE2 is essential for vascular stability. The findings support the use of vorolanib for therapeutic inhibition of angiogenesis observed in DR, DME, and wAMD.

Abstract Background Few studies have described the settings cancer decedents spend their end‐of‐life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death. Methods A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population‐level health administrative datasets in Ontario, Canada. Results Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end‐of‐life experience at home. Conclusions In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end‐of‐life may provide people dying of cancer with a preferred dying experience.

Background: Since 2015, the College of Family Physicians of Canada has certified enhanced skills in palliative care (PC) with a certificate of added competence. Aim: This study aimed to describe the ways family physicians with enhanced skills in PC contribute within their communities, the factors that influence ways of practicing, and the perceived impacts. Design: Secondary analysis of data from a multiple case study on the role and impacts of family physicians with enhanced skills (i.e., PC physicians) was undertaken. Setting/Participants: Interviews were conducted in 2018 to 2019 with PC and generalist family physicians and residents associated with six family medicine practice cases across Canada. An unconstrained qualitative content analysis was performed. Results: Twenty-one participants (nine PC physicians, five generalist family physicians, two residents, and five physicians with enhanced skills in other domains) contributed data. PC physicians worked by enhancing their own family practice or as focused PC physicians. Roles included collaborating with other physicians through consultations, comanaging patients (shared care), or assuming care of the patient as the main provider (takeover). PC physicians increased capacity among their colleagues, with some patient care and education activities not being remunerated. Funding models and other structures were perceived as incentivizing the takeover model. Conclusion: Family physicians with enhanced skills in PC contribute to comprehensive care through the end of life. Remuneration should support system capacity and relationships that enable family physicians to provide primary PC especially outside the takeover model.

Introduction: The College of Family Physicians of Canada (CFPC) offers the Certificate of Added Competence (CAC) program to designate a family physician with enhanced skills. In 2015, the College expanded its program to introduce enhanced certification in four new domains: Palliative Care, Care of the Elderly, Sports and Exercise Medicine, and Family Practice Anesthesia. In this study, we elicited perceptions from Canadian family physicians with and without the CAC on practice impacts associated with the program. Methods: Active family physicians in Canada with and without CACs were surveyed between November 2019 to January 2020. Descriptive statistics were generated to describe the perceptions of family physicians regarding the CAC program and its impacts on practice. Results: Respondents agreed with several benefits of the program including enhancing the capacity to deliver comprehensive care, alleviating the burden of patient travel by increasing the availability of care in rural and remote communities, and providing opportunities to engage in various collaborative care models and new leadership roles. All respondents perceived CAC holders to pursue the certificate to meet both professional interests and community needs. Conclusions: There is a need for strong and continued investment in systemic practice improvements that incentivize the delivery of comprehensive family medicine practice.

BackgroundSince the COVID-19 pandemic began, there have been concerns that interruptions to the health care system may have led to changes in primary care, especially for care of chronic conditions such as diabetes and heart failure. Such changes may have longer term implications for population health. ObjectiveThis study aims to describe the impacts of the COVID-19 pandemic on indicators of primary care access, comprehensiveness, and appropriateness among adult patients, as well as on specific indictors of chronic conditions. Additionally, this study aims to determine whether any identified changes were associated with patient sociodemographic characteristics and multimorbidity. MethodsThis is a retrospective, single-arm, pre-post study using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data. CPCSSN is a research network supported by a primary care electronic medical record database, comprising over 1500 physicians and nearly 2 million patients. We are examining changes in care (eg, frequency of contacts, laboratory tests and investigations, referrals, medications prescribed, etc) among adults. We will also examine indicators specific to evidence-based recommendations for care in patients with diabetes and those with heart failure. We will compare rates of outcomes during key periods of the pandemic between March 13, 2020, and December 31, 2022, with equal time periods before the pandemic. Differences will be examined among specific subgroups of adults, including by decade of age, number of comorbidities, and socioeconomic status. Regression models appropriate to outcome distributions will be used to estimate changes, adjusting for potential confounders. This analysis is part of a mixed-methods study with a qualitative component investigating how patients with diabetes with or without concurrent heart failure perceived the impact of the pandemic on access to primary care and health care–related decisions. This study was approved by the Hamilton Integrated Research Ethics Board (14782-C). ResultsThe start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. As of May 2023, the study cohort (n=875,934) is defined, data cleaning is complete, and exploratory analyses have begun. Extended analyses using 2022 data are planned once the new data becomes available. We will disseminate results through peer-reviewed publications and academic conference, as well as creating evidence briefs, infographics, and a video for policy maker and patient audiences. ConclusionsThis study will investigate whether the COVID-19 pandemic has resulted in changes in the provision of primary care in Canada and whether these potential changes have led to gaps in care. This study will also identify patient-level characteristics associated with changes in care patterns across the COVID-19 pandemic. Indicators specific to chronic conditions, namely diabetes and heart failure, will also be explored to determine whether there were changes in care of these conditions. Trial RegistrationClinicalTrials.gov NCT05813652; https://clinicaltrials.gov/ct2/show/NCT05813652 International Registered Report Identifier (IRRID)RR1-10.2196/49131

Objectives Frailty is a multidimensional syndrome of loss of reserves in energy, physical ability, cognition and general health. Primary care is key in preventing and managing frailty, mindful of the social dimensions that contribute to its risk, prognosis and appropriate patient support. We studied associations between frailty levels and both chronic conditions and socioeconomic status (SES).Design Cross-sectional cohort studySetting A practice-based research network (PBRN) in Ontario, Canada, providing primary care to 38 000 patients. The PBRN hosts a regularly updated database containing deidentified, longitudinal, primary care practice data.Participants Patients aged 65 years or older, with a recent encounter, rostered to family physicians at the PBRN.Intervention Physicians assigned a frailty score to patients using the 9-point Clinical Frailty Scale. We linked frailty scores to chronic conditions and neighbourhood-level SES to examine associations between these three domains.Results Among 2043 patients assessed, the prevalence of low (scoring 1–3), medium (scoring 4–6) and high (scoring 7–9) frailty was 55.8%, 40.3%, and 3.8%, respectively. The prevalence of five or more chronic diseases was 11% among low-frailty, 26% among medium-frailty and 44% among high-frailty groups (χ2=137.92, df 2, p

IntroductionPregnant people have a higher risk of severe COVID-19 disease. They have been disproportionately impacted by COVID-19 infection control policies, which exacerbated conditions resulting in intimate partner violence, healthcare access, and mental health distress. This project examines the impact of accumulated individual health decisions and describes how perinatal care and health outcomes changed during the COVID-19 pandemic.ObjectivesQuantitative strand: Describe differences between 2019, 2021, and 2022 birth groups related to maternal vaccination, perinatal care, and mental health care. Examine the differential impacts on racialized and low-income pregnant people.Qualitative strand: Understand how pregnant people's perceptions of COVID-19 risk influenced their decision-making about vaccination, perinatal care, social support, and mental health.Methods and analysisThis is a Canadian convergent parallel mixed-methods study. The quantitative strand uses a retrospective cohort design to assess birth group differences in rates of Tdap and COVID-19 vaccination, gestational diabetes screening, length of post-partum hospital stay, and onset of depression, anxiety, and adjustment disorder, using administrative data from ICES, formerly the Institute for Clinical Evaluative Sciences (Ontario) and PopulationData BC (PopData) (British Columbia). Differences by socioeconomic and ethnocultural status will also be examined. The qualitative strand employs qualitative description to interview people who gave birth between May 2020- December 2021 about their COVID-19 risk perception and health decision-making process. Data integration will occur during design and interpretation.Ethics and disseminationThis study received ethical approval from McMaster University and the University of British Columbia. Findings will be disseminated via manuscripts, presentations, and patient-facing infographics.Trial registrationRegistration: Clinicaltrials.gov registration number: NCT05663762.

Objectives Prescribing of symptom management medications may reflect the quality of end-of-life care provided to nursing home residents who are nearing death. The objective of this study was to examine variations in the prescribing of end-of-life symptom management medications in nursing home residents in the last 14 days of life. Approach This was a retrospective cohort study of nursing home residents age 65+ who died in Ontario, Canada between January 2017 and February 2020. Through expert consultations, we compiled a list of medications used to manage common end-of-life symptoms. Using routinely collected health administrative data held at ICES, we linked resident data to prescription claims to identify whether residents were prescribed these medications in the last 14 days of life. We grouped nursing homes into quintiles according to the proportion of decedents in a home who received ≥1 prescription and examined variations in resident and facility characteristics across quintiles. Results There were 55,029 deaths across 626 nursing homes. Overall, 64.8% of residents received at least one end-of-life symptom management medication. The proportion of dying residents who received ≥1 end-of-life medication ranged from 37.6% in quintile 1, 59.8% in quintile 2, 69.1% in quintile 3, 74.8% in quintile 4, and 82.9% in quintile 5. Opioids were the most commonly prescribed medications, with an average of 62.2% of residents receiving a prescription (35.9% to 81.2% across the quintiles). Nursing home residents that resided in homes in the lowest prescribing quintile were older and more likely to be Allophones (first language not English or French). Low prescribing homes were also larger, with a higher number of beds, and were more likely to be in rural areas. Conclusion The observed variations in the prescribing of medications to manage end-of-life symptoms in nursing home residents raises concerns that some residents may have received inadequate end-of-life symptom management. Prescription data may provide an opportunity to rapidly evaluate the quality of end-of-life care in nursing homes at a population level.

Objectives Our preliminary work revealed significant variations in the prescribing of end-of-life symptom management medications in nursing homes prior to the onset of the COVID-19 pandemic. In this study, we sought to explore whether the prescribing of end-of-life medications in nursing homes changed with the onset of the pandemic. Approach This was a retrospective cohort study of nursing home residents age 65+ who died in Ontario, Canada, divided into two time periods based on death date: pre-COVID-19 (January 1st, 2017 – March 17th, 2020) and during COVID-19 (March 18th, 2020 – March 31st, 2021). Using routinely collected health administrative data and our evidence-based end-of-life medications list, we linked resident data to prescription claims to identify whether residents were prescribed these medications in the last 14 days of life. We grouped homes into quintiles according to the proportion of decedents who received ≥1 prescription and examined changes in prescribing before and during COVID-19. Results Nursing homes in the lowest prescribing quintile prescribed, on average, 11.5% fewer end-of-life symptom management medications during COVID-19 compared to pre-pandemic. Conversely, homes in the highest quintile prescribed an average of 13.7% more medications during COVID-19. Nursing homes in the lowest quintile had more COVID-19-positive residents (33% of residents) compared to homes in the highest quintile (9% of residents). Additionally, nursing homes in the lowest prescribing quintile spent more time with active COVID-19 outbreaks compared to homes in the highest quintile (mean 72.7 days versus 24.1 days, respectively, standardized difference 0.819). Conclusion The COVID-19 pandemic has disproportionately impacted nursing homes across Canada. Our findings suggest that nursing homes with low rates of prescribing of end-of-life medications prior to the pandemic had even lower prescribing rates during the pandemic. These homes were also harder hit by COVID-19 infections and outbreaks.

Objectives The objective of this study was to describe the receipt of potentially non-beneficial interventions in the last 100 days of life of cancer patients and to examine variations in these interventions according to patient characteristics and cancer site. Approach We conducted a population-based retrospective cohort study of all adults age 18+ who died of cancer in Ontario, Canada between January 1, 2013 and December 31, 2017 using linked administrative health data held at ICES. Potentially non-beneficial interventions were captured via hospital discharge records and included chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy. We used bivariate analyses and multivariable Poisson regression to examine associations between the receipt of interventions and decedent age, sex, rurality, area-level income, and cancer site. Results Among the 125,755 decedents, the most common intervention was blood transfusion (18.1%) and major surgery (12.8%); 23.8% received no interventions, while 14% of decedents received 3+ interventions. Lower intervention rates were observed in older patients (adjusted rate ratio (RR) 0.46, 95% confidence interval (CI) 0.44-0.49 for age 95+ vs. 19-44), females (RR 0.93, 95% CI 0.92-0.94), and individuals living in higher income areas (RR 0.96, 95% CI 0.95-0.98 for highest vs. lowest income quintile). Higher intervention rates were observed in rural patients (RR 1.13, 95% CI 1.11-1.14). Patients with pancreatic cancer had the highest intervention rate (RR 1.13, 95% CI 1.10-1.16), while breast cancer patients had the lowest intervention rate (RR 0.86, 95% CI 0.84-0.89) compared to colorectal cancer patients. Conclusion Potentially non-beneficial interventions were common in the last 100 days of life of patients with cancer. Variations in interventions across patient demographics and cancer site may reflect differences in healthcare access, end-of-life care preferences, patients’ prognostic awareness, and disease factors.

Background: Infection control protocols, including visitor restrictions, implemented during the COVID-19 pandemic threatened the ability to provide compassionate, family-centered care to patients dying in the hospital. In response, clinicians used videoconferencing technology to facilitate conversations between patients and their families., Objectives: To understand clinicians' perspectives on using videoconferencing technology to adapt to pandemic policies when caring for dying patients., Methods: A qualitative descriptive study was conducted with 45 clinicians who provided end-of-life care to patients in 3 acute care units at an academically affiliated urban hospital in Canada during the first wave of the pandemic (March 2020-July 2020). A 3-step approach to conventional content analysis was used to code interview transcripts and construct overarching themes., Results: Clinicians used videoconferencing technology to try to bridge gaps in end-of-life care by facilitating connections with family. Many benefits ensued, but there were also some drawbacks. Despite the opportunity for connection offered by virtual visits, participants noted concerns about equitable access to videoconferencing technology and authenticity of technology-assisted interactions. Participants also offered recommendations for future use of videoconferencing technology both during and beyond the pandemic., Conclusions: Clinician experiences can be used to inform policies and practices for using videoconferencing technology to provide high-quality end-of-life care in the future, including during public health crises., (©2022 American Association of Critical-Care Nurses.)