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Aims This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. Methods We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. Results Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. Conclusion The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients. Cite this article: Bone Joint J 2023;105-B(2):180–189.

Background and ObjectivesThe multiple sclerosis (MS) population's survival from breast cancer and colorectal cancer is compromised. Cancer screening and timely diagnoses affect cancer survival and have not been studied in the MS cancer population. We investigated whether the diagnostic route, cancer stage, or diagnostic interval differed in patients with cancer with and without MS.MethodsWe conducted a matched population-based cross-sectional study of breast cancers (2007–2015) and colorectal cancers (2009–2012) in patients with MS from Ontario, Canada, using administrative data. Exclusion criteria included second or concurrent primary cancers, no health care coverage, and, for the patients without MS, those with any demyelinating disease. We based 1:4 matching of MS to non-MS on birth year, sex (colorectal only), postal code, and cancer diagnosis year (breast only). Cancer outcomes were diagnostic route (screen-detected vs symptomatic), stage (stage I vs all others), and diagnostic interval (time from first presentation to diagnosis). Multivariable regression analyses controlled for age, sex (colorectal only), diagnosis year, income quintile, urban/rural residence, and comorbidity.ResultsWe included 351 patients with MS and breast cancer, 1,404 matched patients with breast cancer without MS, 54 patients with MS and colorectal cancer, and 216 matched patients with colorectal cancer without MS. MS was associated with fewer screen-detected cancers in breast (odds ratio [OR] 0.68 [95% CI 0.52, 0.88]) and possibly colorectal (0.52 [0.21, 1.28]) cancer. MS was not associated with differences in breast cancer stage at diagnosis (stage I cancer, OR 0.81 [0.64, 1.04]). MS was associated with greater odds of stage I colorectal cancer (OR 2.11 [1.03, 4.30]). The median length of the diagnostic interval did not vary between people with and without MS in either the breast or colorectal cancer cohorts. Controlling for disability status attenuated some findings.DiscussionBreast cancers were less likely to be detected through screening and colorectal cancer more likely to be detected at early stage in people with MS than without MS. MS-related disability may prevent people from getting mammograms and colonoscopies. Understanding the pathways to earlier detection in both cancers is critical to developing and planning interventions to ameliorate outcomes for people with MS and cancer.

Background Few reports have evaluated prognostic modelling studies of tools used for surgical decision-making. This systematic review aimed to describe and critically appraise studies that have developed or validated multivariable prognostic models for post-operative liver decompensation following partial hepatectomy. Methods This study was designed using the CHARMS checklist. Following a comprehensive literature search, two reviewers independently screened candidate references for inclusion and abstracted relevant study details. Qualitative assessment was performed using the PROBAST tool. Results We identified 36 prognostic modelling studies; 25 focused on development only, 3 developed and validated models, and 8 validated pre-existing models. None compared routine use of a prognostic model against standard clinical practice. Most studies used single-institution, retrospective cohort designs, conducted in Eastern populations. In total, 15 different outcome definitions for post-operative liver decompensation events were used. Statistical concerns surrounding model overfitting, performance assessment, and internal validation led to high risk of bias for all studies. Conclusions Current prognostic models for post-operative liver decompensation following partial hepatectomy may not be valid for routine clinical use due to design and methodologic concerns. Landmark resources and reporting guidelines such as the TRIPOD statement may assist researchers, and additionally, model impact assessment studies represent opportunities for future research.

This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups.This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits.Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits.This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.

The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007–2010), Manitoba (2007–2011), Ontario (2007–2010), Nova Scotia (2007–2012), and Alberta (2004–2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient’s cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

ObjectivesRegional variation in cancer survival is an important health system performance measurement. We evaluated if regional variation in colon cancer survival may be driven by differences in the patient population, their health and healthcare utilisation, and/or cancer care delivery.DesignPopulation-based retrospective cohort study using routinely collected linked health administrative data.SettingOntario, Canada.ParticipantsPatients with colon cancer diagnosed between 1 January 2009 and 31 December 2012.OutcomeCancer-specific survival was compared across the province’s 14 health regions. Using accelerated failure time models, we assessed whether regional survival variations were mediated through differences in case mix, including age, sex, comorbidities, stage at diagnosis and colon subsite, potential marginalisation and/or prediagnosis healthcare.ResultsThe study population included 16 895 patients with colon cancer. There was statistically significant regional variation in cancer-specific survival. Three regions had cancer-specific survival that was between 30% (95% CI 1.03 to 1.65) and 39% (95% CI 1.13 to 1.71) longer and one region had cancer-specific survival that was 26% shorter (95% CI 0.58 to 0.93) than the reference region. For three of these regions, case mix explained between 26% and 56% of the survival variation. Further adjustment for rurality explained 22% of the remaining survival variation in one region. Adjustment for continuity of primary care and the diagnostic interval length explained 10% and 11% of the remaining survival variation in two other regions. Socioeconomic marginalisation, recent immigration and colonoscopy history did not explain colon cancer survival variation.ConclusionsCase mix accounted for much of the regional variation in colon cancer survival, indicating that efforts to monitor the quality of cancer care through survival metrics should consider case mix when reporting regional survival differences. Future work should repeat this approach in other settings and other cancer sites considering a broad range of potential mediators.

ObjectiveThere is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation.DesignWe conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18–99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex.ResultsThere were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%–55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, pConclusionThe substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decision-makers to address these potential inequalities in access in order to support the use of this medically necessary procedure.

336 Background: Pancreatic cancer is a leading cause of cancer death, largely due to vague presenting symptoms and late stage at diagnosis. Population-based administrative data can be a valuable resource for studying the diagnostic interval. The objective of this study was to determine the first encounter in the diagnostic interval and to calculate that interval in a cohort of patients with pancreatic cancer using an empirical approach. Methods: This is a retrospective, cohort study of patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) from 2007 – 2015 in Alberta, Canada. We used the Alberta Cancer Registry (ACR), physician billing claims, hospital discharge and emergency room visits to identify health encounters that occurred more frequently in the 3 months prior to diagnosis compared to those in the 3-24 months prior to diagnosis. We used statistical control charts to define the lookback period for each encounter category and identify the earliest encounter that represented the start of the diagnostic interval (index contact date). The end of the interval was the diagnosis date. Quantile regression was used to determine factors associated with the diagnostic interval. Results: We identified 3142 patients with PDAC. Median age of diagnosis was 71 (IQR 61-80). We identified an index contact date in 96.5% of the patients. The median length of the diagnostic interval was 76 days (IQR 21-191; 90th percentile 276 days). A higher Elixhauser comorbidity score (+18.57 days/ 1 point increase, 95% CI 16.07-21.07, p < 0.001) and stage 3 disease (+22.55 days, 95% CI 5.02-40.08, p = 0.01) was associated with a longer diagnostic interval. Conclusions: In this cohort of patients with pancreatic cancer, there was a wide range in the diagnostic interval with 10% of patients having a diagnostic interval approaching one year. Diagnostic interval research using administrative databases can understand variations in diagnosis times, can inform early detection efforts and can improve quality of care.