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To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic. Retrospective cohort study using routinely collected health administrative data in Ontario, Canada. We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021). For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles. We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%). LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak. [ABSTRACT FROM AUTHOR]

Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted. [ABSTRACT FROM AUTHOR]

• Prescribed safer opioid supply programs continue to expand across Canada. • We conducted a scoping review of client outcomes and client/provider perceptions. • Generally, program participation is associated with beneficial client outcomes. • Large population level studies are required to study rarer outcomes and diversion. • More research is needed for program adaption and to address unique regional needs. Safer opioid supply programs provide prescription pharmaceutical opioids, often with supportive services, to people at high risk of experiencing harms related to substance use. However, questions regarding the effectiveness and safety of this practice remain. We conducted a scoping review of literature describing client outcomes from formal opioid supply programs providing prescriptions for pharmaceutical opioids, and the perceptions of involved clients/providers. We performed a scoping review of peer-reviewed studies and grey literature published between January 1, 2012, to September 12, 2023. We included articles reporting either safer opioid supply client outcomes or clients/providers perspectives. Extracted data included study objectives, substance use patterns, client outcomes, client/provider perspectives, and estimates of effectiveness and/or harm. Our search yielded 1,597 articles. Following removal of duplicates and application of exclusion criteria, 24 publications comprising 17 peer-reviewed and seven grey literature publications were included in our study. We generated eight themes summarizing topics in the available literature: opioid-related toxicities, infectious complications, other clinical outcomes, client-reported outcomes, program access barriers, diversion, program retention, and costs to the healthcare system. Specific findings included low rates of opioid toxicities, improved physical and mental health, and improved quality of life among clients. A lack of access to adequate opioid doses and the limited range of opioid options offered within safer opioid supply programs was described by clients and providers as a potential reason for diversion and a barrier to program access. Generally, evidence suggests that safer opioid supply programs are beneficial to clients through measurable outcomes. However, the available literature has important limitations, including limited inferences about the effectiveness, safety, and potential for diversion within safer opioid supply programs. Further research is needed to support the ongoing evaluation of safer opioid supply programs as one component of a multifactorial response to escalating rates of substance-related harms. [ABSTRACT FROM AUTHOR]

Opioid use and related harms have been of growing concern in North America and elsewhere. In Canada, while policies and programs intended to mitigate opioid-related harms have been introduced by public health agencies, the medical profession, and different levels of government, there remains a paucity of evidence regarding the unintended consequences of these initiatives, including their impacts on people with chronic pain, a population often treated with opioids. This institutional ethnography investigated how opioid-related policies and programs are developed, deployed, and translated into practice in Ontario, Canada. Semi-structured interviews were conducted with people with chronic pain and practitioners to trace the institutional relations organizing opioid prescribing and use. Data analysis proceeded through an iterative process of identifying and mapping social relations, as well as textual analysis. Participants identified two policies that have been particularly impactful for people with chronic pain and clinicians: Ontario's Narcotics Monitoring System and the 2017 Guideline for Opioids for Chronic Non-Cancer Pain. Both interventions have contributed to fear among physicians that they will be investigated and disciplined by their licensing college for 'overprescribing' opioids. In the face of pressure to adhere to more conservative opioid prescribing practices, physicians have taken up strategies including rapidly tapering patients' doses and refusing to prescribe opioids. These changing work practices have had significant repercussions for people with chronic pain, such as increased pain, reduced quality of life, greater risks of harm, and the erosion of the physician–patient relationship. Policies intended to mitigate opioid-related harms by reducing the number of opioids prescribed have had repercussions for people with chronic pain and for practitioners. There is an urgent need to investigate the unintended and unanticipated impacts of drug policies, which may only be uncovered through explorations of people's everyday lives and experiences. [ABSTRACT FROM AUTHOR]

Objectives: The Coping Strategies Inventory-Short Form (CSI-SF) measures four coping strategies based on 16 items: 4 items each indicating problem- vs. emotion-focused engagement or disengagement. Here we provide the first assessment of reliability and construct validity of the CSI-SF among hemodialysis patients across 13 countries.Methods: The CSI-SF was completed by patients in 9 languages in phase 4 of the Dialysis Outcomes and Practice Patterns Study (2009-11). Cronbach's alpha was used to assess internal consistency. Exploratory and confirmatory factor analyses were applied to assess the factor structure of the CSI-SF by country and language. CSI-SF data were analyzed from 7201 patients (60% male; median age 62.5 [range 18-96] years).Results: Good internal consistency (α=0.56-0.80) was seen for three scales in English (US, UK, Canada, Australia, New Zealand), German, and Swedish versions. The fourth scale was internally consistent if two items were dropped. In these countries, both exploratory and confirmatory factor analyses indicated a factor structure consistent with the four CSI-SF scales. Other language versions showed a factor structure inconsistent with these four scales.Conclusion: The slightly modified English, German, and Swedish versions of the CSI-SF are reliable and valid instruments for measuring coping strategies in hemodialysis patients. [ABSTRACT FROM AUTHOR]

Background: Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms. However, many young people are not accessing OAT. This study sought to explore how young people navigated OAT over time, including periods of engagement, disengagement, and avoidance.Methods: Semi-structured, in-depth qualitative interviews were conducted between January 2018 and August 2020 with 56 young people in Vancouver, Canada who reported illicit, intensive heroin and/or fentanyl use. Following the verbatim transcription of longitudinal interviews, an iterative thematic analysis was used to extrapolate key themes.Results: Young people contemplating OAT expressed fears about its addictiveness. Many experienced pressure from providers and family members to initiate buprenorphine-naloxone, despite a desire to explore other treatment options such as methadone. Once young people initiated OAT, staying on it was difficult and complicated by daily witnessed dosing requirements and strict rules around repeated missed doses, especially for those receiving methadone. Most young people envisioned tapering off OAT in the not-too-distant future.Conclusions: Findings underscore the importance of working collaboratively with young people to develop treatment plans and timelines, and suggest that OAT engagement and retention among young people could be improved by expanding access to the full range of OAT; updating clinical guidelines to improve access to safer prescription alternatives to the increasingly poisonous, unregulated drug supply; addressing treatment gaps arising from missed doses and take-home dosing; and providing a clear pathway to OAT tapering. [ABSTRACT FROM AUTHOR]

• The impact of COVID-19 pandemic on child maltreatment investigators was examined. • The changes in work practices during the pandemic were investigated through a survey. • Child maltreatment investigators experienced greater stress levels during the pandemic. • Workers perceived higher stress levels among children and families receiving services. As cases of child maltreatment become an increasing concern during the COVID-19 pandemic, the perspectives of those charged with protecting and supporting children and families is an important area of inquiry. We sought to examine the experiences of child maltreatment workers during the first wave of the pandemic (i.e., May-July 2020). We specifically aimed to examine child maltreatment experiences related to the following: (1) their work practices during the pandemic, (2) their perceived safety during the pandemic, and (3) their perceptions on the safety of the children and families with whom they work. A total of 106 child maltreatment investigators and forensic interviewers provided responses to a national survey disseminated across Canada. Using a cross-sectional design, data were collected through a survey management program. The survey combined both open-ended and forced choice questions to gather perspectives on respondents' experiences. More than half (67%) reported a reduction in their caseloads during the pandemic (May-July 2020) and continued in-person interviews, with the use of preventative health measures (i.e., PPE, physical distancing, gloves). Most respondents reported elevated stress levels and similarly high stress levels amongst the children and families to whom they provide services. Overall, our findings highlight both how child maltreatment investigators have adapted to preventative measures and the continuing areas of weakness where further supports are required. [ABSTRACT FROM AUTHOR]

Background: Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists. Objective: To identify the practice patterns of clinical nurse specialists in Canada. Design: A descriptive cross-sectional survey. Participants: Self-identified clinical nurse specialists in Canada. Methods: A 50-item self-report questionnaire was developed, pilot-tested in English and French, and administered to self-identified clinical nurse specialists from April 2011 to August 2011. Data were analyzed using descriptive and inferential statistics and content analysis. Results: The actual number of clinical nurse specialists in Canada remains unknown. The response rate using the number of registry-identified clinical nurse specialists was 33% (804/2431). Of this number, 608 reported working as a clinical nurse specialist. The response rate for graduate-prepared clinical nurse specialists was 60% (471/782). The practice patterns of clinical nurse specialists varied across clinical specialties. Graduate- level education influenced their practice patterns. Few administrative structures and resources were in place to support clinical nurse specialist role development. The lack of title protection resulted in confusion around who identifies themselves as a clinical nurse specialist and consequently made it difficult to determine the number of clinical nurse specialists in Canada. Conclusions: This is the first national survey of clinical nurse specialists in Canada. A clearer understanding of these roles provides stakeholders with much needed information about clinical nurse specialist practice patterns. Such information can inform decisions about policies, education and organizational supports to effectively utilize this role in healthcare systems. This study emphasizes the need to develop standardized educational requirements, consistent role titles and credentialing mechanisms to facilitate the identification and comparison of clinical nurse specialist roles and role outcomes internationally. [ABSTRACT FROM AUTHOR]

Abstract: Context: The Provincial Palliative Care Integration Project (PPCIP) was implemented in Ontario, Canada, to enhance the quality of palliative care delivery. The PPCIP promoted collaboration and integration across service sectors to improve screening and assessment, palliative care processes, as well as clinician practice and outcomes for cancer patients. Objectives: The project involved 1) implementation of the Edmonton Symptom Assessment System (ESAS) for symptom screening, 2) use of “rapid-cycle change” quality improvement processes to improve screening and symptom management, and 3) improvements in integration and access to palliative care services. Methods: Symptom scores were collected and made accessible to the care team through a web-based tool and kiosk technology, which helped patients enter their ESAS scores at each visit to the regional cancer center or at home with their nurse. Symptom response data were gathered through clinical chart audits. Results: Within one year of implementation, regional cancer centers saw improvements in symptom screening (54% of lung cancer patients), symptom control (69% of patients with pain scores and 31% of patients with dyspnea scores seven or more were reduced to six or less within 72 hours), and functional assessment (23% of all patients and 64% of palliative care clinic patients). ESAS screening rates reached 29%, and functional assessment reached 26% of targeted home care patients. Conclusion: The PPCIP demonstrated that significant strides in symptom screening and response can be achieved within a year using rapid-cycle change and collaborative approaches. It showed that both short- and long-term improvement require ongoing facilitation to embed the changes in system design and change the culture of clinical practice. [Copyright &y& Elsevier]

Abstract: Purpose: To survey the current use and future plans for image-guided brachytherapy (BT) for cervical cancer by radiation oncologists in Canada. Methods and Materials: Canadian radiation oncologists treating gynecologic malignancies were identified in January 2009. A 29-item questionnaire (English and French) querying the current practice in the use of imaging in BT planning, and plans for transition to three-dimensional (3D) image guidance for BT for cervical cancer (curative intent, intact cervix), was electronically circulated. Questionnaire responses were tabulated and analyzed by respondent and by center. Results: Response rate was 62% (36 of 58 radiation oncologists), representing 71% (22 of 31) of Canadian radiation oncology centers with a gynecologic BT facility. Most of the centers were using high-dose-rate BT (68%), followed by low-dose-rate BT (23%) and pulsed dose-rate BT (10%). Main imaging used for treatment planning by center was plain X-ray (50%), computerized tomography (CT) (45%), and magnetic resonance imaging (MRI) (5%). For respondents using CT or MRI for planning, point A was the most common dose prescription point (50%), followed by gross tumor volume/clinical target volume as per Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology and Oncology guidelines (44%). For centers using plain X-rays for planning, 73% planned to transition to a 3D image-based approach, with the majority to adopt CT imaging. Eighty percent of respondents agreed that 3D image-guided BT should become standard of care for treatment of cervical cancer in Canada, and additionally support the development of national guidelines. Conclusions: Most of the Canadian radiation oncologists surveyed and Canadian cancer centers are either using 3D imaging and planning or transitioning to a 3D image-based approach within the next year. Point A remained a commonly documented prescription point. Access to MRI was very low. These results may lead to national treatment guidelines. [Copyright &y& Elsevier]

Abstract: Aims: A growing and aging population is associated with an increased incidence of cancer. Advances in radiotherapy technology have changed the way radiation is planned and delivered. This population-based study documented changes in workload and treatment complexity over a 10 year period in a Canadian province. Materials and methods: We examined the population-based radiation records of a provincial Canadian cancer centre from 2000 (or from 2005 for some measures) to 2009 inclusive. We propose new measures of workload and treatment complexity currently used in our centre that can be easily adopted by other cancer centres. Results: Workload measured by total new-to-doctor consultations increased 30% from 2000 to 2009 (3.3% annually, P =0.0008). Total treatment commencements increased 35% over the same time (3.9% annually, P <0.0001) but linear accelerator (linac) commencements increased at a slower rate of 2.0% annually (P =0.0002). The rates of increase in consultations and total commencements were faster than the rates of increase in the total population, the population over age 50 years, or the incidence of cancer. Implementation of stereotactic radiosurgery and increased brachytherapy treatments explain much of the increased workload. Measures of treatment complexity including simulations per linac course and radiation computer plans per linac course increased at steady rates of 3.6% (P =0.0019) and 3.2% (P =0.0088) annually, respectively, but portals (fields) per linac treatment course increased exponentially after the implementation of intensity-modulated radiotherapy. The number of fractions per linac patient declined by 2.6% annually (P <0.0001). Conclusions: This population-based study showed that radiation oncology workload increased at faster rates than the population or incidence of cancer. Measures of treatment complexity indicate an increasing investment for each course of linac treatment, but also the adoption of hypofractionated regimens. These results indicate that radiotherapy manpower requirements cannot be based on population or cancer incidence alone if current technological trends continue. [Copyright &y& Elsevier]

In-field cancer recurrence after previous adjuvant or radical radiotherapy presents particularly challenging clinical issues to the oncologists. A Canadian pattern of practice survey showed a wide range of approaches in treatment intent, planning and dose fractionation. A workshop on re-irradiation was conducted at the 2009 Canadian Association of Radiation Oncology annual scientific meeting, under the guidance of the Symptom Control Committee, in an effort to promote a uniform approach among radiation oncologists in their approach to re-irradiation. The workshop has made various recommendations in an effort to bring consistency among radiation oncologists across Canada to their approach towards re-irradiation. [Copyright &y& Elsevier]

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment. • The "problem" of prescription opioid diversion is examined. • Diversion was rationalized as a protective measure for others. • Social and structural contexts framed motivations for diversion. • Strategies are needed to reduce harms and alleviate contextual constraints. • Policies promoting decriminalization and a safer drug supply are needed. [ABSTRACT FROM AUTHOR]

Background Antibiotic use is highly prevalent in long-term care facilities (LTCFs); a resident's annual exposure to at least 1 course of antibiotic is approximately 50% to 80%. The objective of this study was to understand the extent of antibiotic use in the population of residents in British Columbia's (BC) LTCFs from 2007 to 2014. Methods Antibiotic prescription data for LTCF residents was extracted from the central prescription database and linked to the physician billing plan to obtain antibiotic indication. Total defined daily dose (DDD) per 1000 residents per day was calculated. Results Our database had 381 LTCFs with an average of nearly 24,694 residents annually and 419,036 antibiotic prescriptions. Antibiotic utilization did not change dramatically between 2007 and 2014, ranging from 39.2 in 2007 to 35.2 DDD per 1000 residents per day in 2014. Although usage of most antibiotics declined, use of moxifloxacin, amoxicillin-clavulanate, doxycycline, and amoxicillin increased significantly. The indication most frequently linked to prescription was urinary tract infection (6.58 DDD per 1000 residents per day), with nitrofurantoin, ciprofloxacin, and trimethoprim/sulfamethoxazole being the most commonly prescribed agents. This was followed closely by prescriptions for respiratory infections (5.34 DDD per 1000 residents per day), with moxifloxacin being the most commonly prescribed antibiotic, primarily for upper respiratory tract infection (URTI), whereas doxycycline is used commonly for lower respiratory tract infection. Duration of antibiotic therapy in LTCF residents has decreased significantly from 9.29 days to 7.3 days per prescription in 2014. Conclusion Antibiotic use in LTCFs is high relative to the general population. Our study underscores that stewardship in LTCFs should continue to focus on length of treatment, appropriate detection of urinary tract infections, and avoidance of treating URTIs with antibiotics. [ABSTRACT FROM AUTHOR]

Objectives To assess the effect of a proton pump inhibitor (PPI) deprescribing guideline on PPI usage and PPI drug costs in one long-term care home in Ontario, Canada. Design Interrupted time-series analysis to compare monthly PPI usage and average monthly PPI cost per resident 9 months before guideline implementation to 12 months after. Setting One long-term care home in Ottawa, Ontario, Canada. Participants Long-term care residents prescribed a PPI over a 21-month period (n = 335). Intervention PPI deprescribing guideline and decision support tool used during quarterly medication reviews. Measurements (1) Total number of PPI prescriptions (PPI usage) and (2) average PPI drug cost per resident. We also measured the proportion of residents whose PPI was deprescribed in the preguideline period and postguideline period. Results The deprescribing guideline was associated with a decrease in PPI usage but the association was not statistically significant (−8.7 prescriptions, 95% confidence interval [CI] −22.0 to 4.6). The PPI guideline led to a significant decrease in average monthly PPI drug cost per resident over time (0.16 CAD reduction per month; 95% CI −0.29 to −0.03). In the 9 months before intervention, 57 (27.8%) of 205 eligible residents had their PPI deprescribed, and in the 12 months after intervention 134 (50.0%) of 268 eligible residents had their PPI deprescribed (difference in proportions of 22.2%; 95% CI 13.4–30.4). Discussion/conclusion The deprescribing guideline was associated with a decline PPI usage; however, this negative association was not statistically significant. PPI usage declined in the initial 6 months after guideline implementation but began to climb back to baseline after this, which may explain the lack of a significant reduction in PPI usage. This suggests that it was difficult to maintain PPI deprescribing efforts long-term. Although implementation of a PPI deprescribing guideline may lead to an initial reduction in PPI usage, and a significant reduction in the average cost of PPI prescriptions over time, it is imperative to explore ways to sustain deprescribing guideline use. [ABSTRACT FROM AUTHOR]