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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.

Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.

Background and ObjectivesWe tested the hypothesis that overall and cancer-specific survival after a colorectal cancer diagnosis is lower in persons with multiple sclerosis (MS) than in those without MS using a retrospective matched cohort design.MethodsUsing population-based administrative data in Manitoba and Ontario, we identified persons with MS from a validated case definition and linked these cohorts to cancer registries to identify those with colorectal cancer. We selected persons with colorectal cancer and without MS, matching 4:1 on birth year, sex, cancer diagnosis year, and region. We used Cox proportional hazards regression to compare all-cause survival between cohorts, adjusting for age at cancer diagnosis, cancer diagnosis year, income, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a cause-specific hazards model. We pooled findings across provinces using random-effects meta-analysis. Complementary analyses using a subcohort from Ontario, adjusted for cancer stage and disability status, as measured from the use of home care or long-term care services.ResultsWe included 338 MS cases and 1,352 controls with colorectal cancer. The mean (SD) age at cancer diagnosis was 64.7 (11.1) years. After adjustment, MS was associated with an increased hazard for all-cause death that was highest 6 months after diagnosis (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.19–1.76) and then declined over time (HR [95% CI] at 1 year 1.34 [1.09–1.63], 2 years 1.24 [0.99–1.56], 5 years 1.10 [0.80–1.50]). MS was associated with increased cancer-specific death at 6 months after diagnosis only (HR 1.29, 95% CI 1.04–1.61). After adjustment for cancer stage, MS was associated with an increased hazard of death due to any cause (1.60, 95% CI 1.16–2.21) and with cancer-specific death (HR 1.47, 95% CI 1.02–2.12). The association of MS and all-cause death was partially attenuated after adjustment for disability status (HR 1.37, 95% CI 0.97–1.92), as was the association with cancer-specific death (HR 1.34, 95% CI 0.91–1.97).DiscussionOverall and cancer-specific survival was lower in persons with than without MS in the early period after colorectal cancer diagnosis. Further study is warranted to determine what factors underlie these worse outcomes.

Mortality secondary to cirrhosis in North America is increasing. We describe the incidence of cirrhosis stratified by birth cohort and cirrhosis etiology and project disease burden to 2040.This is a retrospective cohort study in Ontario, Canada, using population-based administrative health care data. Individuals with incident cirrhosis (2000-2017) were identified, and etiology was defined as HCV, HBV, NAFLD, alcohol-associated liver disease (ALD), or autoimmune liver disease/other using validated case definitions. Annual age/sex-adjusted cirrhosis incidence rate per 100,000 person-years was calculated with incidence projection to 2040 using age-period-cohort modeling along with average annual percent change (AAPC) in cirrhosis incidence stratified by birth cohort and etiology. In total, 159,549 incident cases of cirrhosis were identified. Incidence increased by 26% with an AAPC of 2%/year (95% CI, 1.6-2.4; P 0.001). The largest increases were for HCV (AAPC, 4.1%/year; 95% CI, 2.6-5.7; P 0.001) and NAFLD (AAPC, 3.3%/year; 95% CI, 2.6-4.1%; P 0.001). ALD and HCV cirrhosis in those born1980 increased by 11.6%/year (95% CI, 9.3-13.9; P 0.001) and 9.5%/year (95% CI, 6.2-13.0; P 0.001), respectively. However, by 2040, cirrhosis incidence is projected to continue to increase, driven mostly by NAFLD, especially in postmenopausal women, and ALD in individuals born1980.Cirrhosis incidence will continue to increase over the next two decades secondary to NAFLD with a worrisome rapid rise in ALD cirrhosis among young adults. Public education, policy, and intervention targeting NAFLD risk factors and alcohol use in young adults are urgently needed.

ObjectiveTo test the hypotheses that overall survival and cancer-specific survival after breast cancer diagnosis would be lower in persons with multiple sclerosis (MS) as compared to persons without MS using a retrospective matched cohort design.MethodsWe applied a validated case definition to population-based administrative data in Manitoba and Ontario, Canada, to identify women with MS. We linked the MS cohorts to cancer registries to identify women with breast cancer. Then we selected 4 breast cancer controls without MS matched on birth year, cancer diagnosis year, and region. We compared all-cause survival between cohorts using Cox proportional hazards regression adjusting for age at cancer diagnosis, cancer diagnosis period, income quintile, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a multivariable cause-specific hazards model. We pooled findings between provinces using meta-analysis.ResultsWe included 779 patients with MS and 3,116 controls with breast cancer. Most patients with stage data (1,976/2,822 [70.0%]) were diagnosed with stage I or II breast cancer and the mean (SD) age at diagnosis was 57.8 (10.7) years. After adjustment for covariates, MS was associated with a 28% increased hazard for all-cause mortality (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.08–1.53), but was not associated with altered cancer-specific survival (HR 0.98; 95% CI 0.65–1.46).ConclusionWomen with MS have lower all-cause survival after breast cancer diagnosis than women without MS. Future studies should confirm these findings in other populations and identify MS-specific factors associated with worse prognosis.

A prolonged time from first presentation to cancer diagnosis has been associated with worse disease-related outcomes. This study evaluated potential determinants of a long diagnostic interval among symptomatic breast cancer patients. This was a population-based, cross-sectional study of symptomatic breast cancer patients diagnosed in Ontario, Canada from 2007 to 2015 using administrative health data. The diagnostic interval was defined as the time from the earliest breast cancer-related healthcare encounter before diagnosis to the diagnosis date. Potential determinants of the diagnostic interval included patient, disease and usual healthcare utilization characteristics. We used multivariable quantile regression to evaluate their relationship with the diagnostic interval. We also examined differences in diagnostic interval by the frequency of encounters within the interval. Among 45,967 symptomatic breast cancer patients, the median diagnostic interval was 41 days (interquartile range 20–92). Longer diagnostic intervals were observed in younger patients, patients with higher burden of comorbid disease, recent immigrants to Canada, and patients with higher healthcare utilization prior to their diagnostic interval. Shorter intervals were observed in patients residing in long-term care facilities, patients with late stage disease, and patients who initially presented in an emergency department. Longer diagnostic intervals were characterized by an increased number of physician visits and breast procedures. The identification of groups at risk of longer diagnostic intervals provides direction for future research aimed at better understanding and improving breast cancer diagnostic pathways. Ensuring that all women receive a timely breast cancer diagnosis could improve breast cancer outcomes.

ObjectiveTo determine whether cancer risk differs in people with and without multiple sclerosis (MS), we compared incidence rates and cancer-specific mortality rates in MS and matched cohorts using population-based data sources.MethodsWe conducted a retrospective matched cohort study using population-based administrative data from Manitoba and Ontario, Canada. We applied a validated case definition to identify MS cases, then selected 5 controls without MS matched on birth year, sex, and region. We linked these cohorts to cancer registries, and estimated incidence of breast, colorectal, and 13 other cancers. For breast and colorectal cancers, we constructed Cox models adjusting for age at the index date, area-level socioeconomic status, region, birth cohort year, and comorbidity. We pooled findings across provinces using meta-analysis.ResultsWe included 53,983 MS cases and 269,915 controls. Multivariable analyses showed no difference in breast cancer risk (pooled hazard ratio [HR] 0.92 [95% confidence interval (CI) 0.78–1.09]) or colorectal cancer risk (pooled HR 0.83 [95% CI 0.64–1.07]) between the cohorts. Mortality rates for breast and colorectal did not differ between cohorts. Bladder cancer incidence and mortality rates were higher among the MS cohort. Although the incidence of prostate, uterine, and CNS cancers differed between the MS and matched cohorts, mortality rates did not.ConclusionThe incidence of breast and colorectal cancers does not differ between persons with and without MS; however, the incidence of bladder cancer is increased. Reported differences in the incidence of some cancers in the MS population may reflect ascertainment differences rather than true differences.

OBJECTIVE: Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces. METHODS: Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer. RESULTS: There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50–69 but women aged 50–59 had approximately 4–8% lower screen detection than those aged 60–69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62–0.89 relative to highest income quintile/urban patients aged 50–69. Lack of visits to primary care 30 months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37–0.76). CONCLUSION: Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

Chemotherapy has improved outcomes in early-stage breast cancer, but treatment practices vary, and use of acute care is common. We conducted a pan-Canadian study to describe treatment differences and the incidence of emergency department visits (edvs), edvs leading to hospitalization (edvhs), and direct hospitalizations (hs) during adjuvant chemotherapy. The cohort consisted of women diagnosed with early-stage breast cancer (stages i&ndash, iii) during 2007&ndash, 2012 in British Columbia, Manitoba, Ontario, or Nova Scotia who underwent curative surgery. Parallel provincial analyses were undertaken using linked clinical, registry, and administrative databases. The incidences of edvs, edvhs, and hs in the 6 months after treatment initiation were examined for patients treated with adjuvant chemotherapy. The cohort consisted of 50,224 patients. The proportion of patients who received chemotherapy varied by province, with Ontario having the highest proportion (46.4%), and Nova Scotia, the lowest proportion (38.0%). Age, stage, receptor status, comorbidities, and geographic location were associated with receipt of chemotherapy in all provinces. Ontario had the highest proportion of patients experiencing an edv (36.1%), but the lowest proportion experiencing h (6.4%). Conversely, British Columbia had the lowest proportion of patients experiencing an edv (16.0%), but the highest proportion experiencing h (26.7%). The proportion of patients having an edvh was similar across provinces (13.9%&ndash, 16.8%). Geographic location was associated with edvs, edvhs, and hs in all provinces. Intra- and inter-provincial differences in the use of chemotherapy and acute care were observed. Understanding variations in care can help to identify gaps and opportunities for improvement and shared learnings.

Background: Readmission in patients with cirrhosis is common. We aimed to determine the association between early hospital readmission and survival in the general population of patients with cirrhosis. Methods: This retrospective cohort study used routinely collected health care data from Ontario. We identified adults with cirrhosis using a validated case definition, and included those with at least one hospital admission between 1992 and 2016 resulting in discharge. Patients were classified into two groups based on timing of readmission after index admission: 1) ≤90 days, or 2) >90 days or no readmission. We described overall survival (OS) 90 days after the index hospitalization by readmission status using Kaplan–Meier curves and the log-rank test. The association between readmission and OS was evaluated using a multivariate Cox proportional hazards regression model. Results: Our study included 115,081 patients. The median OS was shorter in patients readmitted in ≤90 days (4.1 years, IQR 0.9, 13.1) compared with those readmitted in >90 days or not readmitted during the study period (9.6 years, IQR 3.2, 21.9, p

Background In order to maximize later health, there are established components and guidelines for quality follow-up care of breast cancer survivors. However, adherence to quality follow-up in Canada may not be optimal, and may vary by province. We determined and compared the proportion of patients in each province who received adherent and non-adherent surveillance for recurrence, new cancers and late effects, recommended preventive care, and recommended physician visits for comorbidities. Methods Cohorts consisted of all adult women diagnosed with incident invasive breast cancer between 2007 and 2010/2012 in four Canadian provinces (British Columbia (BC) N = 9338; Manitoba N = 2688; Ontario N = 23,700; Nova Scotia (NS) N = 2735), identified from provincial cancer registries, alive and cancer-free at 30 months post-diagnosis. Their healthcare utilization was determined from one to 5 years post-treatment, using linked administrative databases. Adherence, underuse, and overuse of recommended services were evaluated yearly and compared using descriptive statistics. Results In all provinces and follow-up years, the majority of survivors had more than the recommended number of visits to either an oncologist or primary care physician (range 53.8% NS Year 3; 85.8% Ontario Year 4). The proportion of patients with the guideline-recommended number of oncologist visits varied by province (range 29.8% BC Year 5; 74.8% Ontario Year 5), and the proportion of patients with less than the recommended number of specified breast cancer-related visits with either an oncologist or primary care physician ranged from 32.6% (Ontario Year 2) to 84.4% (NS Year 3). Underuse of surveillance breast imaging was identified in NS and BC. The proportion of patients receiving imaging for metastatic disease (not recommended in the guidelines) in BC, Manitoba, and Ontario (not reported in NS) ranged from 20.3% (BC Year 5) to 53.3% (Ontario Year 2). Compliance with recommended physician visits for patients with several chronic conditions was high in Ontario and NS. Preventive care was less than optimal in all provinces with available data. Conclusions Quality of breast cancer survivor follow-up care varies among provinces. Results point to exploration of factors affecting differences, province-specific opportunities for care improvement, and the value of administrative datasets for health system assessment.

Recent data show that the prevalence of chronic liver disease and cirrhosis is increasing in adolescents and young adults in the USA. We aimed to describe the epidemiology of cirrhosis using an age-period-cohort approach to define birth-cohort effects on the incidence of cirrhosis in Ontario, Canada.We did a retrospective population-based cohort study in Ontario, Canada, using linked administrative health data from the databases of ICES, formerly the Institute for Clinical Evaluative Sciences. Patients aged at least 18 years with cirrhosis were identified by use of a validated case definition (defined as at least one inpatient or outpatient visit with a diagnosis of cirrhosis or oesophageal varices without bleeding). We calculated annual standardised incidence and prevalence in the general population. We used an age-period-cohort approach to assess the independent association between birth cohort and incidence of cirrhosis in men and women.Between Jan 1, 1997, and Dec 31, 2016, 165 979 individuals with cirrhosis were identified. The age-standardised incidence increased over the study (from 70·6 per 100 000 person-years in 1997 to 89·6 per 100 000 person-years in 2016) as did the prevalence (from 0·42% in 1997 to 0·84% in 2016). Using age-period-cohort modelling and the median birth year as the reference, the incidence of cirrhosis was higher in participants born in 1980 (incidence rate ratio 1·55, 95% CI 1·50-1·59, p0·0001); and in participants born in 1990 (2·16, 95% CI 2·06-2·27, p0·0001) compared with a person of the same age born in 1951. The increase in incidence of cirrhosis was greater in women than in men (eg, women born in 1990: 2·60, 95% CI 2·41-2·79; men born in 1990: 1·98, 1·85-2·12).The incidence of cirrhosis has increased over the past two decades, and more so in younger birth cohorts and in women. Future studies to define the cause and natural history of cirrhosis in these groups are essential to develop strategies that could reverse these trends for future generations.Southeastern Ontario Academic Medical Association New Clinician Scientist Award; American Association for the Study of Liver Disease (AASLD) Foundation Clinical, Translational and Outcomes Research Award in Liver Disease (JAF).

Background The overuse of medical tests leads to higher costs, wasting of resources, and the potential for overdiagnosis of disease. This study was designed to determine whether the patients of family doctors who order more routine medical tests are diagnosed with more cancers. Method A retrospective population‐based cross‐sectional study using administrative health care data in Ontario Canada. We investigated the ordering of 23 routine laboratories and imaging tests 2008‐20012 by 6849 Ontario family physicians on their 4.9 million rostered adult patients. We compared physicians’ test utilization and calculated case‐mix adjusted observed to expected (O:E) utilization ratios to categorize physicians as Typical, Higher or Lower testers. Age‐sex standardized rates (cases/10 000 patient years) and Rate Ratios were determined for cancers of the thyroid, prostate, breast, lymphoma, kidney, melanoma, uterus, ovary, lung, esophagus, and pancreas for each tester group. Results There was wide variation in the use of the 23 tests by Ontario physicians. 26% and 24% of physicians were deemed Higher Testers for laboratory and imaging tests, while 41% and 38% were Typical Testers. The patients of higher test users were diagnosed with more cancers of thyroid (laboratory [RR 1.61, 95% CI 1.39‐1.87] and imaging [RR 2.08, 95% CI 0.88‐2.30]) and prostate (laboratory [RR 1.10, 95% CI 1.03‐1.18] and imaging [RR 1.05, 95% CI 1.00‐1.10]). Conclusion There is a wide variation in the ordering of routine and common medical tests among Ontario family doctors. The patients of higher testers were diagnosed with more thyroid and prostate cancers.

Appendectomy is a common emergency procedure. The risks have been reported in previous studies but often are limited to inpatient complications. The purpose of this study was to describe inpatient and outpatient rates of complications associated with appendectomy in a contemporary population-based cohort and explore factors associated with these complications.We conducted a retrospective study using linked data for Ontario within Institute for Clinical Evaluative Sciences databases. Patients who underwent emergent appendectomy between 2009 and 2014 were included. The primary outcome was a complication (death, readmission, emergency department visit, lengthy [7 d] hospital stay, percutaneous abscess drainage, reoperation or 1 of the predefined complication codes) occurring within 30 days of surgery. We used modified Poisson regression to identify predictors of complications.A total of 50 369 patients underwent emergent appendectomy over the study period, of whom 16 953 (33.7%) had a perforated appendix. Overall, 14 451 patients (28.7%) (8428 [25.2%] in the nonperforated group and 6023 [35.5%] in the perforated group) had at least 1 complication. The most common complication was an emergency department visit (7942 patients [15.8%]), followed by surgical site infection (4792 [9.5%]). Increasing age, female sex, rural residence, perforation status, daytime surgery and open surgical technique were associated with increased risk of complications.We found a higher rate of complications after appendectomy than previously reported. The most common complication was presentation to the emergency department. Our definition of complications is more inclusive than in previous studies and provides a deeper understanding of complications after appendectomy.L'appendicectomie est une intervention urgente qui est courante. Les risques qui y sont associés ont déjà fait l'objet d'études, mais se limitent souvent aux complications perhospitalières. Cette étude avait pour but de décrire les taux de complications chez les patients durant et après leur hospitalisation pour appendicectomie dans une cohorte contemporaine basée dans la population et d'explorer les facteurs associés à ces complications.Nous avons procédé à une étude rétrospective à partir des données reliées des bases de données de l'Institute for Clinical Evaluative Sciences pour l'Ontario. Les patients soumis à une appendicectomie urgente entre 2009 et 2014 ont été inclus. Le paramètre principal était la survenue d'une complication (décès, réadmission, consultation aux urgences, séjour hospitalier prolongé [7 j], drainage d'abcès percutané, réintervention ou l'un des codes de complications prédéfinis) dans les 30 jours suivant la chirurgie. Nous avons utilisé la régression de Poisson pour identifier les facteurs prédicteurs de complications.En tout, 50 369 patients ont subi une appendicectomie urgente au cours de la période de l'étude, dont 16 953 (33,7 %) présentaient un appendice perforé. Globalement, 14 451 patients (28,7 %) (8 428 [25,2 %] dans le groupe ayant l'appendice non perforé et 6 023 [35,5 %] dans le groupe ayant l'appendice perforé) ont eu au moins une complication. La complication la plus fréquente a été une consultation aux urgences (7942 patients [15,8 %]), suivie de l'infection du site opératoire (4792 [9,5 %]). L'âge avancé, le fait d'être de sexe féminin, de vivre en milieu rural, un appendice perforé, la chirurgie effectuée durant le jour et la technique chirurgicale ouverte ont tous été associés à un risque accru de complications.Nous avons observé un taux de complications post-appendicectomie plus élevé comparativement aux rapports précédents. La complication la plus fréquente était la consultation aux urgences. Notre définition du terme complications est plus inclusive que celle des précédentes études et permet une compréhension plus approfondie des complications post-appendicectomie.

Introduction Colorectal cancer (CRC) is the third most common cancer worldwide (Ferlay et al., 2015, International Journal of Cancer, 136, E359), and delayed diagnosis is associated with mortality (Torring et al., 2011, British Journal of Cancer, 104, 934; Torring et al., 2012, Journal of Clinical Epidemiology, 65, 669). The purpose of this review was to determine the factors associated with time to diagnosis in symptomatic CRC using scoping review methods. Methods We performed database and citation searches to identify studies which examine the length of any interval from symptom presentation to diagnosis. Study selection was conducted by two independent reviewers. Factors contributing to time to diagnosis were extracted from selected articles and mapped onto a conceptual framework consisting of four levels: patient and disease factors, provider factors, organisation/setting factors and sectors of influence. Results From the 31 studies included in this review, we identified 138 unique factors, 17 of which were investigated by at least three studies and 11 of which had consistent results. Patient and disease factors were most commonly studied. Patient perception that their symptoms were benign, a non-urgent referral, female sex and rectal tumour location were each associated with a longer time to diagnosis. Conclusion Thus far, the literature has focused on patient or disease-related factors, while other levels of influence have been relatively understudied.

IntroductionDespite recommendations, most studies examining health inequalities fail to report both absolute and relative summary measures. We examine colorectal cancer (CRC) survival for patients with and without severe psychiatric illness (SPI) to demonstrate the use and importance of relative and absolute effects. Objectives and ApproachWe conducted a retrospective cohort study of CRC patients diagnosed between 01/04/2007 and 31/12/2012, using linked administrative databases. SPI was defined as diagnoses of major depression, bipolar disorder, schizophrenia, and other psychotic illnesses six months to five years preceding cancer diagnosis and categorized as inpatient, outpatient or none. Associations between SPI history and risk of death were examined using Cox Proportional Hazards regression to obtain hazard ratios and Aalen’s semi-parametric additive hazards regression to obtain absolute differences. Both models controlled for age, sex, primary tumour location, and rurality. ResultsThe final cohort included 24,507 CRC patients, 482 patients had an outpatient SPI history and 258 patients had an inpatient SPI history. 58.1% of patients with inpatient SPI history died, and 47.1% of patients with outpatient SPI history died. Patients with an outpatient SPI history had a 40% (HR 1.40, 95% CI: 1.22-1.59) increased risk of death and patients with an inpatient SPI history had a 91% increased risk of death (HR 1.91, 95% CI: 1.63-2.25), relative to no history of a mental illness. An outpatient SPI history was associated with an additional 33 deaths per 1000 person years, and an inpatient SPI was associated with an additional 82 deaths per 1000 person years after controlling for confounders. Conclusion / ImplicationsWe demonstrated that reporting of both relative and absolute effects is possible and calculating risk difference is relatively simple using Aalen models. We encourage future studies examining inequalities with time-to-event data to use this method and report both relative and absolute effect measures.

BACKGROUND: Randomized trials have shown that transjugular intrahepatic portosystemic shunt (TIPS) improves control of ascites compared with serial large volume paracentesis (LVP) in patients with refractory ascites. However, the effect of TIPS on liver transplant-free (LTF) survival is controversial. Our objective was to compare TIPS versus serial LVP on LTF survival in the general population of patients with refractory ascites. METHODS: This is a retrospective, population-based cohort study using linked administrative health data from Ontario, Canada. Adult patients identified with refractory ascites from January 1, 2008 to December 31, 2016 were included and followed until December 31, 2017. A propensity score was used to match patients treated with serial LVP to those who received TIPS in a 2:1 ratio. LTF survival was evaluated using Kaplan–Meier analysis and Cox proportional hazards regression with TIPS treated as a time-varying exposure. RESULTS: Overall, 4,935 patients with refractory ascites were identified and 488 patients were matched (325 serial LVP, 163 TIPS). The mean age was 58 years, 70% were male, 50% had viral hepatitis, the median model for end-stage liver disease (MELD) score was 12, 13% received liver transplant and the 1-year LTF survival was 72%. After TIPS, 80 patients (49%) had no further requirement for LVP by 6 months and 61 patients (37%) never required a repeat paracentesis. In survival analysis, there was marginally worse LTF survival in patients receiving TIPS (TIPS HR 1.29, 95% CI 1.00–1.67; p = .052). CONCLUSION: In this population-based study of patients with refractory ascites, TIPS was associated with improved control of ascites but not improved LTF survival.

Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group’s (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia. This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on ‘lessons learned’. The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved. Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ. Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and include a list of ‘lessons learned’ and a study process checklist for future use. Key FindingsThe conduct of inter-sectoral research using linked administrative health data requires a committedteam that is adequately resourced and has a set of clear, feasible objectives at the start. Guiding principles include: maximization of sectoral participation by including single-jurisdictionexpertise and making the most inclusive data decisions; use of living documents that track all datadecisions and careful consideration about data quality and availability differences. Inter-sectoral research requires a good understanding of the local healthcare system and othercontextual issues for appropriate interpretation of observed differences.

Breast assessment sites (bass) were developed to provide expedited and coordinated care for patients being evaluated for breast cancer (bca) in Ontario. We compared the diagnostic and treatment intervals for patients diagnosed at a bas and for those diagnosed through a usual care (uc) route. This population-based, cross-sectional study of patients diagnosed with bca in Ontario during 2007&ndash, 2015 used linked administrative data. &ldquo, Diagnostic interval&rdquo, was the time from the earliest cancer-related health care encounter before diagnosis to diagnosis, &ldquo, treatment interval&rdquo, was the time from diagnosis to treatment. Diagnosis at a bas was determined from the patient&rsquo, s biopsy and mammography institutions. Interval lengths for the bas and uc groups were compared using multivariable quantile regression, stratified by detection method. The diagnostic interval was shorter for patients who were bas-diagnosed than for those who were uc-diagnosed, with adjusted median differences of &minus, 4.0 days [95% confidence interval (ci): &minus, 3.2 days to &minus, 4.9 days] for symptomatic patients and &minus, 5.4 days (95% ci: &minus, 4.7 days to &minus, 6.1 days) for screen-detected patients. That association was modified by stage at diagnosis, with larger differences in patients with early-stage cancers. In contrast, the treatment interval was longer in patients who were bas-diagnosed than in those who were uc-diagnosed, with adjusted median differences of 4.2 days (95% ci: 3.8 days to 4.7 days) for symptomatic patients and 4.2 days (95% ci: 3.7 days to 4.8 days) for screen-detected patients. Diagnosis of bca through a bas was associated with a shorter diagnostic interval, but a longer treatment interval. Although efficiencies in the diagnostic interval might help to reduce distress experienced by patients, the longer treatment intervals for patients who are bas-diagnosed remain a cause for concern.

Background Advanced cancer stage at diagnosis may explain high cancer mortality among patients with a severe psychiatric illness (SPI). Studies to date investigating advanced stage cancer at diagnosis as a potential explanation for high cancer mortality in individuals with a history of mental illness have been inconclusive. We examined the relationship between a SPI history and unknown cancer stage at diagnosis in colorectal cancer (CRC) patients. Methods This was a population-based, cross-sectional study using linked administrative databases of CRC patients diagnosed between 01/04/2007 and 31/12/2012. Individuals who had a history of mental illness but did not meet the definition of a SPI were excluded. An SPI was measured in the 5 years prior to the cancer diagnosis and categorized as inpatient, outpatient or no SPI. Individuals with a best stage in Stage 0 to Stage IV were considered staged and absence of staging information was defined as unknown stage. The risk of unknown stage cancer was estimated using modified Poisson regression. Results The final study cohort included 24,507 CRC patients. 258 (1.1%) individuals experienced a history of inpatient SPI and 482 (2.0%) experienced outpatient SPI. After adjusting for confounders, CRC patients with an inpatient or outpatient history of SPI were at greater risk of having missing TNM stage at diagnosis, compared to patients with no history of a mental illness (RR 1.45 (95% CI: 1.14–1.85) and RR1.17 (95% CI 0.95–1.43), respectively). The results did not change when alternate practices to assign SPI history using administrative data were used. Conclusions Individuals with an SPI, especially those with a psychiatric admission, were more likely to have missing stage data compared to individuals without a history of a mental illness. Incomplete and low quality cancer staging data likely undermines the quality of cancer care following initial diagnosis. Understanding why patients with an SPI are missing this information is a critical first step to providing excellent care to this vulnerable population.

Delays in surgery for patients with acute appendicitis may increase the risk of perforation and complications. These risks must be balanced with the theoretical risk of nighttime operations.To determine the effect of (i) time of day of surgery and (ii) time between triage presentation and surgery, on surgical complications in patient undergoing appendectomy for appendicitis.Population level data from Ontario from 2009 to 2015 was used to conduct this retrospective cohort study. The primary exposure was (i) time of day of surgery and (ii) time between triage and surgery. The primary outcome was a composite outcome of perioperative complications. Conditional logistic regression adjusted for patient factors was used to estimate adjusted odds ratios (OR) between the exposure and complications.Twelve thousand nine hundred thirty-seven matched pairs (N = 25,874) of adult patients were included. Compared to day operations, the odds of complications were lower during the evening (OR, 0.90; 95% confidence interval [CI], 0.84-0.96) and no different at night (OR, 0.90; 95% CI, 0.77-1.04). The odds of complications were higher in patients who waited longer than 24 hours for surgery compared with those who waited less than 6 hours (OR, 1.27; 95% CI, 1.14-1.43) with no increased risk in those who waited 6 hours to 12 hours or 12 hours to 24 hours.This large population study is the first to assess surgical risks using a case-crossover design to account for the surgeon as a potential confounder. Nighttime surgery and delaying surgery up to 24 hours were not associated increased risks of complications.Therapeutic, level III.

BACKGROUND Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval. METHODS This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile. RESULTS The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively). CONCLUSIONS This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.

Mortality reduction attributable to organized breast screening is modest. Screening may be less effective at detecting more aggressive cancers at an earlier stage. This study was conducted to determine the relative efficacy of screening mammography to detect cancers at an earlier stage by molecular phenotype. We identified 2882 women with primary invasive breast cancer diagnosed between January 1, 2008 and December 31, 2012 and who had a mammogram through the Ontario Breast Screening Program in the 28 months before diagnosis. Five tumor phenotypes were defined by expression of estrogen (ER) and progesterone (PR) receptors and HER2/neu oncogene. We conducted univariable and multivariable analyses to describe the predictors of detection as an interval cancer. Additional analyses identified predictors of detection at stages II, III, or IV compared with stage I, by phenotype. Analyses were adjusted for the effects of age, grade, and breast density. ER negative and HER2 positive tumors were over-represented among interval cancers, and triple negative cancers were more likely than ER +/HER2 − cancers to be detected as interval cancers OR 2.5 (95% CI 2.0–3.2, p

Aims To describe the quality of the non-technical component of the care (personal care) of patients receiving radical radiotherapy for prostate cancer and to identify elements of personal care that should be priorities for quality improvement. Materials and methods One hundred and eight patients undergoing radiotherapy for localised prostate cancer completed a self-administered questionnaire that asked them to rate the importance of 143 non-technical elements of care and to rate the quality of their own care with respect to each element. The elements that a patient rated as both ‘very important' and less than ‘very good' were deemed to be his priorities for improvement. The priorities of the population were established by ranking the elements based on the percentage of patients who identified them as a priority (importance/quality analysis). Results The response rate was 65%. The percentage of elements rated ‘very good' varied from patient to patient: median 79% (interquartile range 69–92%). The percentage of elements rated either ‘very good' or ‘good' was higher: median 96% (interquartile range 86–98%). Nonetheless, almost every patient rated at least some elements of his care as less than optimal, regardless of the cut-off point used to define optimal quality. Patients assigned their lowest quality ratings to elements relating to the quality of the treatment environment and comprehensiveness of additional services available to them. However, patients rated most of these elements as relatively unimportant, and importance/quality analysis identified elements of care relating to communication of information about the disease and its treatment as the highest priorities for quality improvement. Conclusions Most patients rated most elements of their personal care as very good, but almost all were able to identify some elements that were less than optimal. When ratings of quality were integrated with ratings of importance, elements relating to communication emerged as the patients' highest priorities for quality improvement.

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.

Introduction There is an evidence gap regarding the duration of SARS-CoV-2 shedding and of its variability across different care settings and by age, sex, income, and co-morbidities. Such evidence is part of understanding of infectivity and reinfection. We examine direct measures of viral shedding using a linked population-based health administrative dataset. Methods Laboratory and sociodemographic databases for Ontario, Canada were linked to identify those testing positive (RT-PCR) between Jan. 15 and April 30, 2020 who underwent subsequent testing by May 31, 2020. To maximise use of available data, we computed two shedding duration estimates defined as the time between initial positive and most recent positive (documented shedding) or second of two negative tests (documented resolution). We also report multivariable results using quantile regression to examine subgroup differences. Results In Ontario, of the 16,595 who tested positive before April 30, 2020, 6604 had sufficient subsequent testing to allow shedding duration calculation. Documented shedding median duration calculated in 4,889 (29% of 16,595) patients was 19 days (IQR 12–28). Documented resolution median duration calculated in 3,219 (19% of the 16,595) patients was 25 days (IQR 18–34). Long-term care residents had 3–5 day longer shedding durations using both definitions. Shorter documented shedding durations of 2–4 days were observed in those living in higher income neighbourhoods. Shorter documented resolution durations of 2–3 days were observed at the 25th% of the distribution in those aged 20–49. Only 11.5% of those with definitive negative test results reverted to negative status by day 14. Conclusions Viral shedding continued well beyond 14 days among this large subset of a population-based group with COVID-19, and longer still for long-term care residents and those living in less affluent neighborhoods. Our findings do not speak to duration of infectivity but are useful for understanding the expected duration of RT-PCR positivity and for identifying reinfection.

e13551 Background: PDAC is a leading cause of cancer death that is often diagnosed at an advanced stage. Population-based administrative data can be a valuable resource for studying the diagnostic interval, defined as the time from the first related healthcare encounter to cancer diagnosis. The objective of this study was to determine the diagnostic interval in a cohort of patients with PDAC using an empirical approach. Methods: This is a retrospective, cohort study of patients diagnosed with PDAC from 2007 – 2015 in Alberta, Canada. We used the Alberta Cancer Registry, physician billing claims, hospital discharge and emergency room visits to identify and categorize cancer-related healthcare encounters before diagnosis. We used statistical control charts to define the lookback period for each encounter category and used these lookback periods to 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 3,142 patients with PDAC. Median age of diagnosis was 71 (IQR 61-80). We identified an index contact date and thus a diagnostic interval in 96.5% of patients. The median diagnostic interval length 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

Objective: A substantial evidence base in the peer-reviewed literature exists investigating mental illness in the military, but relatively less is documented about mental illness in veterans. This study uses provincial, administrative data to study the use of mental health services by Canadian veterans in Ontario. Method: This was a retrospective cohort study of Canadian Armed Forces and Royal Canadian Mounted Police veterans who were released between 1990 and 2013 and resided in Ontario. Mental health–related primary care physician, psychiatrist, emergency department (ED) visits, and psychiatric hospitalisations were counted. Repeated measures were presented in 5-year intervals, stratified by age at release. Results: The cohort included 23,818 veterans. In the first 5 years following entry into the health care system, 28.9% of veterans had ≥1 mental health–related primary care physician visit, 5.8% visited a psychiatrist at least once, and 2.4% received acute mental health services at an ED. The use of mental health services was consistent over time. Almost 8% of veterans aged 30 to 39 years saw a psychiatrist in the first 5 years after release, compared to 3.5% of veterans aged ≥50 years at release. The youngest veterans at release (Conclusion: Understanding how veterans use the health care system for mental health problems is an important step to ensuring needs are met during the transition to civilian life.

Integrating diverse types of prognostic information into accurate, individualized estimates of outcome in colorectal cancer is challenging. Significant heterogeneity in colorectal cancer prognostication tool quality exists. Methodology is incompletely or inadequately reported. Evaluations of the internal or external validity of the prognostic model are rarely performed. Prognostication tools are important devices for patient management, but tool reliability is compromised by poor quality. Guidance for future development of prognostication tools in colorectal cancer is needed.

Factors associated with time-to-surgery (TTS) and survival in colon cancer has not been well studied. Cancer Care Ontario recommends surgery within 42 days of diagnosis and that 90% of patients meet this benchmark. We describe factors associated with TTS and survival in routine clinical practice.Retrospective population-based cohort study of patients receiving elective colonic resection after diagnosis of colon cancer in Ontario, Canada from 2002 to 2008 followed until 2012. Factors associated with TTS were identified using multivariate log-binomial and Quantile regression at 42 days and 90th percentiles. The association between TTS and cancer-specific (CSS) and overall survival (OS) were examined using multivariate Cox regression.4326 patients; median age 71 years and 52% male. Median TTS was 24 days (IQR 14-37); at the 90th percentile 56 days. Factors associated with TTS ≥ 42 days and90th percentile included older age, co-morbid illness, surgeon volume, and stage I disease (P 0.05 for all). In patients whose TTS was either at 42 days or 90th percentile, those ≥80 years old waited two weeks longer than those60 years, individuals with co-morbid illness waited 10 days longer than without co-morbidity, and patients with stage I disease waited 10 days longer than those with stage IV disease (P 0.05 for all). Delay in TTS 42 days or90th percentile was not associated with OS or CSS.Age, co-morbidity, and stage of cancer are associated with TTS. There was no association between TTS and CSS or OS.

Background Early diagnosis is important in head and neck cancer (HNC) patients in order to maximize the effectiveness of the treatments and minimize the debilitation associated with both the cancer and the invasive treatments of advanced disease. Many patients present with advanced disease, and there is little understanding as to why. This study investigated patients’ symptom appraisal, help-seeking and lay-consultancy up to the time they first went to see a health care professional (HCP). Methods We interviewed 83 patients diagnosed with HNC. The study design was cross-sectional and consisted of structured telephone interviews and a medical chart review. We gathered information on the participant's personal reactions to their symptoms, characteristics of their social network and the feedback they received. Results We found that 18% of the participants thought that their symptoms were urgent enough to warrant further investigation. Participants rarely (6%) attributed their symptoms to cancer. Eighty-nine percent reported that they were unaware of the early warning signs and symptoms of HNC. Fifty-seven percent of the participants disclosed their symptoms to at least one lay-consultant before seeking help from an HCP. The lay-consultants were usually their spouse (77%) and the most common advice they offered was to see a doctor (76%). Lastly, 81% of the participants report that their spouse influenced their decision to see an HCP. Conclusions The results of this study suggest that patients frequently believe that their symptoms were non-urgent and that their lay-consultants influence their decision to seek help from an HCP.

IntroductionIndividuals with a pre-existing mental illness, especially those experiencing reduced social, occupational and functional capacity, are at risk for cancer care disparities. However, uncertainty surrounding the effect of a mental illness on cancer outcomes exists.MethodsWe conducted a systematic review and meta-analysis of observational studies using MEDLINE and PubMed from 1 January 2005 to 1 November 2018. Two reviewers evaluated citations for inclusion. Advanced stage was defined as regional, metastatic or according to a classification system. Cancer survival was defined as time survived from cancer diagnosis. Pooled ORs and HRs were presented. The Newcastle-Ottawa bias risk assessment scale was used. Random-effects models used the Mantel-Haenszel approach and the generic inverse variance method. Heterogeneity assessment was performed using I2.Results2381 citations were identified; 28 studies were included and 24 contributed to the meta-analysis. Many demonstrated methodological flaws, limiting interpretation and contributing to significant heterogeneity. Data source selection, definitions of a mental illness, outcomes and their measurement, and overadjustment for causal pathway variables influenced effect sizes. Pooled analyses suggested individuals with a pre-existing mental disorder have a higher odds of advanced stage cancer at diagnosis and are at risk of worse cancer survival. Individuals with more severe mental illness, such as schizophrenia, are at a greater risk for cancer disparities.DiscussionThis review identified critical gaps in research investigating cancer stage at diagnosis and survival for individuals with pre-existing mental illness. High-quality research is necessary to support quality improvement for the care of psychiatric patients and their families during and following a cancer diagnosis.

The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home.To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients.This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regressions were used to evaluate outcomes according to patients' receipt of intervention(s).The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (P 0.0001). Compared with patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk = 2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalization or emergency department visit rates in the six months before death.Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end of life. This association was stronger when these interventions were used together.

Background In Canada, clinical practice guidelines recommend breast cancer screening, but there are gaps in adherence to recommendations for screening, particularly among certain hard-to-reach populations, that may differ by province. We compared stage of diagnosis, proportion of screen-detected breast cancers, and length of diagnostic interval for immigrant women versus long-term residents of BC and Ontario. Methods We conducted a retrospective cohort study using linked administrative databases in BC and Ontario. We identified all women residing in either province who were diagnosed with incident invasive breast cancer between 2007 and 2011, and determined who was foreign-born using the Immigration Refugee and Citizenship Canada database. We used descriptive statistics and bivariate analyses to describe the sample and study outcomes. We conducted multivariate analyses (modified Poisson regression and quantile regression) to control for potential confounders. Results There were 14,198 BC women and 46,952 Ontario women included in the study population, of which 11.8 and 11.7% were foreign-born respectively. In both provinces, immigrants and long-term residents had similar primary care access. In both provinces, immigrant women were significantly less likely to have a screen-detected breast cancer (adjusted relative risk 0.88 [0.79–0.96] in BC, 0.88 [0.84–0.93] in Ontario) and had a significantly longer median diagnostic interval (2 [0.2–3.8] days in BC, 5.5 [4.4–6.6] days in Ontario) than long-term residents. Women from East Asia and the Pacific were less likely to have a screen-detected cancer and had a longer diagnostic interval, but were diagnosed at an earlier stage than long-term residents. In Ontario, women from Latin America and the Caribbean and from South Asia were less likely to have a screen-detected cancer, had a longer median diagnostic interval, and were diagnosed at a later stage than long-term residents. These findings were not explained by access to primary care. Conclusions There are inequalities in breast cancer diagnosis for Canadian immigrant women. We have identified particular immigrant groups (women from Latin America and the Caribbean and from South Asia) that appear to be subject to disparities in the diagnostic process that need to be addressed in order to effectively reduce gaps in care.

The 7th edition American Joint Committee on Cancer (AJCC) melanoma staging system classifies patients according to prognosis. Significant within-stage heterogeneity remains and the inclusion of additional clinicopathologic and other host- and tumor-based prognostic factors have been proposed. Clinical prognostic tools have been developed for use in clinical practice to refine survival estimates. Little is known about the comparative features of tools in melanoma. We performed a systematic search of the scientific published literature for clinical prognostic tools in melanoma and web-based resources. A priori criteria were used to evaluate their quality and clinical relevance, and included intended clinical use, model development approaches, validation strategies, and performance metrics. We identified 17 clinical prognostic tools for primary cutaneous melanoma. Patients with stages I-III and T1 or thin melanoma were the most frequently considered populations. Seventy-five percent of tools were developed using data collected from patients diagnosed in 2006 or earlier, and the well-established factors of tumor thickness, ulceration, and age were included in 70 % of tools. Internal validity using cross-validation or bootstrapping techniques was performed for two tools only. Fewer than half were evaluated for external validity; however, when done, the appropriate statistical methodology was applied and results indicated good generalizability. Several clinical prognostic tools have the potential to refine survival estimates for individual melanoma patients; however, there is a great opportunity to improve these tools and to foster the development of new, validated tools by the inclusion of contemporary clinicopathological covariates and by using improved statistical and methodological approaches.

The overall quality of patient care is a function of the quality of both its technical and its nontechnical components. The purpose of this study was to identify the elements of nontechnical (personal) care that are most important to patients undergoing radiation therapy for prostate cancer.We reviewed the literature and interviewed patients and health professionals to identify elements of personal care pertinent to patients undergoing radiation therapy for prostate cancer. We identified 143 individual elements relating to 10 aspects of personal care. Patients undergoing radical radiation therapy for prostate cancer completed a self-administered questionnaire in which they rated the importance of each element. The overall importance of each element was measured by the percentage of respondents who rated it as "very important." The importance of each aspect of personal care was measured by the mean importance of its elements.One hundred eight patients completed the questionnaire. The percentage of patients who rated each element "very important" ranged from 7% to 95% (mean 61%). The mean importance rating of the elements of each aspect of care varied significantly: "perceived competence of caregivers," 80%; "empathy and respectfulness of caregivers," 67%; "adequacy of information sharing," 67%; "patient centeredness," 59%; "accessibility of caregivers," 57%; "continuity of care," 51%; "privacy," 51%; "convenience," 45%; "comprehensiveness of services," 44%; and "treatment environment," 30% (P.0001). Neither age nor education was associated with importance ratings, but the patient's health status was associated with the rating of some elements of care.Many different elements of personal care are important to patients undergoing radiation therapy for prostate cancer, but the 3 aspects of care that most believe are most important are these: the perceived competence of their caregivers, the empathy and respectfulness of their caregivers, and the adequacy of information sharing.

Introduction Accurate, individualized prognostication for lung cancer patients requires the integration of standard patient and pathologic factors, biological, genetic, and other molecular characteristics of the tumor. Clinical prognostic tools aim to aggregate information on an individual patient to predict disease outcomes such as overall survival, but little is known about their clinical utility and accuracy in lung cancer. Methods A systematic search of the scientific literature for clinical prognostic tools in lung cancer published from January 1, 1996 to January 27, 2015 was performed. In addition, web-based resources were searched. A priori criteria determined by the Molecular Modellers Working Group of the American Joint Committee on Cancer were used to investigate the quality and usefulness of tools. Criteria included clinical presentation, model development approaches, validation strategies, and performance metrics. Results Thirty-two prognostic tools were identified. Patients with metastases were the most frequently considered population in non–small-cell lung cancer. All tools for small-cell lung cancer covered that entire patient population. Included prognostic factors varied considerably across tools. Internal validity was not formally evaluated for most tools and only 11 were evaluated for external validity. Two key considerations were highlighted for tool development: identification of an explicit purpose related to a relevant clinical population and clear decision points and prioritized inclusion of established prognostic factors over emerging factors. Conclusions Prognostic tools will contribute more meaningfully to the practice of personalized medicine if better study design and analysis approaches are used in their development and validation.

ObjectivesTo identify inequalities in cancer survival rates for patients with a history of severe psychiatric illness (SPI) compared to those with no history of mental illness and explore differences in the provision of recommended cancer treatment as a potential explanation.DesignPopulation-based retrospective cohort study using linked cancer registry and administrative data at ICES.SettingThe universal healthcare system in Ontario, Canada.ParticipantsColorectal cancer (CRC) patients diagnosed between April 1st, 2007 and December 31st, 2012. SPI history (schizophrenia, schizoaffective disorders, other psychotic disorders, bipolar disorders or major depressive disorders) was determined using hospitalization, emergency department, and psychiatrist visit data and categorized as 'no history of mental illness, 'outpatient SPI history', and 'inpatient SPI history'.Main outcome measuresCancer-specific survival, non-receipt of surgical resection, and non-receipt of adjuvant chemotherapy or radiation.Results24,507 CRC patients were included; 482 (2.0%) had an outpatient SPI history and 258 (1.0%) had an inpatient SPI history. Individuals with an SPI history had significantly lower survival rates and were significantly less likely to receive guideline recommended treatment than CRC patients with no history of mental illness. The adjusted HR for cancer-specific death was 1.69 times higher for individuals with an inpatient SPI (95% CI 1.36-2.09) and 1.24 times higher for individuals with an outpatient SPI history (95% CI 1.04-1.48). Stage II and III CRC patients with an inpatient SPI history were 2.15 times less likely (95% CI 1.07-4.33) to receive potentially curative surgical resection and 2.07 times less likely (95% CI 1.72-2.50) to receive adjuvant radiation or chemotherapy. These findings were consistent across multiple sensitivity analyses.ConclusionsIndividuals with an SPI history experience inequalities in colorectal cancer care and survival within a universal healthcare system. Increasing advocacy and the availability of resources to support individuals with an SPI within the cancer system are warranted to reduce the potential for unnecessary harm.

Breast cancer is detected through screening or through signs and symptoms. In Canada, mammograms for breast cancer screening are offered in organized programs or independently (opportunistic screening). Province of Ontario breast Diagnostic Assessment Units (DAUs) are facility-based programs that provide coordinated breast cancer diagnostic services, as opposed to usual care, in which the primary care provider arranges the tests and consultations. This study describes breast cancer detection method, diagnostic interval and DAU use across Ontario.The study cohort consisted of 6898 women with invasive breast cancer diagnosed in 2011. We used the Ontario Cancer Registry linked to administrative health care databases. We determined the detection method using the Ontario Breast Screening Program (OBSP) data and physician claims. The diagnostic interval was the time between the initial screen, specialist referral or first diagnostic test and the cancer diagnosis. The diagnostic route (whether through DAU or usual care) was determined based on the OBSP records and biopsy or surgery location. We mapped the diagnostic interval and DAU coverage geographically by women's residence.In 2011, 36% of Ontario breast cancer patients were screen-detected, with a 48% rate among those aged 50 to 69. The provincial median diagnostic interval was 32 days, with county medians ranging from 15 to 65 days. Provincially, 48.4% were diagnosed at a DAU, and this ranged from zero to 100% across counties.The screening detection rate in age-eligible breast cancer patients was lower than published population-wide screening rates. Geographic mapping of the diagnostic interval and DAU use reveals regional variations in cancer diagnostic care that need to be addressed.Le cancer du sein est détecté soit par un examen de dépistage, soit à l’aide de signes et symptômes. Au Canada, les mammographies pour le dépistage du cancer du sein sont offertes dans le cadre de programmes organisés ainsi qu'en contexte indépendant (dépistage opportuniste). Les unités d’évaluation diagnostique (UED) de la province de l’Ontario sont des programmes en établissement qui fournissent des services diagnostiques coordonnés pour le cancer du sein, à la différence des soins habituels où le fournisseur de soins de première ligne organise les examens et les consultations. Cette étude décrit les méthodes de détection, l’intervalle diagnostique et l’utilisation des UED pour le cancer du sein en Ontario.L’étude a porté sur une cohorte de 6 898 femmes ayant reçu un diagnostic de cancer du sein envahissant en 2011. Nous avons utilisé le Registre d’inscription des cas de cancer de l’Ontario jumelé à des bases de données administratives sur les soins de santé. Nous avons déterminé la méthode de détection à l’aide des données du Programme ontarien de dépistage du cancer du sein (PODCS) et des demandes de règlement des médecins. L’intervalle diagnostique a été défini comme le temps écoulé entre le dépistage initial, l’aiguillage vers un spécialiste ou la première épreuve diagnostique et le diagnostic de cancer lui-même. Le parcours diagnostique (qu'il passe par les UED ou les soins habituels) a été déterminé en fonction des dossiers du PODCS et du lieu de biopsie ou d’intervention chirurgicale. Nous avons cartographié l’intervalle diagnostique et de la couverture des UED en fonction du lieu de résidence des femmes.En 2011, 36 % des cas de cancer du sein en Ontario ont été détectés par dépistage, dont 48 % chez des femmes de 50 à 69 ans. L’intervalle diagnostique provincial médian était de 32 jours, les médianes par comté variant entre 15 et 65 jours. À l’échelle provinciale, 48,4 % des cas ont été diagnostiqués dans une UED, ce pourcentage variant entre 0 et 100 % selon les comtés.Le taux de détection au dépistage correspondant aux patientes admissibles du fait de leur âge s'est révélé inférieur au taux de dépistage officiel du cancer du sein pour l’ensemble de la population. La répartition géographique de l’intervalle diagnostique et du recours aux UED révèle des variations régionales dans les soins diagnostiques en oncologie qu'il est nécessaire de corriger.

IntroductionBreast cancer survivors are at risk for late and ongoing problems including cancer recurrence and late effects of treatment. Lack of access to quality follow-up care may affect later mortality, morbidity, and quality of life. This study examines variation in utilization of guideline-based follow-up care separately for four Canadian provinces. Objectives and ApproachFor our retrospective population-based cohort study of breast cancer survivors diagnosed from 2007 to 2010 in British Columbia (BC), 2007-2011 in Manitoba (MB), 2007-2010 in Ontario (ON), and 2007-2012 in Nova Scotia (NS), we linked provincial cancer registries, clinical and health administrative databases, and followed cases alive at 30 months post-diagnosis to five years from diagnosis. For each province, we calculated percent adherence, overuse, and underuse of recommended follow-up care, including surveillance for recurrent and new cancer, surveillance for late effects, and general preventive care. We also examined variation among provinces and over time. ResultsSurvivor numbers were 23,700 (ON), 9493 (BC), 2688 (MB), and 2735 (NS). Annual oncologist visit guideline compliance varied provincially (e.g. Year 2 ON=32.7%, BC=15.0%). For most provinces and follow-up years, the majority of survivors had fewer oncologist visits than recommended. However, survivors had additional annual breast cancer-related visits to a primary care provider. Surveillance breast imaging guideline compliance was high (e.g. Year 2, ON=81.1%, MB=72.0%, NS=52.8%, BC =49.7%), with rates declining in ON and MB (to approximately 64%), but increasing in NS and BC (to approximately 58%) by Year 5. Overuse of breast imaging was identified in NS (9.1%-20.7% overuse in follow-up years 2-5). As per the guideline, 72.9%-79.7% (Years 2-5) of BC survivors had no imaging for metastastic disease, highest among all provinces. Conclusion/ImplicationsProvincial and temporal variations in guideline adherence were identified. Patterns differed by guideline, and both overuse and underuse were observed. These results point to opportunities to improve survivor care and efficiencies in care delivery. In particular, regular care with a primary care physician has been shown to improve follow-up care.

IntroductionBreast cancer screening is intended to identify cancer in early stages when prognosis is better and treatments less invasive. Objectives and ApproachWe describe Canadian inter- and intra-provincial variation in the percentage of screen-detected cases and identify factors related to having a screen-detected versus a non-screen detected breast cancer. Breast cancers diagnosed from 2004/7 to 2010/11/12 in 5 Canadian provinces were included. Standard provincial datasets were created using screening program and claims data. A common algorithm (Alberta, Ontario) or variable from the screening dataset (British Columbia, Manitoba, Nova Scotia) was used to identify the mode of diagnosis (screening versus not). Relationship between screen-detected cancer and several demographic, clinical and healthcare utilization factors were explored. ResultsThe percentage of screen-detected breast cancers varied from 25 to 40 percent across provinces; it ranged 43 to 51 percent for those aged 50-69. Within provinces, the percentage of screen-detected cancers varied across regional health authorities by a low of 1\% to a high of 33\%. Urban residence was positively associated with screen-detection in some provinces and negatively in others. Women in the lowest neighborhood income quintile had the smallest proportion of screen-detected cancers; the absolute difference from those in the highest quintiles ranged from 3.3-11.5\% across provinces. High continuity of care with a usual primary care provider was positively associated with having a screen-detected cancer compared to those with no usual care provider. Conclusion/ImplicationsThe proportion of screen-detected breast cancers varied significantly across and within provinces suggesting geographic variability in access to screening services. Variation across provinces in terms of factors associated with screen-detected breast cancer also likely reflect access issues. The positive association of high continuity of care with screen-detection in all provinces suggests that regular care with a primary care physician is an important factor in improving screening rates and detection.

IntroductionBreast cancer survivors are at risk for late and ongoing problems including cancer recurrence and late effects of treatment. Vulnerable groups may not enjoy equitable access to quality follow-up care. This study examines utilization of guideline-based follow-up care among vulnerable subpopulations in four Canadian provinces. Objectives and ApproachFor vulnerable groups of breast cancer survivors diagnosed from 2007-2010 in British Columbia (BC), 2007-2011 in Manitoba (MB), 2007-2010 in Ontario (ON), and 2007-2012 in Nova Scotia (NS), alive at 30 months post-diagnosis and followed for five years from diagnosis, we undertook a retrospective population-based cohort study linking cancer registries, clinical and health administrative databases. We calculated adherence to recommended follow-up care for surveillance of recurrent and new cancer, late effects, and general preventive care, and examined variation among provinces. Vulnerable groups were defined as those diagnosed at older ages, with lower income status, and/or who resided in rural area. ResultsSurvivor numbers were 23,700 (ON), 9493 (BC), 2688 (MB), and 2735 (NS). In Year 2, between 9.3% (BC) and 28.1% (ON) of survivors diagnosed aged 74+ years received annual breast cancer-related PCP or oncologist follow-up visits, a lower proportion than their younger-diagnosed counterparts; rates of surveillance breast imaging (between 34.2% (BC) and 68.6% (ON) in Year 2) were also lower than those diagnosed at younger ages. Those with incomes in the lowest 40\% did not have different rates of primary care physician and oncologist visits compared to the top 60%, nor did their utilization of surveillance imaging or imaging for metastatic disease differ. Guideline-adherent surveillance breast imaging was conducted on a higher proportion of urban than rural patients in all provinces. Conclusion/ImplicationsWhile area-level incomes do not appear to appreciably affect follow-up care, older age and rural residence resulted in differential access to care. These results suggest that there are gaps in provision of follow-up care that potentially can be addressed through system and practice-level change.

IntroductionA long breast cancer diagnostic process can affect patient anxiety and survival. Variations in the length of the diagnostic interval for similar patient presentations can indicate health system inequities and/or inefficiencies. Objectives and ApproachWe describe the breast cancer diagnostic interval across Canada and factors associated with its length. We studied breast cancer patients diagnosed from 2004/7 to 2010/11/12 in the Canadian provinces: British Columbia, Alberta, Manitoba, Ontario, and Nova Scotia. Using administrative data, we created parallel population-based, provincial-level datasets and ran common analyses. The diagnostic interval was defined from the screening mammogram to the diagnosis for screen-led and from the first referral/test ordering date to the diagnosis for diagnostic-led patients. Stratified by these two diagnostic routes, we describe the variation in the interval across provinces and report on the province-specific associations between the diagnostic interval and: patient age, comorbid disease burden, socioeconomic status combined with rural residence, and continuity of primary care while controlling for cancer stage. ResultsThe median diagnostic interval varied by 6 days (29 to 35 days) across provinces. Screen-led patients were diagnosed more quickly (median 2-12 days quicker). The 90th percentile diagnostic interval was 84-126 days longer in diagnostic-led patients. In the diagnostic-led group, increasing comorbid burden was consistently associated with longer diagnostic intervals and being >70 was associated with a shorter interval at the 90th percentile in Manitoba and Ontario. There was no evidence of a clear rural or low socioeconomic status effect and patients without a primary care physician had shorter intervals. In the screen-led group, patients age 40-49 and those in the medium or low income rural areas waited longer for a diagnosis. Conclusion/ImplicationsDiagnostic wait times differ across Canada and are variably associated with comorbidity, age, area-level socioeconomic status and rural residence. These results point to practice and system-level effects that warrant further study.

BACKGROUND: Patients with cirrhosis have high rates of hospital re-admission. The association between short-term re-admission and long-term survival at the population level is unknown. AIMS: Our study aimed to examine the relationship between 30 and 90 day hospital re-admission and overall survival in patients with cirrhosis in Ontario, Canada. METHODS: Population-based cohort study using the data holdings from the Institute of Comparative Evaluative Sciences from 1992–2015. Individuals with cirrhosis were identified using validated administrative coding algorithms. Those with at least one hospital admission after cirrhosis diagnosis from 1992–2012 resulting in discharge were included with follow-up to 2015. Data on demographics, hospitalizations, and survival were defined using linked administrative datasets. Overall survival (OS) after index hospital discharge was described using Kaplan-Meier curves and the log-rank test. The association between 30 and 90 day hospital re-admission and OS post-discharge were evaluated using multivariate Cox proportional hazards regression. RESULTS: Out of 178,152 patients with cirrhosis, a total of 116,047 had a least one hospital admission resulting in 443,706 unique hospitalization events and formed the cohort; 61% male, median age 58 yrs (IQR 47–68 yrs) and 60% died during a median follow-up of 7.6 yrs (IQR 3.0–14.5 yrs). A single hospital admission was identified in 30% while 5 or more admissions occurred in 27%, median length of stay was 5 days (IQR 2–10 days). The 30 and 90 day re-admission rates were 19.9% and 33.4% respectively. The median OS post-discharge was considerably shorter in patients re-admitted by 30 days (2.6 yrs, 95% CI 0.5–9.7 yrs) or 90 days (3.0 yrs, 95% CI 0.7–10 yrs) compared to those > 90 days/never re-admitted (6.0 yrs years, 95% CI 1.6–16.7 yrs, P < .001). After adjusting for potential confounders, those re-admitted within 30 or 90 days had a higher hazard of death post-discharge then those who were not (HR 1.51, 95% CI 1.48–1.53, P < .001; HR 1.42, 95% CI 1.40–1.44, P < .001 respectively). Other factors associated with decreased OS were a liver-related admission (HR 1.32, 95% CI 1.29–1.34, P

BACKGROUND: Factors associated with time-to-surgery (TTS) and survival in patients with colon cancer has not been well studied. Cancer Care Ontario recommends surgery within 42 days of diagnosis and that 90% of patients meet this benchmark. AIMS: We describe factors associated with TTS and survival in routine clinical practice. METHODS: Retrospective population-based cohort study of patients receiving elective colonic resection after diagnosis of colon cancer in Ontario, Canada from 2002–2008. Factors associated with TTS were identified using multivariate log-binomial and Quantile regression at 42 days and 90(th) percentiles. The association between TTS and cancer-specific (CSS) and overall survival (OS) were examined using multivariate Cox regression. RESULTS: 4,326 patients; median age 71 years and 52% male. Median TTS was 24 days (IQR 14–37); at the 90(th) percentile 56 days. Factors associated with TTS ≥ 42 days and > 90(th) percentile included older age, co-morbid illness, surgeon volume, and stage I disease (P < 0.05 for all). In patients whose TTS was either at 42 days or 90(th) percentile, those ≥ 80 years old waited two weeks longer than those < 60 years, individuals with co-morbid illness waited 10 days longer than those without co-morbidity, and patients with stage I disease waited 10 days longer than those with stage IV disease (P < 0.05 for all). Delay in TTS > 42 days or > 90(th) percentile was not associated with OS or CSS. CONCLUSIONS: Age, co-morbidity, and stage of cancer are associated with TTS. There was no association between TTS and CSS or OS. FUNDING AGENCIES: Southeastern Ontario Academic Medical Association (SEAMO)

Background: Recent data shows the prevalence of chronic liver disease (CLD) and cirrhosis mortality is increasing in adolescents and young adults in the United States. We aimed to describe the epidemiology of cirrhosis using an Age-Period-Cohort (APC) approach to define birth cohort effects on cirrhosis incidence. Methods: Retrospective population-based cohort study in Ontario, Canada from January 1, 1997 - December 31, 2016 using linked administrative health data. Patients ≥ 18 years with cirrhosis were identified using a validated case definition. Annual standardized incidence rates (ASIR) and prevalence rates (ASPR) in the general population were calculated. An APC approach was used to assess the independent association between birth cohort and cirrhosis incidence. Findings: 165,979 individuals with cirrhosis were identified. The ASIR increased over the study (70.6/100,000 person-years 1997 vs. 89.6/100,000 in 2016) as did the prevalence (ASPR: 0.42% in 1997 vs. 0.84% in 2016). Using APC modeling and the median birth year as the reference, cirrhosis incidence was 55% higher if born in 1980 (IRR 1.55: 95% CI 1.50-1.59, P

Background: The duration of the cancer diagnostic process has considerable influence on patients' psychosocial well-being. Breast diagnostic assessment units (DAUs) in Ontario, Canada are designed to improve the quality and timeliness of care during a breast cancer diagnosis. We compared the diagnostic duration of patients diagnosed through a DAU vs usual care (UC). Methods: Retrospective population-based cohort study of 2499 screen-detected breast cancers (2011) using administrative health-care databases linked to the Ontario Cancer Registry. The diagnostic interval was measured from the initial screen to cancer diagnosis. Diagnostic assessment unit use was based on the biopsy and/or surgery hospital. We compared the length of the diagnostic interval between the DAU groups using multivariable quantile regression. Results: Diagnostic assessment units had a higher proportion of patients diagnosed within the 7-week target compared with UC (79.1% vs 70.2%, P

The management of differentiated thyroid cancer has traditionally consisted of total thyroidectomy with or without adjuvant radioactive iodine. However, in the last two decades, this approach has been challenged, with the consideration of more conservative approaches such as less radical surgery and deferring adjuvant treatment, especially in lower-risk patients. The objective of this study was to consider the effectiveness of current treatment options by comparing the survival outcomes from different geographic regions with different treatment philosophies. This study design was based on the concept of natural experiments in patient care that occur when physicians in different regions treat the spectrum of typical patients with varying treatments.This population-based retrospective cohort study investigated 2444 patients with differentiated thyroid cancer ≤4 cm between 1990 and 2001 from Ontario, Canada. Extent of disease and extent of surgery were abstracted from pathology reports and were linked to downstream administrative medical information on treatments and outcomes. Patient demographics, tumor characteristics, treatments, and outcomes were compared between those geographic regions with more aggressive treatments and those regions with less aggressive treatments.Treatment varied across the province. When comparing outcomes in regions where patients had more extensive treatment to those in regions where patients had less extensive therapy, similar rates were found for 15-year survival, recurrence, and survival after recurrence.There were significant variations in treatment but no differences in outcomes for regions with more versus less aggressive approaches. These findings support the trend toward more conservative management approaches in the treatment of thyroid cancer.