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Background and aims: There is an incomplete understanding of the full safety profiles of repeated COVID-19 vaccinations in patients with inflammatory bowel disease (IBD). Among individuals with IBD, we assessed whether COVID-19 vaccines were associated with serious adverse events of special interest (AESI) and health care utilization [all-cause hospitalizations, Emergency Department (ED) visits, gastroenterology visits, IBD-related visits]. Methods: Using comprehensive administrative health data from Ontario, Canada, adults with IBD who received at least one COVID-19 vaccine from December 2020-January 2022 were included. Self-controlled case series analyses were conducted to evaluate the relative incidence rates of AESI and health care utilization outcomes across post-vaccination risk and control periods. Results: Among 88,407 IBD patients, 99.7% received mRNA vaccines and 75.9% received ≥ 3 doses. Relative to control periods, we did not detect an increase in AESI. IBD patients had fewer all-cause hospitalizations during post-vaccination risk periods. Patients experienced more all-cause ED visits after dose 2 [Relative Incidence (RI):1.08(95%CI:1.04–1.12)] but fewer visits after doses 3 [RI:0.85 (95%CI:0.81–0.90)] and 4 [RI:0.73 (95%CI:0.57–0.92)]. There was no increase in gastroenterologist visits or IBD-related health care utilization post-vaccination. There were fewer IBD-related hospitalizations after dose 1 [RI:0.84 (95%CI:0.72–0.98)] and 3 [RI:0.63 (95%CI:0.52–0.76)], fewer IBD-related ED visits after dose 3 [RI:0.81 (95%CI:0.71–0.91)] and 4 [RI:0.55 (95%CI:0.32–0.96)], and fewer outpatient visits after dose 2 [RI:0.91 (95%CI:0.90–0.93)] and 3 [RI:0.87 (95%CI:0.86–0.89)]. Conclusion: This population-based study did not detect increased AESI, all-cause or IBD-related health care utilization following COVID-19 vaccination, suggesting a lack of association between vaccination and increased disease activity. [ABSTRACT FROM AUTHOR]

Introduction: We examined the coronavirus disease 2019 (COVID-19) pandemic impact on weekly trends in the billing of virtual and in-person physician visits in Ontario, Canada. Methods: In this retrospective cohort study, physician billing records from Ontario were aggregated on a weekly basis for in-person and virtual visits from 3 January 2016 to 27 March 2021. For each type of visit, a segmented negative binomial regression analysis was performed to estimate the weekly pre-pandemic trend in billing volume per thousand adults (3 January 2016 to 14 March 2020), the immediate change in mean volume at the start of the pandemic, and additional change in weekly volume in the pandemic era (15 March 2020 to 27 March 2021). Results: Before the start of the pandemic, the weekly volume of virtual visits per thousand adults was low with a 0.5% increase per week (rate ratio [RR]: 1.0053, 95% confidence interval [CI]: 1.0050–1.0056). A dramatic 65% reduction in in-person visits (RR: 0.35, 95% CI: 0.32–0.39) occurred at the start of the pandemic while virtual visits grew by 21-fold (RR: 21.3, 95% CI: 19.6–23.0). In the pandemic era, in-person visits rose by 1.4% per week (RR: 1.014, 95% CI: 1.011–1.017) but no change was observed for virtual visits (p -value = 0.31). Overall, we noted a 57.6% increase in total weekly physician visits volume after the start of the pandemic. Discussion: These results are meaningful for virtual care reimbursement models. Future study needs to assess the quality of care and whether the increase in virtual care volume is cost-effective to society. [ABSTRACT FROM AUTHOR]

Background: Little is known about the COVID‐19 pandemic impact on the provision of diagnostic imaging and physician visits at cancer diagnosis. Methods: We used administrative databases from Ontario, Canada, to identify MRI/CT/ultrasound scans and in‐person/virtual physician visits conducted with cancer patients within 91 days around the date of diagnosis in 2016–2020. In separate segmented regression procedures, we assessed the trends in weekly volume of these services per thousand cancer patients in prepandemic (June 26, 2016 to March 14, 2020), the change in mean volume at the start of the pandemic, and the additional change in weekly volume during the pandemic (March 15, 2020, to September 26, 2020). Results: Totally, 403,561 cancer patients were included. On March 15, 2020 (COVID‐19 arrived), mean scan volume decreased by 12.3% (95% CI: 6.4%–17.9%) where ultrasound decreased the most by 31.8% (95% CI: 23.9%–37.0%). Afterward, the volume of all scans increased further by 1.6% per week (95% CI: 1.3%–2.0%), where ultrasound increased the fastest by 2.4% (95% CI: 1.8%–2.9%). Mean in‐person visits dropped by 47.4% when COVID‐19 started (95% CI: 41.6%–52.6%) while virtual visits rose by 55.15‐fold (95% CI: 4927%‐6173%). In the pandemic (until September 26, 2020), in‐person visits increased each week by 2.6% (95% CI: 2.0%–3.2%), but no change was observed for virtual visits (p ‐value = 0.10). Conclusions: Provision of diagnostic imaging and virtual visits at cancer diagnosis has been increasing since the start of COVID‐19 and has exceeded prepandemic utilization levels. Future work should monitor the impact of these shifts on quality of delivered care. [ABSTRACT FROM AUTHOR]

Observational studies suggest an anti-neoplastic effect associated with statins, metformin, and dipeptidyl peptidase-4 inhibitors (DPP4i), while sulfonylureas may have a neutral or detrimental effect. We linked the Ontario subset of a prospective Canadian myelodysplastic syndromes (MDS) registry with provincial administrative databases. We assessed the impact of statin/oral hypoglycemic medication exposure on overall survival (OS) using Cox regression analysis, controlling for comorbidities and sociodemographic factors. Five hundred thirty-three patients aged ≥ 66 years were included: 49.3% used statins, 18.9% used metformin, 9.0% used sulfonylureas, and 6.4% used DPP4i. Three hundred ninety-five patients were lower-risk based on the International Prognostic Scoring System. On univariate analysis, we identified a marginal improvement in OS in the lower-risk group using DPP4i (HR 0.98, 95% CI 0.95–1.00, P = 0.05), while there was no impact on mortality for higher-risk DPP4i users (HR 1.03, CI 0.99–1.07, P = 0.21). There was no mortality difference for statins (HR 1.00, CI 1.00–1.01, P = 0.93), metformin (HR 1.00, CI 0.99–1.01, P = 0.81), or sulfonylureas (HR 1.00, CI 0.99–1.02, P = 0.43) in the entire cohort, as well as when stratified into lower/higher-risk groups. On multivariable analysis in the lower-risk group, there was no association between DPP4i and OS (HR 0.98, CI 0.95–1.00, P = 0.06). Prospective studies with larger cohorts of patients and longer follow-up are required to further study the impact of DPP4i in MDS. [ABSTRACT FROM AUTHOR]

Background: Patients diagnosed with cancer often experience considerable challenges with mental health, and those who had more intense psychiatric care prior to their cancer diagnosis have a higher risk of mortality. As prior research demonstrated a survival benefit among patients screened for symptoms using the Edmonton symptom assessment system (ESAS), this study aims to examine the association between being ESAS‐screened and the risk of mortality across varying intensity levels of pre‐diagnosis psychiatric care utilization. Methods: We conducted a retrospective matched cohort study using population‐wide administrative databases. All patients diagnosed with cancer in Ontario, Canada, from January 2007 to December 2015 were identified. Propensity score matching was used to pair ESAS‐screened individuals to those not screened. Pairs were also hard matched on a pre‐diagnosis psychiatric care utilization gradient. A multivariable Cox proportional hazards regression model was implemented to estimate the association between ESAS and mortality, for each intensity level of pre‐diagnosis psychiatric care. Results: The matched cohort consisted of 119,806 patient pairs (ESAS‐screened and not screened), of whom 54,468 (45.5%) pairs had prior outpatient psychiatric care and 2249 (1.8%) pairs had experienced emergency department visits or had been hospitalized for psychiatric care. Overall being exposed to ESAS was significantly associated with a 51% decrease in the hazard of mortality (HR 0.49, 95%CI 0.48–0.50, p‐value <0.0001). This association was similar across all levels of prior psychiatric use, however, there was no evidence of a differential impact. Conclusion: In addition to routinely monitoring symptom severity, including depression, among patients with cancer, it is also important to identify those with preexisting psychiatric comorbidities at the time of diagnosis. This information can be used to ensure that timely and appropriate psycho‐oncology services and psycho‐social supports are offered to help the patient and their family cope during the cancer disease trajectory. [ABSTRACT FROM AUTHOR]

Background: The Edmonton Symptom Assessment System (ESAS) is a validated instrument whose use has been standardized in the Ontario cancer system to measure symptoms among ambulatory cancer patients. The objective was to examine the effect of ESAS exposure on overall survival. We hypothesized, a priori, that patients exposed to ESAS would have higher rates of overall survival than those who were not exposed. Methods: This was a retrospective matched cohort study of adults diagnosed with cancer between 2007 and 2015. Patients were considered exposed if they were screened with ESAS at least once during the study period. Their first ESAS screening date defined the index date. Each exposed patient was matched randomly to a cancer patient without ESAS using a combination of hard matching (4 variables) and propensity score matching (14 variables). Kaplan‐Meier curves and multivariable Cox regression were used to evaluate the impact of ESAS exposure on survival. Results: There were 128,893 pairs well matched on all baseline characteristics. The probability of survival within the first 5 years was higher among those exposed to ESAS compared to those who were not (81.9% vs. 76.4% at 1 year, 68.3% vs. 66.1% at 3 years, 61.9% vs. 61.4% at 5 years, P‐value <.0001). In the multivariable Cox regression model, ESAS was significantly associated with a decreased mortality risk (HR: 0.48, 95% CI: 0.47‐0.49). Conclusions: Our results show that ESAS exposure is associated with improved survival in cancer patients. This provides real world evidence of the impact of routine symptom assessment in cancer care. [ABSTRACT FROM AUTHOR]

Background: Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system.Methods: A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases.Results: Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers.Conclusion: Progressive increases in hospital volume correspond to improved 90-day outcomes following PD. [ABSTRACT FROM AUTHOR]

Background: In June 2013, Ontario Health (Cancer Care Ontario), the agency responsible for advancing cancer care in Ontario, Canada, published practice guidelines recommending that gynecologic oncologists at tertiary care centers manage the treatment of patients with high-grade endometrial cancers. This study examines the effects of this regionalization of care on patient outcomes.Objective: This study aimed to evaluate the impact of the regionalization of surgery for high-grade endometrial cancer on patient and treatment outcomes.Study Design: In this retrospective cohort study, patients diagnosed with nonendometrioid high-grade endometrial cancer from 2003 to 2017 were identified using province-wide administrative databases. To allow 6 months for knowledge translation, 2 periods were defined, with January 1, 2014, as the cutoff. Methods for segmented regression were used to test the effect of the guidelines. Multivariable Cox proportional hazards regression was used to evaluate whether regionalization of care had an impact on patient survival.Results: There were 3518 patients with nonendometrioid high-grade endometrial cancer identified. The case mix as represented by patient comorbidities and the disease stage distribution did not differ significantly between the 2 regionalization periods. There was a significant increase (69%-85%; P<.001) in the proportion of primary surgeries performed by gynecologic oncologists after regionalization, which was not explained by secular trends. After regionalization, the proportion of patients who had surgical staging (50%-63%; P<.001) and the proportion of patients who received adjuvant treatment (65%-71%; P<.001) increased significantly. After adjusting for age, stage, and comorbidities, there was a decrease in the hazard of mortality (hazard ratio, 0.85 [95% confidence interval, 0.73-0.99]; P=.04) after regionalization.Conclusion: The publication of a regionalization policy for the treatment of high-grade endometrial cancers in Ontario led to an increase in the proportion of surgeries performed by gynecologic oncologists. This also translated into a significant improvement in patient survival. [ABSTRACT FROM AUTHOR]

Although different treatment protocols for childhood acute lymphoblastic leukaemia (ALL) all achieve high cure rates, their health care utilisation and costs have not been rigorously compared. Disease, treatment, and outcome data were chart abstracted for all children with ALL in Ontario, Canada, diagnosed 2002–2012. Linkage to population-based databases identified health care utilisation. Utilisation-associated costs were determined through validated algorithms. Chemotherapy-associated costs were calculated separately. Health care utilisation and costs were compared between patients receiving Children's Oncology Group (COG) versus Dana-Farber Cancer Institute (DFCI)-based treatment. Of 802 patients, 146 (18.2%) were treated on DFCI-based protocols. COG patients experienced significantly higher rates of emergency department (ED) visits (adjusted rate ratio [aRR]: 1.3, 95% confidence interval [CI]: 1.1–1.5; p = 0·01), whereas outpatient visit rates were 60% higher among DFCI patients (aRR: 1.6, 95% CI: 1.5–1.7, p < 0.0001). In adjusted analyses, DFCI-associated cost intensity was 70% higher (aRR: 1.7, 95% CI: 1.5–1.9; p < 0.0001), mainly attributable to outpatient visit costs. Total chemotherapy costs were higher among COG-treated patients ($39,400 ± $1100 versus $33,400 ± $2800; p = 0.02). Among PEG-ASNase–treated patients, total chemotherapy costs were highest among DFCI patients (median $54,200 ± $7400; p = 0.003 versus COG patients). COG and DFCI treatments were associated with higher ED visit rates and higher outpatient visit rates, respectively. Overall utilisation-associated costs were increased in DFCI-treated patients. Administration of some intravenous chemotherapy at home and decreases in PEG-ASNase cost would decrease health care utilisation and costs for all patients and mitigate differences between COG and DFCI protocols. C17 Research Network. • Few studies compare health care use or cost of different paediatric acute lymphoblastic leukaemia protocols. • We compared population-based patient cohorts treated with Children's Oncology Group (COG) versus Dana-Farber Cancer Institute (DFCI) protocols. • We found more emergency department visits with COG but more outpatient visits with DFCI. • During the study period, cost intensity was higher among DFCI patients. • Strategies minimising burden of both protocols are warranted. [ABSTRACT FROM AUTHOR]

Practice guidelines advocating for regionalization of endometrial cancer surgery to gynecologic oncologists practicing in designated gynecologic oncology centres were published in Ontario in June 2013. Our objectives were to determine whether this policy affected surgical wait times, and whether longer wait time to surgery is a predictor of survival in high grade endometrial cancer patients. This was a population-based retrospective cohort study, which included patients diagnosed with high-grade non-endometrioid endometrial cancer who had a hysterectomy between 2003 and 2017. Multivariable Cox proportional hazards regression with a spline function was used to model the relationship between surgical wait time and overall survival (OS). We identified 3518 patients who underwent hysterectomy for high-grade non-endometrioid endometrial cancer. Patients who had surgery with a gynecologic oncologist had a median surgical wait time from diagnosis to hysterectomy of 53 days compared to 57 days pre-regionalization (p = 0.0007), and from first gynecologic oncology consultation to hysterectomy of 29 days compared to 32 days pre-regionalization (p = 0.0006). Survival was inferior for patients who had surgery within 14 days of diagnosis (HR death 2.7 for 1–7 days, 95% CI 1.61–4.51, and HR death 1.96 for 8–14 days, 95% CI 1.50–2.57), reflective of disease severity. Decreased survival occurred with surgical wait times of more than 45 days from the patient's first gynecologic oncology appointment (HR death 1.19 for 46–60 days, 95% CI 1.04–1.36, and HR death 1.42 for 61–75 days, 95% CI 1.11–1.83). Regionalization of surgery for high-grade endometrial cancer has not had an impact on surgical wait times. Patients who have surgery more than 45 days after surgical consultation have reduced survival. • Regionalization of surgery for high-grade endometrial cancer did not have a negative impact on surgical wait times. • Survival was inferior for patients who had surgery 45 days or later from their first gynecologic oncology appointment. • Patients with long wait times were more likely to be of low SES and less likely to have had staging or adjuvant treatment. [ABSTRACT FROM AUTHOR]