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Purpose: This study examined the impact of multimorbidity on severe COVID-19 outcomes in community and long-term care (LTC) settings, alone and in interaction with age and sex. Methods: We conducted a retrospective cohort study of all Ontarians who tested positive for COVID-19 between January-2020 and May-2021 with follow-up until June 2021. We used cox regression to evaluate the adjusted impact of multimorbidity, individual characteristics, and interactions on time to hospitalization and death (any cause). Results: 24.5% of the cohort had 2 or more pre-existing conditions. Multimorbidity was associated with 28% to 170% shorter time to hospitalization and death, respectively. However, predictors of hospitalization and death differed for people living in community and LTC. In community, increasing multimorbidity and age predicted shortened time to hospitalization and death. In LTC, we found none of the predictors examined were associated with time to hospitalization, except for increasing age that predicted reduced time to death up to 40.6 times. Sex was a predictor across all settings and outcomes: among male the risk of hospitalization or death was higher shortly after infection (e.g. HR for males at 14 days = 30.3) while among female risk was higher for both outcome in the longer term (e.g. HR for males at 150 days = 0.16). Age and sex modified the impact of multimorbidity in the community. Conclusion: Community-focused public health measures should be targeted and consider sociodemographic and clinical characteristics such as multimorbidity. In LTC settings, further research is needed to identify factors that may contribute to improved outcomes.

Objectives There is mixed evidence on the influence of number of conditions on inequalities in mortality, we explored the association between number of conditions and deprivation on mortality whilst assessing the difference between working age and older adults. We replicated the analysis in England and Ontario, to provide a cross-jurisdiction comparison. Approach We used individual level-linked data from primary care activity, secondary care and mortality data in England and Ontario. For both jurisdictions, we took a random sample of 600,000 adults from 1 January 2015 and followed them up till 31 December 2019. We used cox proportional hazard to test the influence of deprivation (measured using area-level deprivation in deciles) and number of conditions (measured at baseline and capped at six conditions) on survival. Age and sex were also measured at baseline. Analyses were stratified by working age (18-64 years) and older adults (65+ years) and were repeated for England and Ontario. Results Deprivation gradient in mortality rate was steeper in working age than older adults in both jurisdictions. Number of conditions was associated with increased mortality rate, this was stronger for working age than older adults, in England (working age HR = 1.60, 95% CI 1.56,1.64 and older adults HR= 1.26, 95% CI 1.25,1.27) and Canada (working age HR=1.69, 95% CI 1.66,1.72 and older adults HR= 1.39, 95% CI 1.38,1.40). After accounting for number of conditions, the mortality rate associated with deprivation decreased but remained significant. The interaction between number of conditions and deprivation showed that adults with more conditions have a higher mortality rate and those living in deprived areas also have a higher mortality rate but having more conditions attenuates the deprivation gradient in mortality. Conclusion Number of conditions contribute to higher mortality rate and inequalities in morality, this is stronger for working age than older adults in England and Ontario. The fragmented health-care system may be contributing to poorer outcomes, further research should help identify which part of the pathway is driving these inequalities further.

BackgroundMultiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England.Methods and findingsA random sample of primary care patients from Clinical Practice Research Datalink (CPRD) was followed from 1st January 2015 until 31st December 2019. Ethnicity, usually self-ascribed, was obtained from primary care records if present or from hospital records. Long-term conditions were counted from a list of 32 that have previously been associated with greater primary care, hospital admissions, or mortality risk. Cox regression models were used to estimate mortality by count of conditions, ethnicity and their interaction, with adjustment for age and sex for 532,059 patients with complete data. During five years of follow-up, 5.9% of patients died. Each additional condition at baseline was associated with increased mortality. The direction of the interaction of number of conditions with ethnicity showed a statistically higher mortality rate associated with long-term conditions in Pakistani, Black African, Black Caribbean and Other Black ethnic groups. In ethnicity-stratified models, the mortality rate per additional condition at age 50 was 1.33 (95% CI 1.31,1.35) for White ethnicity, 1.43 (95% CI 1.26,1.61) for Black Caribbean ethnicity and 1.78 (95% CI 1.41,2.24) for Other Black ethnicity.ConclusionsThe higher mortality rate associated with having multiple conditions is greater in minoritised compared with White ethnic groups. Research is now needed to identify factors that contribute to these inequalities. Within the health care setting, there may be opportunities to target clinical and self-management support for people with multiple conditions from minoritised ethnic groups.

Background Multimorbidity is a concern for people living with cancer, as over 90% have at least one other condition. Multimorbidity complicates care coming from multiple providers who work within separate, siloed systems. Information describing high-risk and high-cost disease combinations has potential to improve the experience, outcome, and overall cost of care by informing comprehensive care management frameworks. This study aimed to identify disease combinations among people with cancer and other conditions, and to assess the health burden associated with those combinations to help healthcare providers more effectively prioritize and coordinate care. Methods We used a population-based retrospective cohort design including adults with a cancer diagnosis between March-2003 and April-2013, followed-up until March 2018. We used observed disease combinations defined by level of multimorbidity and partitive (k-means) clusters, ie groupings of similar diseases based on the prevalence of each condition. We assessed disease combination-associated health burden through health service utilization, including emergency department visits, primary care visits and hospital admissions during the follow-up period. Results 549,248 adults were included in the study. Anxiety, diabetes mellitus, hypertension, and osteoarthritis co-occurred with cancer 1.1 to 5.3 times more often than expected by chance. Disease combinations varied by cancer type and age but were similar between sexes. The largest partitive cluster included cancer and anxiety, with at least 25% of individuals also having osteoarthritis. Cancer also tended to co-occur with hypertension (8.0%) or osteoarthritis (6.2%). There were differences between clusters in healthcare utilization, regardless of the number of disease combinations or clustering approach used. Conclusion Researchers, clinicians, policymakers, and other stakeholders can use the clustering information presented here to improve the healthcare system for people with cancer multimorbidity by developing cluster-specific care management and clinical guidelines for common disease combinations.

IntroductionIndividuals experience negative physical, social and psychological ramifications when they are hurt or become ill at work. Ontario’s Workplace Safety and Insurance Board (WSIB) is intended to mitigate these effects, yet the WSIB process can be difficult. Supports for injured workers can be fragmented and scarce, especially in underserved areas. We describe the experiences and mental health needs of injured and ill Northwestern Ontario workers in the WSIB process, in order to promote system improvements. MethodsCommunity-recruited injured and ill workers (n = 40) from Thunder Bay and District completed an online survey about their mental health, social service and legal system needs while involved with WSIB. Additional Northwestern Ontario injured and ill workers (n = 16) and community service providers experienced with WSIB processes (n = 8) completed interviews addressing similar themes. ResultsNorthwestern Ontario workers described the impacts of workplace injury and illness on their professional, family, financial and social functioning, and on their physical and mental health. Many also reported incremental negative impacts of the WSIB processes themselves, including regional issues such as “small town” privacy concerns and the cost burden of travel required by the WSIB, especially during COVID-19. Workers and service providers suggested streamlining and explicating WSIB processes, increasing WSIB continuity of care, and region-specific actions such as improving access to regional support services through arm’s-length navigators. ConclusionNorthwestern Ontario workers experienced negative effects from workplace injuries and illness and the WSIB process itself. Stakeholders can use these findings to improve processes and outcomes for injured and ill workers, with special considerations for the North.

IntroductionLes accidents du travail et les maladies professionnelles ont des répercussions physiques, sociales et psychologiques négatives sur les personnes qui en sont victimes. Bien que la Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail (WSIB) de l’Ontario ait pour mandat d’atténuer ces effets, son processus de fonctionnement peut conduire à des difficultés. Les soutiens qui sont offerts aux travailleurs blessés peuvent être fragmentés et rares, notamment dans les régions qui sont mal desservies. Nous décrivons les expériences vécues par des travailleurs blessés ou malades du Nord­Ouest de l’Ontario dans le cadre de leurs démarches auprès de la WSIB, de même que les besoins en santé mentale de ces travailleurs, dans le but de promouvoir l’amélioration du système en place. MéthodologieDes travailleurs blessés et malades (n = 40) recrutés dans la collectivité de Thunder Bay et son district ont répondu à un sondage en ligne sur leurs besoins en matière de santé mentale, de services sociaux et de services juridiques lors de leurs démarches auprès de la WSIB. Des entrevues portant sur des thèmes similaires ont aussi été réalisées avec 16 autres travailleurs blessés et malades ailleurs dans le Nord-Ouest de l’Ontario ainsi qu’avec 8 fournisseurs de services communautaires connaissant bien le fonctionnement de la WSIB. RésultatsLes travailleurs du Nord­Ouest de l’Ontario ont décrit les répercussions que leur accident du travail ou leur maladie professionnelle avait eues sur leur situation professionnelle, familiale, financière et sociale, ainsi que sur leur santé physique et mentale. Beaucoup ont aussi souligné les effets négatifs accrus attribuables aux processus mêmes de la WSIB, notamment les problèmes locaux liés à la protection de la vie privée dans les « petites villes » et le fardeau financier associé aux déplacements exigés par la WSIB, en particulier durant la pandémie de COVID­19. Les travailleurs et les fournisseurs de services ont proposé de rationaliser et de clarifier les processus de la WSIB, d’améliorer la continuité des soins offerts par la WSIB et de mettre en place des mesures spécifiques à la région, telles que l’amélioration de l’accès aux services de soutien régionaux par l’intermédiaire d’intervenants­pivots indépendants. Conclusion Les travailleurs du Nord­Ouest de l’Ontario subissent des effets négatifs dus à la fois aux blessures ou maladies professionnelles et au fonctionnement de la WSIB. Les intervenants pourront utiliser les constatations de cette recherche afin d’améliorer les démarches et la situation des travailleurs blessés et malades, en tenant compte plus particulièrement de la région du Nord.

Abstract Background The majority of people with cancer have at least one other chronic health condition. With each additional chronic disease, the complexity of their care increases, as does the potential for negative outcomes including premature death. In this paper, we describe cancer patients’ clinical complexity (i.e., multimorbidity; MMB) in order to inform strategic efforts to improve care and outcomes for people with cancer of all types and commonly occurring chronic diseases. Methods We conducted a population-based, retrospective cohort study of adults diagnosed with cancer between 2003 and 2013 (N = 601,331) identified in Ontario, Canada healthcare administrative data. During a five to 15-year follow-up period (through March 2018), we identified up to 16 co-occurring conditions and patient outcomes for the cohort, including health service utilization and death. Results MMB was extremely common, affecting more than 91% of people with cancer. Nearly one quarter (23%) of the population had five or more co-occurring conditions. While we saw no differences in MMB between sexes, MMB prevalence and level increased with age. MMB prevalence and type of co-occurring conditions also varied by cancer type. Overall, MMB was associated with higher rates of health service utilization and mortality, regardless of other patient characteristics, and specific conditions differentially impacted these rates. Conclusions People with cancer are likely to have at least one other chronic medical condition and the presence of MMB negatively affects health service utilization and risk of premature death. These findings can help motivate and inform health system advances to improve care quality and outcomes for people with cancer and MMB.