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We assessed patterns of enteric infections caused by 14 pathogens, in a longitudinal cohort study of sequelae in British Columbia (BC) Canada, 2005–2014. Our population cohort of 5.8 million individuals was followed for an average of 7.5 years/person; during this time, 40 523 individuals experienced 42 308 incident laboratory-confirmed, provincially reported enteric infections (96.4 incident infections per 100 000 person-years). Most individuals (38 882/40 523; 96%) had only one, but 4% had multiple concurrent infections or more than one infection across the study. Among individuals with more than one infection, the pathogens and combinations occurring most frequently per individual matched the pathogens occurring most frequently in the BC population. An additional 298 557 new fee-for-service physician visits and hospitalisations for enteric infections, that did not coincide with a reported enteric infection, also occurred, and some may be potentially unreported enteric infections. Our findings demonstrate that sequelae risk analyses should explore the possible impacts of multiple infections, and that estimating risk for individuals who may have had a potentially unreported enteric infection is warranted We assessed patterns of enteric infections caused by 14 pathogens, in a longitudinal cohort study of sequelae in British Columbia (BC) Canada, 2005-2014. Our population cohort of 5.8 million individuals was followed for an average of 7.5 years/person; during this time, 40 523 individuals experienced 42 308 incident laboratory-confirmed, provincially reported enteric infections (96.4 incident infections per 100 000 person-years). Most individuals (38 882/40 523; 96%) had only one, but 4% had multiple concurrent infections or more than one infection across the study. Among individuals with more than one infection, the pathogens and combinations occurring most frequently per individual matched the pathogens occurring most frequently in the BC population. An additional 298 557 new fee-for-service physician visits and hospitalisations for enteric infections, that did not coincide with a reported enteric infection, also occurred, and some may be potentially unreported enteric infections. Our findings demonstrate that sequelae risk analyses should explore the possible impacts of multiple infections, and that estimating risk for individuals who may have had a potentially unreported enteric infection is warranted.

Achieving the 95-95-95 targets for HIV diagnosis, treatment, and viral load suppression to end the HIV epidemic hinges on eliminating structural inequalities, including intimate partner violence (IPV). Sub-Saharan Africa has among the highest prevalence of IPV and HIV worldwide. We aimed to examine the effects of IPV on recent HIV infection and women's engagement in the HIV care cascade in sub-Saharan Africa.We did a retrospective pooled analysis of data from nationally representative, cross-sectional surveys with information on physical or sexual IPV (or both) and HIV testing, from Jan 1, 2000, to Dec 31, 2020. Relevant surveys were identified from data catalogues and previous large-scale reviews, and included the Demographic and Health Survey, the AIDS Indicator Survey, the Population-based HIV Impact Assessment, and the South Africa National HIV Prevalence, Incidence, Behavior and Communication Survey. Individual-level data on all female respondents who were ever-partnered (currently or formerly married or cohabiting) and aged 15 years or older were included. We used Poisson regression to estimate crude and adjusted prevalence ratios (PRs) for the association between past-year experience of physical or sexual IPV (or both), as the primary exposure, and recent HIV infection (measured with recency assays), as the primary outcome. We also assessed associations of past-year IPV with self-reported HIV testing (also in the past year), and antiretroviral therapy (ART) uptake and viral load suppression at the time of surveying. Models were adjusted for participant age, age at sexual debut (HIV recency analysis), urban or rural residency, partnership status, education, and survey-level fixed effects.57 surveys with data on self-reported HIV testing and past-year physical or sexual IPV were available from 30 countries, encompassing 280 259 ever-partnered women aged 15-64 years. 59 456 (21·2%) women had experienced physical or sexual IPV in the past year. Six surveys had information on recent HIV infection and seven had data on ART uptake and viral load suppression. The crude PR for recent HIV infection among women who had experienced past-year physical or sexual IPV, versus those who had not, was 3·51 (95% CI 1·64-7·51; n=19 179). The adjusted PR was 3·22 (1·51-6·85). Past-year physical or sexual IPV had minimal effect on self-reported HIV testing in the past year in crude analysis (PR 0·97 [0·96-0·98]; n=274 506) and adjusted analysis (adjusted PR 0·99 [0·98-1·01]). Results were inconclusive for the association of ART uptake with past-year IPV among women living with HIV (crude PR 0·90 [0·85-0·96], adjusted PR 0·96 [0·90-1·02]; n=5629). Women living with HIV who had experienced physical or sexual IPV in the past year were less likely to achieve viral load suppression than those who had not experienced past-year IPV (crude PR 0·85 [0·79-0·91], adjusted PR 0·91 [0·84-0·98], n=5627).Past-year physical or sexual IPV was associated with recent HIV acquisition and less frequent viral load suppression. Preventing IPV is inherently imperative but eliminating IPV could contribute to ending the HIV epidemic.Canadian Institutes of Health Research, the Canada Research Chairs Program, and Fonds de recherche du Québec-Santé.For the French, Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Background: Achieving the 95-95-95 targets for HIV diagnosis, treatment, and viral load suppression (VLS) to end the HIV/AIDS epidemic hinges on eliminating structural inequalities, including intimate partner violence (IPV). Sub-Saharan Africa (SSA) has among the world's highest prevalence of IPV and HIV. We aim to examine the impact of IPV on recent HIV infection and women's engagement in the HIV care cascade. Methods: We pooled individual-level data from nationally representative surveys with information on physical and/or sexual IPV and HIV in SSA (2000-2020). We used Poisson regressions with robust standard errors to estimate adjusted prevalence ratios (aPR) of past year experience of IPV on recent HIV infection (measured using recency assays), past-year HIV testing, antiretroviral therapy (ART) uptake, and VLS among ever-partnered (currently/formerly married or cohabitating) women. Models were adjusted for women's age, age at sexual debut, residence type, marital status, education, and the survey's identifier (proxy of country and year). Findings: Fifty-seven surveys were available from thirty countries, encompassing 280,259 (N) individuals. One-fifth of women reported physical and/or sexual IPV in the past year. Six surveys had information on recent HIV infection and seven had data on ART uptake and VLS. Women experiencing past year IPV were 3.22 times (95%CI: 1.51-6.85, N=19,179) more likely to have a recent HIV infection, adjusting for potential confounders. Past year IPV was not associated with HIV testing (aPR=0.99, 95%CI: 0.98-1.01, N=274,506) or ART uptake (aPR=0.96, 95%CI:0.90-1.03, N=5,629). Women living with HIV (WLHIV) experiencing IPV in the past year were 9% less likely to achieve VLS (aPR=0.91, 95%CI: 0.85-0.98, N=5,627). Interpretation: Past year IPV was associated with recent HIV acquisition and lower VLS among WLHIV. Preventing IPV is inherently imperative but eliminating IPV could also be crucial to ending HIV/AIDS.

BackgroundBetween 2017 and 2020, Ontario implemented overdose prevention sites (OPS) and consumption and treatment services (CTS) in nine of its 34 public health units (PHU). We tested for the effect of booth-hours (spaces within OPS/CTSs for supervised consumption) on opioid-related health service use and mortality rates at the provincial-(aggregate) and PHU-level.MethodsWe used monthly rates of all opioid-related emergency department (ED) visits, hospitalizations, and deaths between January 2015 and March 2021 as our three outcomes. For each PHU that implemented OPS/CTSs, we created a synthetic control as a weighted combination of unexposed PHUs. Our exposure was the time-varying rate of booth-hours provided. We estimated the population-level effects of the intervention on each outcome per treated/synthetic-control pair using controlled interrupted time series with segmented regression; and tested for the aggregate effect using a multiple baseline approach. We adjusted for time-varying provision of prescription opioids for pain management, opioid agonist treatment (OAT), and naloxone kits; and corrected for seasonality and autocorrelation. All rates were per 100,000 population. For sensitivity analysis, we restricted the post-implementation period to before COVID-19 public health measures were implemented (March 2020).ResultsOur aggregate analyses found no effect per booth-hour on ED visit (0.00, 95% CI: -0.01, 0.01; p-value=0.6684), hospitalization (0.00, 95% CI: 0.00, 0.00; p-value=0.9710) or deaths (0.00, 95% CI: 0.00, 0.00; p-value=0.2466). However, OAT reduced ED visits (−0.20, 95% CI: -0.35, -0.05; p-value=0.0103) and deaths (−0.04, 95% CI: -0.05, -0.03; p-value=ConclusionBooth-hours had no population-level effect on opioid-related overdose ED visit, hospitalization, or death rates.

Background:Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality.Methods:For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014.Results:The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25–4.69] and OR, 2.69 [95% CI 1.43–5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital.Conclusions:Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.

ObjectivesUse of illicit substances during sex (chemsex) may increase transmission of HIV and other STIs. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV transmission, providing an important prevention tool for those who practise chemsex. However, it does not prevent acquisition of other STIs. We aim to examine the impact of chemsex on STI incidence among gay, bisexual and other men who have sex with men (gbMSM), and transgender women using PrEP in Montréal, Canada.MethodsWe linked baseline sociodemographic and behavioural data with follow-up STI testing from 2013 to 2020 among PrEP users in the l’Actuel PrEP Cohort (Canada). Focusing on the 24 months following PrEP initiation, we estimated the effect of chemsex reported at baseline on cumulative incidence of gonorrhoea and chlamydia using Kaplan-Meier curves and survival analyses. We investigated the role of polysubstance use and effect modification by sociodemographic factors.ResultsThere were 2086 clients (2079 cisgender gbMSM, 3 transgender gbMSM, 4 transgender women) who initiated PrEP, contributing 1477 years of follow-up. There were no incident HIV infections among clients on PrEP. Controlling for sociodemographic confounders, clients reporting chemsex at baseline had a 32% higher hazard of gonorrhoea/chlamydia diagnosis (adjusted HR=1.32; 95% CI: 1.10 to 1.57), equivalent to a risk increase of 8.9 percentage points (95% CI: 8.5 to 9.4) at 12 months. The effect was greater for clients who reported polysubstance use (adjusted HR=1.51; 95% CI: 1.21 to 1.89). The strength of the effect of chemsex on STI incidence varied by age, education and income.ConclusionAmong PrEP users, chemsex at baseline was linked to increased incidence of gonorrhoea and chlamydia. This effect was stronger for people reporting multiple chemsex substances. The high STI incidence among gbMSM who report chemsex highlights the importance of PrEP for this population and the need for integrated services that address the complexities of sexualised substance use.

Introduction Chemsex among gay, bisexual and other men who have sex with men (gbMSM) has raised public health concerns because of its association with sexual behaviours that can increase transmission of sexually transmitted infections, including HIV. Pre-exposure prophylaxis (PrEP) is highly effective at blocking HIV acquisition, addressing important prevention needs among individuals practicing chemsex. This study aims to improve our understanding of chemsex practices and PrEP trajectories of gbMSM and transgender women consulting for PrEP. Methods We used data from the PrEP cohort of Clinique medicale l’Actuel, a major sexual health clinic in Montreal. We describe the sociodemographic profile of clients consulting for PrEP, characterize chemsex and polysubstance use trends over time, and evaluate PrEP trajectories using Kaplan-Meier curves. Results Among 2923 clients who consulted for PrEP between 2013–2020 (2910 cisgender gbMSM, 6 transgender gbMSM, 7 transgender women), 24 % reported chemsex in the past year and 13 % reported polysubstance use. The most common chemsex substances were ecstasy (14 %), GHB (13 %), and cocaine (12 %). The proportion of clients reporting chemsex and polysubstance use decreased over time. In both the chemsex and no-chemsex group, 73 % of clients initiated PrEP. The median time to discontinuation was similar between the chemsex (6.5 months; 95 %CI: 5.3–7.2) and no-chemsex group (6.9 months; 95 %CI: 6.3–7.5). Conclusion Chemsex is not a barrier to PrEP initiation or persistence. However, these results suggest a high prevalence of chemsex among gbMSM consulting for PrEP, highlighting the need for services addressing the intersection of sexual health and substance use for this population.

British Columbia (BC) has been the hardest hit province in Canada's ongoing overdose epidemic. As part of the province-level response, the College of Physicians and Surgeons of British Columbia (CPSBC) implemented the “Safe Prescribing of Drugs with Potential for Misuse/Diversion” practice standard in June 2016. The practice standard established specific dose and quantity thresholds for opioid prescribing as professional and ethical conduct expectations for physicians in BC. This supply side intervention was based on expert interpretation of available evidence of non-superiority of opioid treatments to non-opioid treatments. However, the potential for misinterpretation of dosage ceiling thresholds and the negative repercussions to patients that could follow raised concerns among both physicians and patients. We provide a comprehensive overview of the rationale, early impact, controversies, and potential shortcomings of the CPSBC's practice standard.

IntroductionBetween 2015 and 2018, there were over 40 000 opioid-related overdose events and 4551 deaths among residents in British Columbia (BC). During this time the province mobilised a variety of policy levers to encourage physicians to expand access to opioid agonist treatment and the College of Physicians and Surgeons of British Columbia (CPSBC) released a practice standard establishing legally enforceable minimum thresholds of professional behaviour in the hopes of curtailing overdose events. Our goal is to conduct a comprehensive investigation of the intended and unintended consequences of these policy changes. Specifically, we aim to understand the effects of these measures on physician prescribing behaviours, identify physician characteristics associated with uptake of the new measures, and measure the effects of the policy changes on patients’ access to quality primary care.Methods and analysisThis is a population-level, retrospective cohort study of all BC primary care physicians who prescribed any opioid medication for opioid-use disorder or chronic non-cancer pain during the study period, and their patients. The study period is 1 January 2013–31 December 2018, with a 1-year wash-in period (1 January 2012–31 December 2012) to exclude patients who initiated long-term opioid treatment prior to our study period or whose pain type (ie, ‘chronic non-cancer’, ‘acute’, ‘cancer or palliative’, or ‘other’) cannot be confirmed. The project combines five administrative health datasets under the authority of the BC Ministry of Health, with the CPSBC’s Physician Registry, BC Cancer Agency’s Cancer Registry and Vital Statistics’ Mortality data. We will create measures of prescribing concordance, access, continuity, and comprehensiveness to assess primary care delivery and quality at both the physician and patient level. We will use generalised estimating equations, interrupted time series, mixed effects models, and funnel plots to identify factors related to changes in prescribing and evaluate the impact of the changes to prescribing policies. Results will be reported using appropriate Enhancing the QUAlity and Transparency Of health Research guidelines (eg, STrengthening the Reporting of OBservational studies in Epidemiology).Ethics and disseminationThis study has been approved by McGill University’s Institutional Review Board (#A11-M55-19A), and the University of British Columbia’s Research Ethics Board (#H19-03537). We will disseminate results via a combination of open access peer-reviewed journal publications, conferences, lay summaries and OpEds.

When futures are uncertain and technological developments stand to have large impacts on healthcare systems, scenario studies can be deployed as a tool for policy exploration. We describe the important differences between firm-based and policy-oriented scenarios, and show how to adapt them for health policy. Our approach involves a five-phase process. Background interviews with a diverse group of stakeholders are used to identify focal points and future challenges. Interview data is analyzed to identify the key drivers of future challenges, which are then used to develop a set of scenarios. The scenarios are deployed in a focus group setting with relevant health policy makers and advisors. We illustrate this approach with our scenario study on coverage decision-making for drugs for rare diseases in Canada. Our focus here is on the extension and application of this scenario method and a sharing of our experiences while applying this method. We demonstrate how scenarios can be applied to identify targets of robust health policy strategies that will be of value irrespective how the future unfolds. Our post-focus group questionnaire show that the majority of participants found the scenario focus group useful, and helped them to identify additional challenges regarding drugs for rare diseases.

IntroductionThe main harm reduction interventions for people who inject drugs (PWID) are supervised injection facilities, needle and syringe programmes and opioid agonist treatment. Current evidence supporting their implementation and operation underestimates their usefulness by excluding skin, soft tissue and vascular infections (SSTVIs) and anoxic/toxicity-related brain injury from cost-effectiveness analyses (CEA). Our goal is to conduct a comprehensive CEA of harm reduction interventions in a setting with a large, dispersed, heterogeneous population of PWID, and include prevention of SSTVIs and anoxic/toxicity-related brain injury as measures of benefit in addition to HIV, hepatitis C and overdose morbidity and mortalities averted.Methods and analysisThis protocol describes how we will develop an open, retrospective cohort of adult PWID living in Québec between 1 January 2009 and 31 December 2020 using administrative health record data. By complementing this data with non-linkable paramedic dispatch records, regional monthly needle and syringe dispensation counts and repeated cross-sectional biobehavioural surveys, we will estimate the hazards of occurrence and the impact of Montréal’s harm reduction interventions on the incidence of drug-use-related injuries, infections and deaths. We will synthesise results from our empirical analyses with published evidence to simulate infections and injuries in a hypothetical population of PWID in Montréal under different intervention scenarios including current levels of use and scale-up, and assess the cost-effectiveness of each intervention from the public healthcare payer’s perspective.Ethics and disseminationThis study was approved by McGill University’s Institutional Review Board (Study Number: A08-E53-19B). We will work with community partners to disseminate results to the public and scientific community via scientific conferences, a publicly accessible report, op-ed articles and open access peer-reviewed journals.

BACKGROUND In 2002 British Columbia, Canada began redistributing its hospital services. OBJECTIVE AND DESIGN We used administrative data and interrupted time series analyses to determine how recent hospital closures affected patient outcomes. SUBJECTS All adult acute myocardial infarction (AMI), stroke, and trauma events in British Columbia between fiscal years 1999 and 2013. Cases were patients whose closest hospital closed. Controls were matched by condition, year of event, and condition-specific hospital volume where treatment was received. MEASURES Thirty-day mortality and hospital bypass rates. RESULTS We matched 3267 AMI, 2852 stroke, and 6318 trauma cases to 1996, 1604, and 3640 controls, respectively. The 30-day mortality rate at baseline was 7.0% [95% confidence interval (CI), 4.0%-10.1%] for AMI, 5.3% (95% CI, 2.4%-8.1%) for stroke, and 1.2% (95% CI, 0.3%-2.1%) for trauma controls. The 30-day mortality rate for cases was 14.3% (95% CI, 7.1%-21.7%) for AMI, 12.0% (95% CI, 5.1%-18.9%) for stroke, and 3.1% for trauma (95% CI, 0.9%-5.2%) cases. There was no significant change in 30-day mortality for cases, and no significant difference in change in mortality rates between cases and controls following the intervention. The difference in hospital bypass rates between cases and controls was 50.1% (95% CI, 42.3%-57.9%) for AMI, 36.2% (95% CI, 27.4%-44.9%) for stroke, and 32.2% (95% CI, 27.7%-36.8%) for trauma cases preintervention. Following the intervention, the difference in bypass rates dropped by 15.5% (95% CI, 3.5%-27.5%) for AMI, 25.3% (95% CI, 11.7%-38.8%) for stroke, and 22.7% (95% CI, 15.7%-29.6%) for trauma cases. CONCLUSIONS Hospital closures did not affect patient mortality.

Background People who inject drugs (PWID) face barriers to healthcare due to reasons including comorbidity. We evaluated access to health and social services by three of the most prevalent comorbid conditions among PWID: HIV, hepatitis C (HCV), and mental health, in an urban setting in Canada. Methods Data were derived from prospective cohorts of community-recruited PWID between 2005 and 2015. HIV and HCV serostatuses were based on antibody tests, while mental health conditions and inability to access health and social services (barriers to access) were determined by participants’ self-report. We employed generalized linear mixed models controlling for confounders to examine associations between health conditions and barriers to access. Results Among 2494 participants, 1632 (65.4%) reported barriers to access at least once over a median of seven (IQR: 3, 12) semi-annual assessments. Mental health conditions were independently associated with increased odds of reporting barriers (adjusted Odds Ratio (aOR): 1.45, 95% Confidence Interval (CI): 1.32, 1.58), while HIV was not (aOR: 0.96, 95% CI: 0.85, 1.08), and HCV was associated with decreased odds (aOR: 0.80, 95% CI: 0.69, 0.93). The associations between mental health conditions and barriers to access were consistent among PWID without HIV/HCV (aOR: 1.35, 95% CI: 1.10, 1.65), with HCV mono-infection (aOR: 1.55, 95% CI: 1.37, 1.75), and HCV/HIV co-infection (aOR: 1.36, 95% CI: 1.15, 1.60). Conclusions Targeted strategies to seek and treat mental health conditions in settings that serve PWID, and assist PWID with mental health conditions in navigating healthcare system may improve the publicly-funded health and social services.

Background Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix. Methods We conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals’ Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities. Results Our cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively. Conclusions We observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province. Electronic supplementary material The online version of this article (10.1186/s12913-019-4391-8) contains supplementary material, which is available to authorized users.

ObjectivesAdministrative data are increasingly being used for surveillance and monitoring of mental health and substance use disorders (MHSUD) across Canada. However, the validity of the diagnostic codes specific to MHSUD is unknown in emergency departments (EDs). Our objective was to determine the concordance, and individual-level and hospital-level factors associated with concordance, between diagnosis codes assigned in ED and at discharge from hospital for MHSUD-related conditions.DesignPopulation-based retrospective cohort study.SettingEDs and hospitals within Vancouver Coastal Health Authority (VCH), British Columbia, Canada.Participants16 926 individuals who were admitted into a VCH hospital following an ED visit from 1 April 2009 to 31 March 2017, contributing to 48 116 pairs of ED and hospital discharge diagnoses.Primary and secondary outcome measuresWe examined concordance in identifying MHSUD between the primary discharge diagnosis codes based on the International Statistical Classification of Diseases, 9th and 10th Revisions (Canada) assigned in the ED and those assigned in the hospital among all ED visits resulting in a hospital admission. We calculated the percent overall agreement, positive agreement, negative agreement and Cohen’s kappa coefficient. We performed multiple regression analyses to identify factors independently associated with discordance.ResultsWe found a high level of concordance for broad categories of MH conditions (overall agreement=0.89, positive agreement=0.74 and kappa=0.67), and a fair level of concordance for SUDs (overall agreement=0.89, positive agreement=0.31 and kappa=0.27). SUDs were less likely to be indicated as the primary cause in ED as opposed to in hospital (3.8% vs 11.7%). In multiple regression analyses, ED visits occurring during holidays, weekends and overnight (21:00–8:59 hours) were associated with increased odds of discordance in identifying MH conditions (adjusted OR 1.47, 95% CI 1.11 to 1.93; 1.27, 95% CI 1.16 to 1.40; 1.30, 95% CI 1.19 to 1.42, respectively).ConclusionsED data could be used to improve surveillance and monitoring of MHSUD. Future efforts are needed to improve screening for individuals with MHSUD and subsequently connect them to treatment and follow-up care.

Purpose For breast cancer (BrCa) survivors, premature menopause can result from conventional cancer treatment. Due to limited treatment options, survivors often turn to complementary therapies (CTs), but struggle to make informed decisions. In this study, we identified BrCa survivors’ CT and general information and decision-making needs related to menopausal symptoms. Methods The needs assessment was informed by interpretive descriptive methodology. Focus groups with survivors (n = 22) and interviews with conventional (n = 12) and CT (n = 5) healthcare professionals (HCPs) were conducted at two Canadian urban cancer centers. Thematic, inductive analysis was conducted on the data. Results Menopausal symptoms have significant negative impact on BrCa survivors. Close to 70 % of the sample were currently using CTs, including mind-body therapies (45.5 %), natural health products (NHPs) and dietary therapies (31.8 %), and lifestyle interventions (36.4 %). However, BrCa survivors reported inadequate access to information on the safety and efficacy of CT options. Survivors also struggled in their efforts to discuss CT with HCPs, who had limited time and information to support women in their CT decisions. Concise and credible information about CTs was required by BrCa survivors to support them in making informed and safe decisions about using CTs for menopausal symptom management. Conclusions High quality research is needed on the efficacy and safety of CTs in managing menopausal symptoms following BrCa treatment. Decision support strategies, such as patient decision aids (DAs), may help synthesize and translate evidence on CTs and promote shared decision-making between BrCa survivors and HCPs about the role of CTs in coping with menopause following cancer treatment.

IntroductionOver one in eight Canadians is affected by a foodborne infection annually; however, the long-term consequences, including the risks and costs of sequelae, are unclear. We aim to estimate the health burden and direct costs of 14 infections commonly transmitted by food, considering the acute illness and subsequent sequelae and mortality, for the population of British Columbia, Canada (~4.7 million).Methods and analysisWe will conduct a population-based retrospective cohort study of the British Columbia provincial population, over a 10-year study period (1 January 2005 to 31 December 2014). Exposure is defined as a provincially reported illness caused by Clostridium botulinum, Campylobacter, Cryptosporidium, Cyclospora, Giardia, hepatitis A virus, Listeria, non-typhoidal Salmonella spp, Salmonella Typhi, Salmonella Paratyphi, Shiga toxin-producing Escherichia coli, Shigella, Vibrio parahaemolyticus or Yersinia (excluding pestis). We will link individual-level longitudinal data from eight province-wide administrative health and reportable disease databases that include physician visits, hospitalisations and day surgeries, deaths, stillbirths, prescription medications (except those to treat HIV) and reportable foodborne diseases. Using these linked databases, we will investigate the likelihood of various sequelae and death. Hazard models will be used to estimate the risk of outcomes and their association with the type of foodborne infection. Epidemiological analyses will be conducted to determine the progression of illness and the fraction of sequelae attributable to specific foodborne infections. Economic analyses will assess the consequent direct healthcare costs.Ethics and disseminationThis study has been approved by a University of Waterloo Research Ethics Committee (no 30645), the University of British Columbia Behavioral Research Ethics Board (no H16-00021) and McGill University’s Institutional Review Board (no A03-M12-19A). Results will be disseminated via presentations to academics, public health practitioners and knowledge users, and publication in peer-reviewed journals. Where such publications are not open access, manuscripts will also be available via the University of Waterloo’s Institutional Repository (https://uwspace.uwaterloo.ca).

e22076 Background: The MSLT-II trial demonstrated no survival benefit of completion lymphadenectomy (CLND) compared to nodal observation (NO) and subsequent therapeutic lymphadenectomy (TLND) in the case of macroscopic nodal relapse in patients with melanoma and SLN metastases. NO avoids the upfront cost and morbidity of CLND. However, patients followed with NO must undergo intensive surveillance and if TLND is required, it is associated with a higher complication rate than CLND. The cost-effectiveness of NO versus CLND in light of data from MSLT-II has not been previously studied. Methods: A Markov model with a 10-year time horizon was constructed to simulate two hypothetical cohorts of patients with SLN metastases undergoing NO and subsequent TLND for nodal recurrence or upfront CLND. Transition probabilities between disease states were derived from the MSLT-II trial. Remaining parameters including complication rates and health state utilities were obtained from an extensive review of the literature. Direct health care system costs were obtained from published US Medicare cost data and the literature. Primary outcomes were cost and quality-adjusted life years (QALYs) saved. Incremental cost-effectiveness ratio (ICER) was used to compare treatment strategies. Sensitivity analysis was performed in order to evaluate model uncertainty. A threshold of acceptance of $100,000/QALY was used. Results: Total projected cost over the study period for CLND was $28,609.87, while that of NO was lower at $20,865.27, resulting in $7,744.60 saved for the NO treatment strategy. Ten-year utility was 4.840 for CLND compared to 5.379 for NO, resulting in a gain of 0.539 QALYs in the NO arm. The NO strategy is dominant in the model as it results in both cost-savings and a gain in health effects, with an average ICER of -$14,368.46/QALY gained. Conclusions: From the payer perspective, the strategy of NO compared to CLND in patients with melanoma and SLN metastases is associated with an improvement in health outcomes and reduction in cost. Taking into account MSLT-II trial data, this study demonstrates NO is more cost-effective than CLND.

Hospital readmission 30 days after discharge is associated with adverse health outcomes, and people living with HIV (PLWH) experience elevated rates of hospital readmission. Although continuity of care with a health care provider is associated with lower rates of 30-day readmission among the general population, little is known about this relationship among PLWH. The objective of this study is to examine whether engaging with the same provider, defined as patient-provider attachment, is associated with 30-day readmission for this population.Data were derived from the Seek and Treat for Optimal Prevention of HIV in British Columbia cohort.Using generalized estimating equation with a logit link function, we examined the association between patient-provider attachment and 30-day hospital readmission. We determined whether readmission was due to all cause or to a similar cause as the index admission.Seven thousand thirteen PLWH were hospitalized during the study period. Nine hundred twenty-one (13.1%) were readmitted to hospital for all cause and 564 (8.0%) for the similar cause as the index admission. Patient-provider attachment was negatively associated with 30-day readmission for all causes (adjusted odds ratio = 0.85, confidence interval = 0.83 to 0.86). A second multivariable model indicated that patient-provider attachment was also negatively associated with 30-day readmission for a similar cause (adjusted odds ratio = 0.86, confidence interval = 0.84 to 0.88).Our results indicate that a higher proportion of patient-provider attachment was negatively associated with 30-day hospital readmission among PLWH. Our study findings support the adoption of interventions that seek to build patient-provider relationships to optimize outcomes for PLWH and enhance health care sustainability.

BACKGROUND: As countries embark on public health-oriented drug law reform, health impact evaluations are needed. In 2012, Mexico mandated the narcomenudeo reform, which depenalised the possession of small amounts of drugs and instituted drug treatment instead of incarceration. We investigated the past and future effect of this drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico.METHODS: In this epidemic modelling study, we used data from the El Cuete IV cohort study to develop a deterministic model of injecting and sexual HIV transmission in people who inject drugs in Tijuana between 2012 and 2030. The population was stratified by sex, incarceration status, syringe confiscation by the police, HIV stage, and exposure to drug treatment or rehabilitation (either opioid agonist treatment or compulsory drug abstinence programmes). We modelled the effect of these exposures on HIV risk in people who inject drugs, estimating the effect of observed and potential future reform enforcement levels.FINDINGS: In 2011, prior to the narcomenudeo reform, 547 (75%) of 733 people who inject drugs in the El Cuete cohort reported having ever been incarcerated, on average five times since starting injecting. Modelling estimated the limited reform implementation averted 2% (95% CI 0·2-3·0) of new HIV infections in people who inject drugs between 2012 and 2017. If implementation reduced incarceration in people who inject drugs by 80% from 2018 onward, 9% (95% CI 4-16) of new HIV infections between 2018 and 2030 could be averted, with 21% (10-33) averted if people who inject drugs were referred to opioid agonist treatment instead of being incarcerated. Referral to compulsory drug abstinence programmes instead of prison could have a lower or potentially negative impact with -2% (95% CI -23 to 9) infections averted.INTERPRETATION: Mexican drug law reform has had a negligible effect on the HIV epidemic among people who inject drugs in Tijuana. However, appropriate implementation could markedly reduce HIV incidence if linked to opioid agonist treatment. Unfortunately, compulsory drug abstinence programmes are the main type of drug rehabilitation available and their expansion could potentially increase HIV transmission.FUNDING: National Institute on Drug Abuse, UC San Diego Center for AIDS Research.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

RÉSUMÉCette étude, utilisant des méthodes mixtes, a permis de déterminer les caractéristiques personnelles et professionnelles qui déterminent la satisfaction au travail des travailleurs de soutien à domicile (TSD) qui offrent de l’aide aux personnes âgées. Les données étaient fondées sur une mesure normalisée de la satisfaction au travail ainsi que sur des entretiens qualitatifs et approfondis avec 176 travailleurs de soutien à domicile de trois administrations provinciales canadiennes (Colombie-Britannique, n = 108; Ontario, n = 28; Nouvelle-Écosse, n = 40). Nous nous attendions à ce que la variabilité des profils démographiques parmi les trois groupes de travailleurs et des différentes fiches de poste soit associées à des différences dans la perception de satisfaction professionnelle. Ce n’était pas le cas. Les résultats de l’analyse qualitative mettent en lumière les principaux domaines qui ont contribué à la satisfaction au travail. Ces domaines concernent le travail (horaires, voyages d’affaires et sécurité), les questions économiques (sécurité de revenu) ou organisationnelles (communication, soutien et respect). Compte tenu de ces constatations, nous recommandons des améliorations en ce qui concerne la communication au lieu de travail, une plus grande marge de temps de déplacement entre les clients et la parité salariale avec des postes équivalents dans les établissements de soins de longue durée.

Introduction : British Columbia has made significant progress in the treatment and prevention of HIV since 1996, when Highly Active Antiretroviral Therapy (HAART) became available. However, we currently lack a historical summary of HIV prevention and care interventions implemented in the province since the introduction of HAART and how they have shaped the HIV epidemic. Guided by a socio-ecological framework, we present a historical review of biomedical and health services, community and structural interventions implemented in British Columbia from 1996–2015 to prevent HIV transmission or otherwise enhance the cascade of HIV care. Methods : We constructed a historical timeline of HIV interventions implemented in BC between 1996 and 2015 by reviewing publicly available reports, guidelines and other documents from provincial health agencies, community organizations and AIDS service organizations, and by conducting searches of peer-reviewed literature through PubMed and Ovid MEDLINE. We collected further programmatic information by administering a data collection form to representatives from BC’s regional health authorities and an umbrella agency representing 45 AIDS Service organizations. Using linked population-level health administrative data, we identified key phases of the HIV epidemic in British Columbia, as characterized by distinct changes in HIV incidence, HAART uptake and the provincial HIV response. Results and Discussion : In total, we identified 175 HIV prevention and care interventions implemented in BC from 1996 to 2015. We identify and describe four phases in BC’s response to HIV/AIDS: the early HAART phase (1996–1999); the harm reduction and health service scale-up phase (2000–2005); the early Treatment as Prevention phase (2006–2009); and the STOP HIV/AIDS phase (2010-present). In doing so, we provide an overview of British Columbia’s universal and centralized HIV treatment system and detail the role of community-based and provincial stakeholders in advancing innovative prevention and harm reduction approaches, as well as “seek, test, treat and retain” strategies. Conclusions : The review provides valuable insight into British Columbia’s HIV response, highlights emerging priorities, and may inform future efforts to evaluate the causal impact of interventions. Keywords British Columbia; historical review; cascade of care; treatment as prevention; quality of care; harm reduction To access the supplementary material to this article please see Supplementary Files under Article Tools online. (Published: 19 September 2017) Olding M et al. Journal of the International AIDS Society 2017, 20 :21941 http://www.jiasociety.org/index.php/jias/article/view/21941 | http://dx.doi.org/10.7448/IAS.20.1.21941

Background Access to prescription contraception is often limited by the availability of physicians, particularly in rural areas. Pharmacists are available but are not authorized in Canada to prescribe contraceptives, an innovation proved successful in the United States. It is unknown whether Canadian pharmacists, particularly those in rural areas, are willing to adopt this innovation and what barriers and facilitators they predict. We explored the acceptability and feasibility for independent provision of contraception at pharmacies throughout British Columbia (BC). Methods This mixed-methods study used validated questionnaires followed by optional structured interviews among all rural, and a sample of urban, community pharmacies in BC. Analyses use descriptive, logistic regression and qualitative thematic evaluation. Results Responding community pharmacies represent all geographic health regions of BC and the range of pharmacy business models. Respondents reported a mean of 17years in practice. Seventy percent of pharmacies reported a private counseling area. Over 80%, including pharmacies in all regions, indicated willingness to prescribe hormonal contraceptives. Factors associated with willingness to prescribe were comfort using a protocol to assess sexual history, confidence about staff availability and public acceptability, and fewer years in practice. Pharmacists requested training in assessment protocols and liability issues prior to implementation. Interpretation Pharmacies from all areas throughout BC, responded and report a high degree of acceptability and feasibility for independent prescription of hormonal contraceptives. As pharmacists are often the most accessible health professional in rural areas, pharmacist provision of hormonal contraceptives has potential to improve access to contraception.