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Background: Huntington’s disease (HD) has been shown to reduce health-related quality of life (HRQoL) and affect healthcare resource utilization (HRU) among patients and care partners internationally but has not been studied specifically in the Canadian context. Objective: To characterize the burden of HD on individuals with HD and care partners of individuals with HD in Canada. Methods: An online survey was distributed (September 14–November 23, 2020) through patient organizations to collect data on demographic and clinical characteristics, as well as: HRQoL, measured using the 36-Item Short-Form Health Survey (SF-36v1); HRU, measured using the Client Service Receipt Inventory (CSRI); and care partner burden, measured using the Caregiver Strain Index (CSI) and Huntington’s Disease Quality of Life Battery for Carers (HDQoL-C). Descriptive statistics were used to report data and compare subgroups. Results: A total of 62 adult individuals with HD (or their proxies) and 48 care partners met defined eligibility criteria. The mean [standard deviation] age was 51.2 [13.8] and 58.1 [13.9] years for individuals with HD and care partner respondents, respectively. For individuals with HD, the greatest HRQoL burden (i.e., lowest score) was for the SF-36v1 Role –Physical scale (46.8 [42.9]). HRU was higher for some services (e.g., general practitioner visits) for respondents who had experienced motor onset transition. Among care partners, 55.3% experienced high strain, as indicated by the CSI. The HDQoL-C showed the greatest HRQoL burden in feelings about life (45.1 [17.9]). Conclusion: This study quantified the substantial burden on individuals with HD and care partners in Canada, addressing a critical knowledge gap that can affect the availability of and access to healthcare services.

Background and Objectives: The primary goal of family medicine residency training is for graduates to provide high-quality, safe, and effective patient care for the population they serve when they enter practice. This study explores (a) the practice profiles, 5 years into practice, of residents who completed family medicine training in Ontario, Canada; and (b) relationships between performance on the College of Family Physicians of Canada’s (CFPC) Certification Examination in Family Medicine and quality of care provided 5 years into practice. Methods: We performed a retrospective study with secondary data analysis. We merged CFPC examination data sets with the ICES (Institute for Clinical Evaluative Sciences) administrative database. We included physicians who passed the examination between the years 2000 and 2010 and practiced in Ontario after graduation. Practice profile indicators included practice type, continuity and comprehensiveness of care, patient rostering and panel size, and rurality index. We explored 11 indicators related to management of diabetes and cancer screening. Results: We included a total of 1,983 physicians in the analyses. Five years after the examinations, 74.3% of the physicians were working in major urban centers, and 67.3% of the physicians were providing comprehensive primary care. We noted significant differences across the six medical schools in multiple practice profile indicators, and three indicators showed significant differences across the examination score quintiles. Conclusions: Graduates of Ontario family medicine residency programs were providing care to a broad spectrum of the population 5 years after passing the examination, and they performed similarly across quality-of-care indicators regardless of examination scores.

Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A

Canadian seniors who undergo hip and knee arthroplasty often experience significant postoperative pain, which could result in persistent opioid use. We aimed to document the impact of preoperative opioid use and other characteristics on postoperative opioid prescriptions in elderly patients following hip and knee replacement before widespread dissemination of opioid reduction strategies. We conducted a historical cohort study to evaluate postoperative opioid use in patients over 65 yr undergoing primary total hip and knee replacement over a ten-year period from 1 April 2006 to 31 March 2016, using linked de-identified Ontario administrative data. We determined the use of preoperative opioids and the duration of postoperative opioid prescriptions (short-term [1–90 days], prolonged [91–180 days], chronic [181–365 days], or undocumented). The study included 49,638 hip and 85,558 knee replacement patients. Eighteen percent of hip and 21% of knee replacement patients received an opioid prescription within 90 days before surgery. Postoperatively, 51% of patients filled opioid prescriptions for 1–90 days, while 24% of hip and 29% of knee replacement patients filled prescriptions between 6 and 12 months, with no impact of preoperative opioid use. Residence in long-term care was a significant predictor of chronic opioid use (hip: odds ratio [OR], 2.64; 95% confidence interval [CI], 1.93 to 3.59; knee: OR, 2.46; 95% CI, 1.75 to 3.45); other risk factors included female sex and increased comorbidities. Despite a main goal of joint arthroplasty being relief of pain, seniors commonly remained on postoperative opioids, even if not receiving opioids before surgery. Opioid reduction strategies need to be implemented at the surgical, primary physician, long-term care, and patient levels. These findings form a basis for future investigations following implementation of opioid reduction approaches.

Mozambique introduced guidelines for integrated gender-based violence (GBV) services in 2012. In 2017, we trained providers on empathetic and supportive services to GBV survivors and introduced home-based services for survivors who are loss-to-follow up. Rate ratios of clinic visits were compared before and after intervention initiation, using exact significance tests. Data of 1,806 GBV survivors were reviewed, with a total of 2005 events. The median age was 23 years (IQR 17-30) and 89% were women. Among those reporting violence, 69% reported physical violence, 18% reported sexual violence (SV), and 12% reported psychological violence. Rates of care-seeking behavior were higher in the intervention period (rate ratio 1.31 [95%CI: 1.18-1.46])

Interactions with predators and parasites can result in traces found on Recent and fossil echinoids. However, identifying specific trace makers, particularly on fossil echinoids, remains contentious. To document the range of trace morphologies present on echinoids and improve our ability to identify and quantify biotic interactions affecting echinoids, we characterized traces found on fossil echinoids using museum collections and field sampling spanning the Jurassic to Recent worldwide. Using light microscopy, 8,564 individual echinoid specimens were examined including 130 species, and 516 traces of potential biotic interactions identified. Morphological characteristics were recorded for each trace, including the shape of the trace outline, maximum diameter and cross-section profile. Based on shared morphological characteristics, it was possible to classify all traces into eight categories: circular, subcircular, elongated, irregular, rectangular, figure-eight, notched, and linear. Cross-section characteristics provided additional insights into the identity of potential trace makers. To further evaluate the proposed biotic origins of these traces, trace diversity was examined through time and compared with anticipated ecological trends associated with the diversification of echinoids, and their predators and parasites. Trace diversity increased over time, starting in the late Eocene, coincident with the proliferation of echinoid-drilling gastropods, an indication that biotic interactions intensified through evolutionary time, as predicted by several macroevolutionary hypotheses previously tested using mollusks. The morphological descriptions provided here enhance our understanding of biotic traces on fossil echinoids, and the potential to identify temporal trends in the intensity and diversity of biotic interactions that have affected echinoids throughout their evolutionary history.

This study examines parental participation in children’s schooling. Using a survey of parents of children attending a majority Hispanic school district, we employ exploratory factor analysis and determine that standard forms of participation align along two dimensions: Involvement and Engagement. Analysis reveals a third dimension: Parental Community. The data suggest that income but not educational attainment influence Involvement, whereas family circumstances correlate best with Engagement. Households with the closest proximity to a Spanish-language/immigrant culture feel the strongest sense of Parental Community. The findings may inform the design of programming to help involve parents more fully in their children’s schooling.

Mentor Mothers (MM) provide peer support to pregnant and postpartum women living with HIV (PPWH) and their infants with perinatal HIV exposure (IPE) throughout the cascade of prevention of vertical transmission (PVT) services. MM were implemented in Zambézia Province, Mozambique starting in August 2017. This evaluation aimed to determine the effect of MM on PVT outcomes.A retrospective interrupted time series analysis was done using routinely collected aggregate data from 85 public health facilities providing HIV services in nine districts of Zambézia. All PPWH (and their IPE) who initiated antiretroviral therapy (ART) from August 2016 through April 2019 were included. Outcomes included the proportion per month per district of: PPWH retained in care 12 months after ART initiation, PPWH with viral suppression and IPE with HIV DNA PCR test positivity by 9 months of age. The effect of MM on outcomes was assessed using logistic regression.The odds of 12-month retention increased 1.5% per month in the pre-MM period, compared to a monthly increase of 7.6% with-MM (35-61% pre-MM, 56-72% with-MM; p0.001). The odds of being virally suppressed decreased by 0.9% per month in the pre-MM period, compared to a monthly increase of 3.9% with-MM (49-85% pre-MM, 59-80% with-MM; p0.001). The odds of DNA PCR positivity by 9 months of age decreased 8.9% per month in the pre-MM period, compared to a monthly decrease of 0.4% with-MM (0-14% pre-MM, 4-10% with-MM; p0.001). The odds of DNA PCR uptake (the proportion of IPE who received DNA PCR testing) by 9 months of age were significantly higher in the with-MM period compared to the pre-MM period (48-100% pre-MM, 87-100% with-MM; p0.001).MM services were associated with improved retention in PVT services and higher viral suppression rates among PPWH. While there was ongoing but diminishing improvement in DNA PCR positivity rates among IPE following MM implementation, this might be explained by increased uptake of HIV testing among high-risk IPE who were previously not getting tested. Additional efforts are needed to further optimize PVT outcomes, and MM should be one part of a comprehensive strategy to address this critical need.

Aims: To evaluate the epidemiology, healthcare resource utilization, and direct healthcare costs associated with Huntington���s Disease in a Canadian setting with a universal healthcare system. Materials and Methods: Using Albertan administrative health data, a retrospective cohort was identified applying an algorithm requiring two HD diagnostic codes within two years, using the first record as the index date (i.e., proxy for diagnosis date), from April 1, 2010 to March 31, 2019 for patients ���21 years old. Incidence/prevalence measures were evaluated from April 1, 2010 to March 31, 2019, while healthcare resource utilization and healthcare costs per person-year (inflated to 2020 Canadian dollars) were evaluated from index to the end of follow-up (death, moved out of province, or March 31, 2020). Results: Mean [standard deviation] age at index (n = 395) was 53.9 [13.8] years and 53.7% were female. From 2010-2019, annual HD incidence varied between 0.47-1.21/100,000 person-years and HD prevalence increased from 7.25-9.33/100,000 persons. The mean number of visits per person-year for general and specialist practitioners was 19.2 [18.8] and 12.2 [25.5], respectively. The mean total all-cause direct healthcare costs were $23,211 [$38,599] per person-year, with hospitalizations accounting for 57.8% of all-cause costs. Costs were higher among individuals with a long-term care stay, a proxy for disease severity. Limitations and Conclusions: This study utilizes administrative health data to describe the epidemiology of HD and utilization of publicly funded care by individuals with HD. While administrative data presents limitations since it is not collected for research purposes, it provides a population-level examination of the burden of HD. There was a substantial economic burden associated with HD in a Canadian setting.

Postoperative opioid use may be associated with increased healthcare utilization and costs. We sought to examine the relationship between duration of postoperative opioid prescriptions and healthcare costs and resource utilization in senior patients following hip and knee replacement.We conducted a historical cohort study evaluating postoperative opioid use and healthcare costs in patients over the age of 65 yr undergoing primary total hip or knee arthroplasty over a ten-year period from 1 April 2006 to 31 March 2016. The last follow-up date was 31 March 2017. We identified preoperative and postoperative opioid prescriptions, patient characteristics, and healthcare costs using deidentified Ontario administrative databases (Institute of Clinical Evaluative Sciences). Duration of postoperative opioid use was divided into four categories: short-term (1-90 days), prolonged (91-180 days), chronic (181-365 days), and undocumented.The study included 49,638 hip and 85,558 knee replacement patients. Although the initial hospitalization accounted for the greatest cost in all patients, over the following year patients in the short-term opioid use group incurred the lowest average costs, and those in the chronic group incurred the highest (hip, CAD 17,528 vs CAD 26,736; knee, CAD 16,043 vs CAD 23,007), driven by increased healthcare resource utilization.Chronic opioid use after arthroplasty was associated with higher resource utilization and healthcare costs during the year following surgery. These results can be used to develop predictors of longer opioid use and higher costs. Further research is planned to determine whether recently implemented opioid reduction strategies can reduce healthcare resource utilization.RéSUMé: OBJECTIF: L’utilisation postopératoire d’opioïdes peut être associée à une augmentation de l’utilisation et des coûts des soins de santé. Nous avons cherché à examiner la relation entre la durée des ordonnances d’opioïdes postopératoires, les coûts des soins de santé et l’utilisation des ressources chez les patients âgés après une arthroplastie de la hanche et du genou. MéTHODE: Nous avons réalisé une étude de cohorte historique évaluant la consommation postopératoire d’opioïdes et les coûts des soins de santé chez les patients de plus de 65 ans subissant une arthroplastie totale primaire de la hanche ou du genou sur une période de dix ans allant du 1

Engaging and important, Threatening Property highlights three dimensions of the history of segregation: geography, class and conflict. While providing the context of national economic, political an...

Background Sub-Saharan Africa reported 550,000 new HIV infections among women in 2018. Pregnancy and the postpartum period are associated with an increased risk of HIV acquisition (adjusted risk ratio [RR]: 2.8 during pregnancy and 4.0 in postpartum period vs. non-pregnant or postpartum women, respectively). Acquisition of HIV during pregnancy and breastfeeding increases risk of mother to child transmission. We propose to test the impact of a peer-delivered oral storytelling intervention to increase retention in, and adherence to, pre-exposure prophylaxis (PrEP)/combination antiretroviral treatment (ART) among expectant couples. Design We propose a randomized controlled trial (RCT) (35 intervention and 35 control couples) at a health facility where 11% of expectant couples were in serodiscordant relationships in 2018. Couples randomized to the storytelling arm will be visited by a two community volunteers and who successfully adhered to PrEP/ART during a recent pregnancy. This expert couple will orate to participating couples three stories (at 1, 3 and 5 weeks after study enrollment) designed to empower, educate, and establish “ideal” interpersonal communication strategies within couples/families, and support adherence practices among participants. The primary outcome among HIV-uninfected women will be adherence to PrEP at 3 months. Conclusions PrEP among at-risk pregnant women must be implemented so that high levels of adherence and retention are achievable for them and their partners. We will test our storytelling intervention to identify an optimal strategy for PrEP education and family engagement in a region with high HIV prevalence. Our results will have an impact by effectively engaging serodiscordant couples in prevention/treatment during pregnancy and beyond.

Background Colorectal cancer (CRC) is the second and third highest cause of cancer deaths among Canadian men and women, respectively. Population‐based screening through fecal occult blood testing (FOBT) has been proven to be effective in reducing CRC morbidity and mortality. Although participation in Ontario's organized CRC screening program has been increasing steadily since 2008, its uptake remains low among recent immigrant populations despite the known benefits of screening. To promote participation in CRC screening, it is imperative to understand both individual and system level barriers and enablers. Although a number of immigrant and nonimmigrant factors have been associated with low participation, there is a dearth of knowledge related to the religious affiliation in CRC screening uptake. Our study is among the first to examine this issue in Ontario, one of the most ethnically diverse Canadian provinces and preferred settlement destinations for immigrants. Methods We conducted a population‐based retrospective cohort study using linked health care administrative databases. Our cohort included Ontario residents, age 50‐74 who were eligible for FOBT from 1 April 2013 to 31 March 2015. Results We found that immigrants from the Middle East and North Africa and Eastern Europe and Central Asia had the lowest rates of screening. Furthermore, being born in a Muslim‐majority country was associated with lower FOBT screening even after controlling for other confounders including world region and income (ie, overall adjusted relative risk (ARR) of screening 0.92 [95% CI 0.90‐0.93]). Moreover, being enrolled in a primary care model, having a female primary care provider and having an internationally trained physician were associated with increased screening among immigrants from Muslim‐majority countries. Conclusions These findings can inform future efforts to improve screening uptake like: enhancing access to primary care providers and enrollment in primary care models, targeted FOBT education for male providers and providers not in a primary care model, development of culturally sensitive and appropriate educational materials, and use of interactive approaches for communication of cancer screening information., The FOBT screening uptake was low among immigrants from Muslim‐majority country. Immigrants from the Middle East and North Africa and Eastern Europe and Central Asia countries were at high risk of under‐screening. FOBT uptake was lower for people with no primary care provider and high income. Having a female primary care provider and having an internationally trained physician were associated with higher FOBT use among immigrants from Muslim majority countries.

Background The management and outcomes of preterm births can vary greatly even among developed nations with the same access to medicine, technology and expertise. We aimed to compare aspects of obstetrical management and mortality for preterm infants in France and Ontario, Canada. Methods The Better Outcomes Registry & Network (BORN) Information System in Ontario and Epidemiologique sur les petits âges gestationnels (EPIPAGE-2) in France collected information on maternal demographics, obstetrical characteristics, obstetrical interventions and neonatal outcomes for infants born between 22 and 34 weeks gestation. We used standardized covariate definitions and extracted data from 2011 (for EPIPAGE-2) and from 2012 and 2013 (for BORN) to conduct a cohort study comparing the 2 data sets (stratified into gestational age groups of 22-26, 27-31 and 32-34 wk) using multivariable logistic regression models. Results Mothers in the BORN cohort were older (30.7 yr v. 29.6 yr) but less likely to have gestational hypertension (13.4% v. 17.9%) than those in the EPIPAGE-2 cohort. Infants from EPIPAGE-2 had lower birth weights (1.3 kg v. 1.5 kg) and were more likely to be born in an institution with level 3 care (71.9% v. 55.8%). After adjustment for these differences, there was significantly higher neonatal mortality among infants from EPIPAGE-2 in the 22-26 week gestation age group (adjusted odds ratio 2.81; 95% confidence interval 1.17 to 6.74). Interpretation Even after we adjusted for both intrinsic population differences and differences in management between Ontario and France, we found a higher rate of neonatal mortality at earlier gestational ages in France. This may be related to differences in ethical approaches and/or postnatal management and should be explored further.

Canadian seniors who undergo hip and knee arthroplasty often experience significant postoperative pain, which could result in persistent opioid use. We aimed to document the impact of preoperative opioid use and other characteristics on postoperative opioid prescriptions in elderly patients following hip and knee replacement before widespread dissemination of opioid reduction strategies.We conducted a historical cohort study to evaluate postoperative opioid use in patients over 65 yr undergoing primary total hip and knee replacement over a ten-year period from 1 April 2006 to 31 March 2016, using linked de-identified Ontario administrative data. We determined the use of preoperative opioids and the duration of postoperative opioid prescriptions (short-term [1-90 days], prolonged [91-180 days], chronic [181-365 days], or undocumented).The study included 49,638 hip and 85,558 knee replacement patients. Eighteen percent of hip and 21% of knee replacement patients received an opioid prescription within 90 days before surgery. Postoperatively, 51% of patients filled opioid prescriptions for 1-90 days, while 24% of hip and 29% of knee replacement patients filled prescriptions between 6 and 12 months, with no impact of preoperative opioid use. Residence in long-term care was a significant predictor of chronic opioid use (hip: odds ratio [OR], 2.64; 95% confidence interval [CI], 1.93 to 3.59; knee: OR, 2.46; 95% CI, 1.75 to 3.45); other risk factors included female sex and increased comorbidities.Despite a main goal of joint arthroplasty being relief of pain, seniors commonly remained on postoperative opioids, even if not receiving opioids before surgery. Opioid reduction strategies need to be implemented at the surgical, primary physician, long-term care, and patient levels. These findings form a basis for future investigations following implementation of opioid reduction approaches.RéSUMé: OBJECTIF: Les aînés canadiens subissant une arthroplastie de la hanche ou du genou éprouvent souvent une douleur postopératoire importante, ce qui pourrait entraîner la consommation persistante d’opioïdes. Nous avons cherché à documenter l’impact d’une utilisation préopératoire d’opioïdes et d’autres caractéristiques sur les prescriptions postopératoires d’opioïdes chez les patients âgés suivant un remplacement de hanche ou de genou avant l’utilisation répandue de stratégies de réduction d’opioïdes. MéTHODE: Nous avons réalisé une étude de cohorte historique pour évaluer la consommation postopératoire d’opioïdes chez les patients de plus de 65 ans subissant une arthroplastie totale primaire de la hanche ou du genou sur une période de dix ans du 1er avril 2006 au 31 mars 2016, à l’aide de données administratives dépersonnalisées et codées de l’Ontario. Nous avons déterminé la durée des ordonnances préopératoires et postopératoires d’opioïdes (à court terme [1-90 jours], prolongées [91-180 jours], chroniques [181-365 jours] ou non documentées). RéSULTATS: L’étude a porté sur 49 638 patients ayant subi une arthroplastie de la hanche et 85 558 patients une arthroplastie du genou. Dix-huit pour cent des patients ayant subi une arthroplastie de la hanche et 21 % des patients ayant subi une arthroplastie du genou ont reçu une ordonnance d’opioïdes dans les 90 jours précédant leur chirurgie. En période postopératoire, 51 % des patients ont utilisé leurs ordonnances d’opioïdes pendant 1 à 90 jours, tandis que 24 % des patients d’arthroplastie de la hanche et 29 % des patients d’arthroplastie du genou ont utilisé leurs ordonnances entre six et 12 mois. Le fait d’habiter dans un établissement de soins de longue durée était un prédicteur important de consommation chronique d’opioïdes (hanche : rapport de cotes [RC], 2,64; intervalle de confiance [IC] à 95 %, 1,93 à 3,59; genou : RC, 2,46; IC 95 %, 1,75 à 3,45); le sexe féminin et l’augmentation des comorbidités constituaient d’autres facteurs de risque. CONCLUSION: Bien que l’un des principaux objectifs de l’arthroplastie articulaire soit le soulagement de la douleur, les personnes âgées continuent généralement à consommer des opioïdes en période postopératoire, même si elles ne prenaient pas d’opioïdes avant leur chirurgie. Il est nécessaire de mettre en œuvre des stratégies de réduction des opioïdes qui s’adressent aux chirurgiens, aux médecins traitants, aux soins de longue durée et aux patients. Ces constatations constituent la base d’études futures réalisées à la suite de la mise en œuvre d’approches de réduction des opioïdes.

Background Physical activity has a strong positive impact on both physical and mental health, and public health interventions often encourage walking as a means to promote physical activity. Social connectivity, such as that among spouses, families, friends, and colleagues, highly influences physical activity. Although technology-based interventions have some influence on human behavior, they have not been fully implemented and evaluated for their influence on walking through social connectivity. Objective We aimed to pilot-test the organization of neighborhood walking clubs and use of a mobile app (Runkeeper) to encourage social connectedness and neighborhood cohesion, as well as to increase physical activity. Methods We used a convenience sampling method to recruit 46 adults from an urban location in Greater Boston, Massachusetts. We assigned participants to teams based on their geographic location and neighborhood and required them to use the app (Runkeeper). Participants completed 2 self-administered web-based surveys before and after the intervention period. The surveys included standard measures to evaluate physical activity, social connectedness, perceived social support, and neighborhood cohesion (Buckner Neighborhood Cohesion Scale) before and after the intervention. Following the intervention, we randomly selected 14 participants to participate in postintervention, in-depth phone interviews to gain an understanding of their experiences. Results This study was approved by the institutional review board in June 2018 and funded in January 2018. Recruitment started in May 2019 and lasted for 2 months. Data were collected from July 2019 to January 2020. In this study, Runkeeper was of limited feasibility as an app for measuring physical activity or promoting social connectedness. Data from the app recorded sparse and uneven walking behaviors among the participants. Qualitative interviews revealed that users experienced difficulties in using the settings and features of the app. In the questionnaire, there was no change between pre-post assessments in walking minutes (b=−.79; 95% CI −4.0 to 2.4; P=.63) or miles (b=−.07; 95% CI −0.15 to 0.01; P=.09). We observed a pre-post increase in social connectedness and a decrease in neighborhood cohesion. Both quantitative and qualitative results indicated that the psychosocial aspects of walking motivated the participants and helped them relieve stress. Interview results showed that participants felt a greater virtual connection in their assigned groups and enhanced connections with friends and family members. Conclusions Our study found that Runkeeper created a virtual connection among walking group members and its data sharing and ranking motivated walking. Participants felt that walking improved their mental health, helped to relieve stress, and made them feel more connected with friends or family members. In future studies, it will be important to use an app that integrates with a wearable physical activity device. There is also a need to develop and test intervention components that might be more effective in fostering neighborhood cohesion.

ObjectiveTo determine 1-year attributable healthcare costs of bronchiolitis.MethodsUsing a population-based matched cohort and incidence-based cost analysis approach, we identified infants ResultsWe identified 58,375 infants with bronchiolitis (mean age 154±95 days, 61.3% males, 4.2% with comorbidities). Total 1-year mean bronchiolitis-attributable costs were $4,313 per patient (95%CI: $4,148–4,477), with $2,847 (95%CI: $2,712–2,982) spent on hospitalizations, $610 (95%CI: $594–627) on physician services, $562 (95%CI: $556–567)] on ED visits, $259 (95%CI: $222–297) on other healthcare costs and $35 ($27–42) on drugs. Attributable bronchiolitis costs were $2,765 (95%CI: $2735–2,794) vs $111 (95%CI: $102–121) in the initial 10 days post index date, $4,695 (95%CI: $4,589–4,800) vs $910 (95%CI: $847–973) in the initial 180 days and $1,158 (95%CI: $1,104–1213) vs $639 (95%CI: $599–679) during days 181–360.Mean 1-year bronchiolitis costs were higher in infants ConclusionsCompared to no bronchiolitis, bronchiolitis incurs five-time and two-time higher healthcare costs within the initial and subsequent six-months, respectively. Most expenses occur in the initial 10 days and relate to hospitalization.

Background Pre-exposure prophylaxis (PrEP) has the potential to reduce HIV transmission and stem the HIV epidemic. Unfortunately, PrEP uptake in rural sub-Saharan Africa has been slow and medication adherence has been suboptimal. Objective To explore the perspectives, attitudes, and experiences of HIV serodiscordant partners taking PrEP and develop a messaging campaign to improve PrEP uptake in rural Mozambique to reduce HIV transmission among serodiscordant partners. Methods In this qualitative study, we interviewed 20 people in serodiscordant relationships using PrEP at a rural health center in Zambézia province, Mozambique and employed inductive and deductive coding to elicit their perspectives, attitudes, and experiences related to learning their partner’s HIV status, barriers to PrEP uptake, obstacles to PrEP adherence, and decisions to disclose their PrEP use with family and friends using thematic analysis. Results Our analysis generated nine themes across various levels of the socioecological model. Participants reported a strong desire to stay in the discordant relationship and highlighted the importance of working together to ensure PrEP and antiretroviral therapy adherence, with the majority skeptical that adherence could be achieved without both partners’ support (individual and interpersonal). Although most participants were reticent about sharing their serodiscordant status with family and friends (individual and interpersonal), those who did found their family and friends supportive (interpersonal). Participants suggested increasing community health agent availability to help people navigate HIV prevention and treatment (organizational). We then created three oral stories, using themes from the interviews, with examples from various levels of the socioecological model that will be used to generate support for PrEP use among community members. Conclusions Our findings informed oral template stories that will be used to emphasize how couples can work together to improve PrEP uptake and reduce incident HIV infections in serodiscordant couples elsewhere in rural Mozambique.

Background The ability to understand another’s emotions and act appropriately, empathy, is an important mediator of relationship function and health intervention fidelity. We adapted the Interpersonal Reactivity Index (IRI) – an empathy scale – among seroconcordant expectant couples with HIV in the Homens para Saúde Mais (HoPS+) trial – a cluster randomized controlled trial assessing couple-based versus individual treatment on viral suppression – in Zambézia Province, Mozambique. Methods Using baseline data from 1332 HoPS+ trial participants (666 couples), an exploratory factor analysis assessed culturally relevant questions from the IRI. Because empathy is interdependent among couples, we validated the results of the exploratory factor analysis using a dyadic confirmatory factor analysis (CFA) with dyadic measurement invariance testing. Finally, we assessed the relationship between scores on our final scale and basic demographic characteristics (sex, age, education, and depression) using t-tests. Results We found two subscales: 1) a seven-item cognitive empathy subscale (Cronbach’s alpha 0.78) and 2) a six-item affective empathy subscale (Cronbach’s alpha 0.73). The dyadic CFA found acceptable model fit and metric invariance across partners (Comparative Fit Index (CFI) = 0.914, Tucker Lewis Index = 0.904, Root Mean Squared Error of Approximation = 0.056, ΔCFI = 0.011). We observed higher cognitive (p: 0.012) and affective (p: 0.049) empathy among males and higher cognitive (p: 0.031) and affective (p: 0.030) empathy among younger participants. More educated participants had higher affective empathy (p: 0.017) and depressed participants had higher cognitive empathy (p: Conclusions This scale will allow us to assess the interplay between empathy and other psychometric constructs (stigma, social support, etc.) in the HoPS+ trial and how each relates to retention in HIV, adherence to treatment, and prevention of maternal to child HIV transmission. Furthermore, this scale can be adapted for other sub-Saharan African populations, which will allow researchers to better assess HIV-related intervention efficacy. Trial registration This study is within the context of the HoPS+ trial, registered at ClinicalTrials.gov as number NCT03149237. Registered May 11, 2017.

Many people poised to move through housing choice voucher programs cite violence as a primary factor in their decision-making. This study synthesizes a body of qualitative data to explore how participants recount their experiences with neighborhood violence and analyzes its relationship to residential decision-making. We find that while participants expressed a desire to move to improve their circumstances, they also recounted how neighborhood violence constrained choice by influencing a multitude of factors in the decision-making process. This shows the stress neighborhood violence places on households and how neighborhood factors constrain housing choice.

Before the 2015 implementation of “Test and Start,” the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under “Test and Start” was higher at +68 cells/mm(3) (95% CI: 57.5–78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.

BACKGROUND Antimicrobials are frequently prescribed to community-dwelling older adults. Our aim was to examine the prevalence, quantity and indications of antimicrobial prescriptions to older residents of Ontario. METHODS We conducted a population-based analysis of outpatient antimicrobial prescriptions to residents of Ontario aged 65 years or more from 2006 to 2015. Antimicrobial prescriptions, infectious disease diagnoses and prescriber information were determined from linked health care databases. Our analyses were primarily focused on antibiotics, which account for most antimicrobial use. RESULTS We identified 2 879 779 unique Ontario residents aged 65 years or more over our study period. On average, 40.7% (range 40.1%-41.5%) of older adult outpatients in any given year received 1 or more antibiotic prescriptions. Antibiotic use remained stable over the study period, averaging 25.1 (range 24.1-25.6) defined daily doses per 1000 person-days per year. Selection of antibiotics evolved, with increasing use of penicillins and decreasing use of fluoroquinolones and macrolides. For 65.7% of prescriptions, no infectious disease diagnoses were identified within 7 days of the prescription. Among prescriptions with an associated diagnosis, upper respiratory tract infection was most common (18.9%), followed by urinary tract infection (6.2%), skin/soft-tissue infection (4.3%), lower respiratory tract infection (4.2%) and other infection (1.2%). Most antibiotics were prescribed by family physicians. INTERPRETATION Antibiotic use among older adult outpatients in Ontario remained stable between 2006 and 2015. Current methods of measuring use are not capable of accurately determining indication, and, thus, additional data sources to monitor the appropriateness of community antimicrobial use are needed.

Background: Immigrant women are less likely to be screened for cervical cancer in Ontario. Religion may play a role for some women. In this population-based retrospective cohort study, we used country of birth as a proxy for religious affiliation and examined screening uptake among foreign-born women from Muslim-majority versus other countries, stratified by region of origin. Methods: We linked provincial databases and identified all women eligible for cervical cancer screening between April 1, 2012, and March 31, 2015. Women were classified into regions based on country of birth. Countries were classified as Muslim-majority or not. Results: Being born in a Muslim-majority country was significantly associated with lower likelihood of being up-to-date on Pap testing, after adjustment for region of origin, neighborhood income, and primary care–related factors [adjusted relative risk (ARR), 0.93; 95% (confidence interval) CI, 0.92–0.93]. Sub-Saharan African women from Muslim-majority countries had the highest prevalence of being overdue (59.6%), and the lowest ARR for screening when compared with women from non–Muslim-majority Sub-Saharan African countries (ARR, 0.77; 95% CI, 0.76–0.79). ARRs were lowest for women with no primary care versus those in a capitation-based model (ARR, 0.28; 95% CI, 0.27–0.29 overall). Conclusions: We have shown that being born in a Muslim-majority country is associated with a decreased likelihood of being up-to-date on cervical screening in Ontario and that access to primary care has a sizeable impact on screening uptake. Impact: Screening efforts need to take into account the background characteristics of population subgroups and to focus on increasing primary care access for all. Cancer Epidemiol Biomarkers Prev; 26(10); 1493–9. ©2017 AACR.

Calvarial vault fractures are commonly encountered finding within the head injury problem. Calvarial or vault fractures may be either closed or open, and either linear, comminuted, or depressed. In closed fractures, the galea over the fracture is intact. With open fractures, the galea is torn and the fracture exposed. Linear fractures, as the name implies, are generally nonbranching, generally do not cross suture lines, and bone on both sides of the fracture remains co-planar. Depressed fractures refer to a difference in height between the fracture plates. Comminuted fractures are characterized by fragmentation of the bone plates, and these fragments may be co-planar or depressed. Because of their wide spectrum of severity, it is critical for testing physicians to recognize the various types, presentations, and diagnostic and therapeutic implications of these entities.

In this study, only 22 of 206 (10.7%) socially marginalized individuals living with HIV and multiple comorbid conditions filled a prescription for antiretroviral therapy within 7 days of discharge from an HIV specialty hospital, despite comprehensive discharge planning. Additional interventions facilitating postdischarge continuity of care are required for this population.

IntroductionIn Ontario, the top 5% of high-cost users account for 66% of health care costs. The heavy use of resources combined with perceived inefficiencies offer an imperative to target strategies to redesign care to better meet patient needs and increase value. Objectives and ApproachAs part of a request submitted to the Applied Health Research Question (AHRQ) review team, the main objective of this study was to identify drivers of high health care use in Ontario in order to find better ways to improve the efficiency in healthcare delivery. Using data in fiscal year 2012/13, characteristics of the top 5% of high costs users were described, and further stratified by mental health status. Total spending by sector of care were also described. Data were linked including physician, hospital, medication and long term care databases for each patient. ResultsIn the top 5% of high-cost users, there were 729,870 patients who accounted for $20,179,208,348 of total healthcare spending in 2012/13, with the highest percentage of spending observed among older adults aged 61-80 years old. Mental health high-cost patients accounted for 6.1% of these patients, of which 51.5% were female, had a low socio-economic status and an average age of 44 years. These patients had an average of 4.9 (SD=2.3) ICD chapters and used an average of 8.7 (SD=3.8) drugs. Using the health accounts methodology (ICHA), as described by the OECD and WHO, over 90% of healthcare costs among the top 5% of high-cost patients were from inpatient care, day surgery and clinic care, physician care, outpatients drugs and inpatient rehabilitation and complex/continuing care. Conclusion/ImplicationsThis study provides a systematic description of the needs in a high cost patient group, and serves as a platform for international comparisons across healthcare systems to better understand gaps and identify targets for intervention. These cross-comparisons offer a tool to evaluate performance of healthcare systems and to prioritize policies.

IntroductionThe Applied Health Research Question (AHRQ) portfolio is an initiative funded by the Ontario Ministry of Health and Long-Term Care, leveraging the linked data and the scientific expertise at ICES to answer questions from Knowledge Users that have a direct impact on healthcare policy, planning or practice. Objectives and ApproachA request from Casey House, a specialty HIV hospital located in Toronto, ON, was reviewed and approved by the ICES AHRQ Team to evaluate patient healthcare utilization and costs. The purpose was to support the design of programs and services, improve transitions from healthcare settings to community services, and inform continuous quality improvement initiatives. Using inpatient records, hospital admissions to Casey House were identified in fiscal years 2009-2014. Inpatient, emergency, outpatient and home care visits were characterized before and after admission. Using the Ontario Drug Benefit Claims, antiretroviral (ARV) prescription fills were examined 7 days post discharge. ResultsBetween April 1, 2009 and March 31, 2015, 268 HIV patients had one or more hospital admissions to Casey House. The majority of Casey House patients had an Aggregated Diagnosis Group (ADG) ≥ 10 (79%) or Resource Utilization Band (RUB) = 5 (78%), indicating a high co-morbidity burden. Rate of emergency department usage declined from 4.61 to 2.46 per person-year, before and after Casey House admission (p < 0.0001). Conversely, home care visits increased from 24.29 to 35.63 per person-year and family physician visits increased from 18.33 to 22.59 per person-year before and after Casey House admission (both p < 0.0001). Interestingly, 89% did not fill an ARV prescription within 7 days of Casey House discharge, however 76% followed up with an outpatient HIV visit within 30 days. Conclusion/ImplicationsHealthcare utilization differed before and after admission to Casey House. Follow-up post-discharge warrants further examination to increase ARV prescription fills. Data from this AHRQ has facilitated future policy and programming changes. Results have been disseminated throughout the Toronto HIV research community to generate discussion on quality improvement in this population.

IntroductionThe Toronto Central (TC) LHIN has aligned its vision with the Ministry of Health and Long-Term Care and Cancer Care Ontario to prioritize participation in population-based cancer screening programs and to address screening inequities. This request was accepted by the ICES AHRQ review team to help impact policy and programs. Objectives and ApproachBy linking cancer screening data to geographic, provider and immigration databases, underlying contributors and barriers to cancer screening can be better understood and used to target interventions to specific groups and areas of the province. Thus, the purpose of this study was to: 1) determine the rates of cancer screening in the TC LHIN by sub-region and neighbourhood, and 2) determine how these differences vary by immigration status, primary care provider characteristics and neighbourhood income level. Using OHIP billing claims, screening for breast, cervical and colorectal cancer was identified between fiscal years 2013 to 2016. ResultsDuring the study period, 58.4% of eligible TC LHIN residents received a mammogram, 57.1% received a pap smear and 55.1% received colorectal cancer screening. Screening rates varied by Toronto neighbourhood: 48.4%–72.9%, 38.8%–70.1% and 42.7%–68.7% for mammograms, pap smears and colorectal cancer screening respectively. Residents who recently immigrated to Ontario received less cancer screening than non-immigrants; 51.8% of immigrant women eligible for cervical cancer screening received a pap smear compared to 60.4% of non-immigrant women in the TC LHIN East region. Not having a female physician (54.3% vs 68.6%), lacking comprehensive care (55.6% vs 62.5%), having a foreign trained physician (56.6% vs 64.7\%) and living in a lower income neighbourhood (51.6%-62.5%) were other factors associated with lower rates of cancer screening. Conclusion/ImplicationsCancer screening rates vary according to neighbourhood, and certain groups may be vulnerable to inadequate screening. These findings will help to address cancer screening disparities due to structural barriers, and will help in the delivery of culturally appropriate and relevant cancer screening educational packages and outreach programs in Toronto.