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Vincent Lo Re III,1,2,* Noelle M Cocoros,3,4,* Rebecca A Hubbard,2 Sarah K Dutcher,5 Craig W Newcomb,2 John G Connolly,3,4 Silvia Perez-Vilar,5 Dena M Carbonari,2 Maria E Kempner,3,4 José J Hernández-Muñoz,5 Andrew B Petrone,3,4 Allyson M Pishko,6 Meighan E Rogers Driscoll,3,4 James T Brash,7 Sean Burnett,8,9 Catherine Cohet,10 Matthew Dahl,8,11 Terese A DeFor,12 Antonella Delmestri,13 Djeneba Audrey Djibo,14 Talita Duarte-Salles,15,16 Laura B Harrington,17 Melissa Kampman,18 Jennifer L Kuntz,19 Xavier Kurz,10 Núria Mercadé-Besora,15 Pamala A Pawloski,12 Peter R Rijnbeek,16 Sarah Seager,7 Claudia A Steiner,20,21 Katia Verhamme,16 Fangyun Wu,8,22 Yunping Zhou,23 Edward Burn,13 J Michael Paterson,8,22,* Daniel Prieto-Alhambra13,16,* 1Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 2Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 3Department of Population Medicine, Harvard Medical School, Boston, MA, USA; 4Harvard Pilgrim Healthcare Institute, Boston, MA, USA; 5Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA; 6Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 7IQVIA, Real World Solutions, Brighton, UK; 8Canadian Network for Observational Drug Effect Studies (CNODES), Toronto, Ontario, Canada; 9Therapeutics Initiative, University of British Columbia, Vancouver, British Columbia, Canada; 10Data Analytics and Methods Task Force, European Medicines Agency, Amsterdam, Netherlands; 11Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada; 12HealthPartners Institute, Bloomington, MN, USA; 13Pharmaco- and Device Epidemiology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK; 14CVS Health, Blue Bell, PA, USA; 15Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; 16Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands; 17Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; 18Health Canada, Ottawa, Ontario, Canada; 19Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA; 20Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA; 21Colorado Permanente Medical Group, Denver, CO, USA; 22ICES, Toronto, Ontario, Canada; 23Humana Healthcare Research, Inc., Louisville, KY, USA*These authors contributed equally to this workCorrespondence: Vincent Lo Re III, Division of Infectious Diseases, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 836 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA, Fax +1 215 573 5315, Email vincentl@pennmedicine.upenn.eduPurpose: Few studies have examined how the absolute risk of thromboembolism with COVID-19 has evolved over time across different countries. Researchers from the European Medicines Agency, Health Canada, and the United States (US) Food and Drug Administration established a collaboration to evaluate the absolute risk of arterial (ATE) and venous thromboembolism (VTE) in the 90 days after diagnosis of COVID-19 in the ambulatory (eg, outpatient, emergency department, nursing facility) setting from seven countries across North America (Canada, US) and Europe (England, Germany, Italy, Netherlands, and Spain) within periods before and during COVID-19 vaccine availability.Patients and Methods: We conducted cohort studies of patients initially diagnosed with COVID-19 in the ambulatory setting from the seven specified countries. Patients were followed for 90 days after COVID-19 diagnosis. The primary outcomes were ATE and VTE over 90 days from diagnosis date. We measured country-level estimates of 90-day absolute risk (with 95% confidence intervals) of ATE and VTE.Results: The seven cohorts included 1,061,565 patients initially diagnosed with COVID-19 in the ambulatory setting before COVID-19 vaccines were available (through November 2020). The 90-day absolute risk of ATE during this period ranged from 0.11% (0.09– 0.13%) in Canada to 1.01% (0.97– 1.05%) in the US, and the 90-day absolute risk of VTE ranged from 0.23% (0.21– 0.26%) in Canada to 0.84% (0.80– 0.89%) in England. The seven cohorts included 3,544,062 patients with COVID-19 during vaccine availability (beginning December 2020). The 90-day absolute risk of ATE during this period ranged from 0.06% (0.06– 0.07%) in England to 1.04% (1.01– 1.06%) in the US, and the 90-day absolute risk of VTE ranged from 0.25% (0.24– 0.26%) in England to 1.02% (0.99– 1.04%) in the US.Conclusion: There was heterogeneity by country in 90-day absolute risk of ATE and VTE after ambulatory COVID-19 diagnosis both before and during COVID-19 vaccine availability.Plain Language Summary: Cohort studies of patients diagnosed with COVID-19 in both the ambulatory and hospital settings have suggested that SARS-CoV-2 infection promotes hypercoagulability that could lead to arterial or venous thromboembolism. However, few studies have examined how the risk of thromboembolism with COVID-19 has evolved over time across different countries. A new collaboration was established among the regulatory authorities of Canada, Europe, and the US within the International Coalition of Medicines Regulatory Authorities to evaluate the 90-day risk of both arterial and venous thromboembolism after initial diagnosis of COVID-19 in the ambulatory or hospital setting from seven countries across North America (Canada, US) and Europe (England, Germany, Italy, Netherlands, and Spain) within periods before and during COVID-19 vaccine availability. The study found that there was variability in the risk of both arterial and venous thromboembolism by month across the countries among patients initially diagnosed with COVID-19 in the ambulatory or hospital setting. Differences in the healthcare systems, prevalence of comorbidities in the study cohorts, and approaches to the case definitions of thromboembolism likely contributed to the variability in estimates of thromboembolism risk across the countries.Keywords: COVID-19, ischemic stroke, myocardial infarction, thromboembolism, venous thromboembolism

Background: Fibric acid derivatives (fibrates) have been shown to increase serum creatinine level in randomized trials. Objective: To assess renal outcomes in elderly adults within 90 days of a new fibrate prescription. Design: Population-based cohort study. Setting: Ontario, Canada. Patients: Patients aged 66 years or older with a new outpatient prescription for a fibrate or ezetimibe (comparator drug) between January 2004 and December 2008. Measurements: Hospitalization for an increase in serum creatinine level (primary outcome) and consultation with a nephrologist, receipt of dialysis for severe acute kidney injury, all-cause mortality, and increases in serum creatinine level (secondary outcomes). All outcomes were assessed within 90 days of a new prescription for ezetimibe or a fibrate. Results: Compared with ezetimibe users (n = 61 831), fibrate users (n = 19 072) were more likely to be hospitalized for an increase in serum creatinine level (adjusted odds ratio, 2.4 [95% CI, 1.7 to 3.3]) and were more likely to consult a nephrologist (absolute risk difference, 0.15% [CI, 0.01% to 0.29%]; adjusted odds ratio, 1.3 [CI, 1.0 to 1.6]). There were no differences between groups in the risk for all-cause mortality or receiving dialysis for severe acute kidney injury. In a subpopulation of 1110 patients (fibrates, n = 220; ezetimibe, n = 890), 9.1% of fibrate users and 0.3% of ezetimibe users had an increase in serum creatinine level of 50% or more (absolute difference, 8.8% [CI, 4.5% to 13.1%]; odds ratio, 29.6 [CI, 8.7 to 100.5]). Risks were greater among fibrate users with chronic kidney disease. Limitations: Because hospitalizations for an increase in serum creatinine level were underestimated, absolute differences may be misleading. Most patients (91%) were prescribed fenofibrate. Serum creatinine levels were measured as part of routine care and were not available for everyone or at predefined times. Conclusion: New fibrate use in elderly adults was associated with an increase in serum creatinine level and a small 90-day absolute increase in hospitalizations and nephrologist consultations. There was no detectable effect on dialysis for severe acute kidney injury or on mortality. The mechanism and clinical significance of the increase in serum creatinine level with fibrates is unclear. Primary Funding Source: Ontario Ministry of Health and Long-Term Care Drug Innovation Fund. [ABSTRACT FROM AUTHOR]

Background: A relation between provider volume and outcome of total joint replacement (TJR) has not been demonstrated in Canada. Given the recent increase in TJR, changing patient characteristics and small sizes of previous Ontario studies, we reassessed whether adverse outcomes of TJR are related to hospital and surgeon procedure volumes.Methods: We included all Ontarians aged 20 years and older who underwent a unilateral elective primary total hip replacement (THR) or total knee replacement (TKR) between April 2000 and March 2004. The main data sources were hospital discharge abstracts and physician billings. We defined provider volume as the average annual number of primary and revision procedures performed by hospitals and surgeons during the study period. We assessed the association between procedure volumes and acute length of hospital stay (ALOS) and between volume and rate of surgical complications during the index admission; death within 90 days of operation; readmission for amputation, fusion or excision within 1 year; and revision arthroplasty within 1 year. We adjusted for age, sex, comorbidity, arthritis type, teaching hospital status and discharge disposition. The analyses of hospital volume were adjusted for surgeon volume and vice versa.Results: We included 20,290 patients who received THR and 27,217 who received TKR. Patient age, sex and comorbidity were significant predictors of complications and mortality. There were no associations between provider volume and mortality. Findings for other outcomes were mixed. Surgeon procedure volume was related to rates of revision THR but not to rates of revision TKR. Shorter ALOS was associated with male sex, younger age, fewer comorbidities, discharge to a rehabilitation unit or facility and greater surgeon volume.Conclusion: Patient characteristics were significant predictors of complications, ALOS and mortality after primary TJR. Evidence for a relation between provider volume and outcome was limited and inconsistent. [ABSTRACT FROM AUTHOR]

Prescription drug plan managers seek 'real-world' evidence regarding the safety and effectiveness of drugs and drug coverage policies. University-based pharmacoepidemiologists with access to administrative health data can help meet these information needs and, by collaborating with other health plans, exploit variations in plan policy. Canada, with its universal health insurance, public drug benefit plans, and population-based linked health care databases, is an ideal setting for such research. Here we describe our initial experience in collaborating with researchers and drug plan managers in British Columbia and Ontario. [ABSTRACT FROM AUTHOR]

Background: Recent data suggest that although smoking during pregnancy has declined in North America, this has more to do with falling rates of smoking initiation among women of childbearing age than with increased rates of pregnancy-related smoking cessation. One possible explanation is poor exposure to effective stop-smoking strategies. Better information about women who smoke during pregnancy may help target these interventions more effectively.Methods: The study was a cross-sectional, self-administered survey of a consecutive sample of 916 (40.4% of eligible) women who delivered healthy babies in 1997-98 at a tertiary teaching hospital in Hamilton, Ontario. Our main focus was on health behaviours (smoking, drinking, eating, and exercise habits) before and during pregnancy; but we also included questions about the presence of (other) children and (other) smokers in the household, perceived health status, the subject's age and level of education, and whether or not the present pregnancy was planned. Factors associated with pregnancy-related smoking cessation were identified using multiple logistic regression.Results: Respondents were better educated and healthier, but smoked at rates similar to women of childbearing age in Hamilton at the time of the survey. Two thirds of prior smokers or 20% of respondents overall continued to smoke during pregnancy. After adjustment for other factors, three factors were associated with ongoing smoking during pregnancy: having other smokers in the household; having other children in the household; and not having post-secondary education.Conclusions: Many pregnant smokers are not being reached by current stop-smoking strategies. New ways to help these women and their partners are needed. [ABSTRACT FROM AUTHOR]

Objectives: To compare reoperation rates of acute versus delayed reverse total shoulder arthroplasty (RTSA) following a period of nonoperative treatment for proximal humerus fractures (PHFs). We also aimed to identify an optimal time interval from PHF to RTSA before the risk of reoperation significantly increased., Methods:  ., Design: Database review., Setting: Ontario, Canada., Patient Selection Criteria: Adults aged 50 years and older who sustained a PHF (OTA/AO 11A-C) between 2004 and 2019 were included. Exclusion criteria included polytrauma, open fractures, non-Ontario residents, invalid health insurance, and any operative treatment before RTSA., Outcome Measures and Comparisons: The primary outcome measure was reoperation within 2 years following RTSA. A risk-adjusted, restricted cubic spline was used to model the probability of reoperation according to the time elapsed between PHF and RTSA to identify a time point at which the risk of reoperation significantly increased. A multivariate logistics regression was used to identify predictors., Results: In total, 891 patients (685 acute, 206 delayed) underwent RTSA for PHF. The acute cohort had a significantly lower reoperation rate (3.9%) compared with the delayed cohort (8.3%) (P = 0.02). The odds of reoperation increased with a delay to RTSA greater than 28 days and continued to rise until 100 days after fracture. Patients who underwent RTSA 28 days after PHF were found to have a significantly higher odds of reoperation by 2 years (P = 0.03)., Conclusions: Among patients undergoing RTSA for acute PHFs, a delay to surgery greater than 28 days is associated with a greater odds of reoperation and may be useful when counseling patients., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Community Paramedicine at Clinic (CP@clinic) is a chronic disease prevention program that decreases 911 calls for emergency medical services, but its wider system effects are unknown., Objective: To evaluate the effects of CP@clinic vs usual care on individual-level health service utilization outcomes., Design, Setting, and Participants: This open-label, pragmatic cluster randomized clinical trial evaluated all residents 55 years or older in 30 social housing buildings in Ontario, Canada, that had (1) a unique postal code, (2) at least 50 apartments, (3) 60% or more residents 55 years or older, and (4) a similar building for pairing (15 intervention and 15 control buildings, pair-matched randomization). The 12-month intervention had a staggered start date from January 1, 2015, to December 1, 2015, and ended between December 31, 2015, and November 30, 2016. Administrative health data analysis was conducted in May 2022., Intervention: CP@clinic was a health promotion and disease prevention program led by specially trained community paramedics who held weekly drop-in sessions in social housing buildings. These paramedics conducted 1-on-1 risk assessments, provided health education and referrals to relevant community resources, and, with consent, sent assessments to family physicians. Control buildings received usual care (universal health care, including free primary and specialty medical care)., Main Outcome and Measures: Individual-level health service utilization was measured from administrative health data, with ED visits via ambulance as the primary outcome; secondary outcomes included ED visits for any reason, primary care visits, hospitalizations, length of hospital stay, laboratory tests, receipt of home care, transfer to long-term care, and medication initiation. Generalized estimating equations were used to estimate intervention effects on individual-level health service utilization, accounting for trial design and individual-level baselines., Results: The 30 social housing buildings had 3695 residents (1846 control and 1849 intervention participants; mean [SD] age, 72.8 [9.1] years; 2400 [65.0%] female). Intention-to-treat analysis found no significant difference in ED visits by ambulance (445 of 1849 [24.1%] vs 463 of 1846 [25.1%]; adjusted odds ratio [AOR], 0.97; 95% CI, 0.89-1.05) but found higher antihypertensive medication initiation (74 of 500 [14.8%] vs 47 of 552 [8.5%]; AOR, 1.74; 95% CI, 1.19-2.53) and lower anticoagulant initiation (48 of 1481 [3.2%] vs 69 of 1442 [4.8%]; AOR, 0.68; 95% CI, 0.53-0.86) in the intervention arm vs the control arm. CP@clinic attendance was associated with higher incidence of primary care visits (adjusted incidence rate ratio, 1.10; 95% CI, 1.03-1.17), higher odds of receiving home care (AOR, 1.07; 95% CI, 1.01-1.13), and lower odds of long-term care transfers (AOR, 0.32; 95% CI, 0.13-0.81)., Conclusions and Relevance: In this cluster randomized clinical trial of CP@clinic, the intervention did not affect the rate of ED visits by ambulance; however, there were increased primary care visits and connections to home care services, which may have increased antihypertensive medication initiation and reduced long-term care transfers from social housing. Health policymakers should consider CP@clinic's impact as an upstream approach to improve care for older adults with low income., Trial Registration: ClinicalTrials.gov Identifier: NCT02152891.

Objective: To describe family physicians who primarily practise in a walk-in clinic setting and compare them with family physicians who provide longitudinal care., Design: A cross-sectional study that linked results from a 2019 physician survey to provincial administrative health care data in Ontario. The characteristics, practice patterns, and patients of physicians primarily working in a walk-in clinic setting were compared with those of family physicians providing longitudinal care., Setting: Ontario., Participants: Physicians who primarily worked in a walk-in clinic setting in 2019, as indicated by an annual physician survey., Main Outcome Measures: Physician demographic and practice characteristics, as well as their patients' demographic and health care utilization characteristics, were reported according to whether the physician was a walk-in clinic physician or a family physician who provided longitudinal care., Results: Compared with the 9137 family physicians providing longitudinal care, the 597 physicians who self-identified as practising primarily in walk-in clinics were more frequently male (67% vs 49%) and more likely to speak a language other than English or French (43% vs 32%). Walk-in clinic physicians tended to have more encounters with patients who were younger (mean 37 vs 47 years), who had lower levels of prior health care utilization (15% vs 19% in highest band), who resided in large urban areas (87% vs 77%), and who lived in highly ethnically diverse neighbourhoods (45% vs 35%). Walk-in clinic physicians tended to have more encounters with unattached patients (33% vs 17%) and with patients attached to another physician outside their group (54% vs 18%)., Conclusion: Physicians who primarily work in walk-in clinics saw many patients from historically underserved groups and many patients who were attached to another family physician., (Copyright © 2024 the College of Family Physicians of Canada.)

Background and Purpose:  Total hip arthroplasty (THA) can be performed through various surgical approaches, including direct anterior (DAA). DAA-THA may offer faster recovery but carries a higher risk of complications, which may be mitigated by surgeon volume and experience. We examined the association of surgeons' annual surgical volume with major complications after DAA-THA in a population-based sample., Methods:  A population-based retrospective cohort study was carried out on primary DAA-THA patients in Ontario between April 2016 and March 2021. We used restricted cubic splines to visually define the association between annual DAA surgeon volume and the risk of major surgical complications (fractures, dislocations, infections, and revisions) within 1 year of surgery. We further compared the complication rates amongst different DAA volume categories (< 30, 30-60, and > 60 cases/year)., Results: The study encompassed 9,672 DAA-THA patients (52% female, median age 67 years). We showed a sharp decline in the probability of complications as the surgical volume of DAA-THA increased within the lower range of 0-30 cases/year; the probability slightly increased after the surgical volume exceeded 60 cases/year. The overall complication rates were 3.09%, 2.24%, and 2.18% for the surgical experience group of < 30 cases/year, 30-60 cases/year, and > 60 cases/year, respectively., Conclusion:  There was an inverse relationship between surgical volume and complication rates in DAA-THA within the lower volume ranges. Maintaining a surgical volume of at least 30 DAA-THA cases/year can minimize complications, emphasizing the importance of surgical volume in this approach.

Background: Periprosthetic joint infection (PJI) remains a dreaded and unpredictable complication after total hip arthroplasty (THA). In addition to causing substantial morbidity, PJI may contribute to long-term mortality risk. Our objective was to determine the long-term mortality risk associated with PJI following THA., Methods: This population-based, retrospective cohort study included adult patients (≥18 years old) in Ontario, Canada, who underwent their first primary elective THA for arthritis between April 1, 2002, and March 31, 2021. The primary outcome was death within 10 years after the index THA. Mortality was compared between propensity-score-matched groups (PJI within 1 year after surgery versus no PJI within 1 year after surgery) with use of survival analyses. Patients who died within 1 year after surgery were excluded to avoid immortal time bias., Results: A total of 175,432 patients (95,883 [54.7%] women) with a mean age (and standard deviation) of 67 ± 11.4 years underwent primary THA during the study period. Of these, 868 patients (0.49%) underwent surgery for a PJI of the replaced joint within 1 year after the index procedure. After matching, patients with a PJI within the first year had a significantly higher 10-year mortality rate than their counterparts (11.4% [94 of 827 patients] versus 2.2% [18 of 827 patients]; absolute risk difference, 9.19% [95% confidence interval (CI), 6.81% to 11.6%]; hazard ratio, 5.49 [95% CI, 3.32 to 9.09])., Conclusions: PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. The findings of this study underscore the importance of prioritizing efforts related to the prevention, diagnosis, and treatment of PJIs., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This study was supported by a strategic operating grant (21-0000000176) from the Arthritis Society and by ICES, an independent research institute funded by the Ontario Ministry of Health and Long-Term Care. The funders and data providers had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; or the decision to submit the manuscript for publication. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H998 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Following the mass recall of valsartan products with nitrosamine impurities in July 2018, the number of patients exposed to these products, the duration of exposure, and the potential for cancer remains unknown. Therefore, we assessed the extent and duration of use of valsartan products with a nitrosamine impurity in the United States, Canada, and Denmark., Methods: We conducted a retrospective cohort study using administrative healthcare data from the US FDA Sentinel System, four Canadian provinces that contribute to the Canadian Network for Observational Drug Effect Studies (CNODES), and the Danish National Prescription Registry. Patients, 18 years and older between May 2012 and December 2020 with a valsartan dispensing were identified in each database. Patients were followed from the date of valsartan dispensing until discontinuation. We defined four valsartan exposure categories based on nitrosamine impurity status; recalled generic products with confirmed NDMA/NDEA levels (recalled-tested); recalled generic products that were not tested (recalled); non-recalled generic and non-recalled branded products. In Denmark, the recalled-tested category was not included due to absence of testing data. The proportion and duration of use of valsartan episodes stratified by nitrosamine-impurity status was calculated., Results: We identified 3.3 and 2.8 million (United States) and 51.3 and 229 thousand (Canada) recalled-tested and recalled valsartan exposures. In Denmark, where valsartan exposure was generally low, there were 10 747 recalled exposures. Immediately after the recall notices were issued, there was increased rates of switching to a non-valsartan ARB. The mean duration of use of the recalled-tested products was 167 (±223.1) and 146 (±255.8) days in the United States and Canada respectively. For the recalled products, mean cumulative duration of use was 178 (±249.6), 269 (±397.3) and 166 (±251.0) days in the United States, Canada, and Denmark, respectively., Conclusion: In this cohort study, despite widespread use of recalled generic valsartan between 2012 and 2018, the duration of use was relatively short and probably did not pose an elevated risk of nitrosamine-induced cancer. However, since products with nitrosamine impurity could have been on the market over a 6-year period, patients exposed to these products for longer durations could have a potentially different risk of cancer., (© 2024 John Wiley & Sons Ltd. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Public funding of cataract surgery provided in private, for-profit surgical centres increased to help mitigate surgical backlogs during the COVID-19 pandemic in Ontario, Canada. We sought to compare the socioeconomic status of patients who underwent cataract surgery in not-for-profit public hospitals with those who underwent this surgery in private for-profit surgical centres and to evaluate whether differences in access by socioeconomic status decreased after the infusion of public funding for private, for-profit centres., Methods: We conducted a population-based study of all cataract operations in Ontario, Canada, between January 2017 and March 2022. We analyzed differences in socioeconomic status among patients who accessed surgery at not-for-profit public hospitals versus those who accessed it at private for-profit surgical centres before and during the period of expanded public funding for private for-profit centres., Results: Overall, 935 729 cataract surgeries occurred during the study period. Within private for-profit surgical centres, the rate of cataract surgeries rose 22.0% during the funding change period for patients in the highest socioeconomic status quintile, whereas, for patients in the lowest socioeconomic status quintile, the rate fell 8.5%. In contrast, within public hospitals, the rate of surgery decreased similarly among patients of all quintiles of socioeconomic status. During the funding change period, 92 809 fewer cataract operations were performed than expected. This trend was associated with socioeconomic status, particularly within private for-profit surgical centres, where patients with the highest socioeconomic status were the only group to have an increase in cataract operations., Interpretation: After increased public funding for private, for-profit surgical centres, patient socioeconomic status was associated with access to cataract surgery in these centres, but not in public hospitals. Addressing the factors underlying this incongruity is vital to ensure access to surgery and maintain public confidence in the cataract surgery system., Competing Interests: Competing interests:: Jonathan Irish is a board member with the Canadian Cancer Society. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: In 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns., Objective: This study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective., Methods: Using administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD $1=US $0.76 is applicable)., Results: We matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral ($2805 vs $2299; difference of $506, 95% CI $139-$885) and significantly lower for the VUC cohort of patients who did not require ED referral ($907 vs $1270; difference of $362, 95% CI 284-$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were $18.9 million (ie, $6.0 million + $12.9 million) versus $22.9 million ($4.9 million + $18.0 million) for the 2 in-person ED cohorts., Conclusions: This costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions., (©Jean-Eric Tarride, Justin N Hall, Shawn Mondoux, Katie N Dainty, Joy McCarron, J Michael Paterson, Lesley Plumptre, Emily Borgundvaag, Howard Ovens, Shelley L McLeod. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 15.07.2024.)

Background: Demand for total knee arthroplasty (TKA) is increasing as it remains the gold-standard treatment for end-stage osteoarthritis (OA) of the knee. Magnetic resonance imaging (MRI) scans of the knee are not indicated for diagnosing knee OA and represent a possible delay to orthopaedic surgeon referral and unnecessary expenditure. The purpose of this study was to determine the proportion of patients who underwent an MRI in the two years prior to their primary TKA for OA and determine patient and physician associations with increased MRI usage., Methods: This is a population-based cohort study using administrative data from Ontario, Canada. All patients over 40 years old who underwent their first primary TKA between April 1, 2008, and March 31, 2019, were included. Statistical analyses were performed using SAS and included the Cochran-Armitage test for trend of MRI prior to surgery. A predictive multivariable regression model was used to determine features correlated to receiving an MRI., Results: There were 194,989 eligible first-time TKA recipients, of which 38,244 (19.6%) received an MRI in the two years prior to their surgery. The majority of these (69.6%) were ordered by primary care physicians. Patients who received an MRI were younger, had fewer comorbidities and were more affluent than patients who did not (p < 0.001). MRI use prior to TKA increased from 2008 to 2018 (p < 0.001)., Conclusion: Despite MRIs rarely being indicated for the work-up of end-stage OA, nearly one in five patients have an MRI in the two years prior to their TKA. This may be increasing healthcare expenditure and surgical wait-times., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Clinical practice guidelines recommend early serum electrolyte monitoring when starting antidepressants in older adults due to the increased risk of hyponatremia. It is unclear whether this monitoring improves outcomes., Methods: Population-based, retrospective cohort study of Ontario adults aged ≥66 years who initiated therapy with a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI) between April 1, 2013, and January 31, 2020. The index date was the date of the first such prescription, and the exposure of interest was serum electrolyte measurement during the subsequent 7 days. The primary outcome was any emergency department or hospital admission with hyponatremia within 8-60 days of antidepressant initiation. Poisson regression models compared individuals who had versus did not have their serum electrolytes tested in the week following SSRI/SNRI initiation, weighting by propensity score-based overlap weights., Results: Among the 420,085 patients aged ≥66 years initiating treatment with an SSRI/SNRI, 26,808 (6.4%) had serum electrolytes measured in the subsequent 7 days and 6109 (1.5%) subsequently presented to hospital with hyponatremia. The time from drug initiation to hospitalization varied (median 29, interquartile range [IQR] 17-44 days), and the median sodium concentration measured in the community (136, IQR 133-138 mmol/L) was marginally higher than those at the time of hospitalization (132, IQR 130-134 mmol/L). Patients who underwent electrolyte testing in the week following SSRI/SNRI treatment were more likely to attend an emergency department (ED) or hospital with hyponatremia within 8-60 days relative to those who did not (relative risk = 2.31, 95% confidence interval: 2.16-2.46)., Conclusions: Testing serum electrolytes in the week after starting an SSRI/SNRI is not associated with a reduced risk of a hospital visit with hyponatremia. These findings do not support current guidelines recommending routine electrolyte monitoring., (© 2024 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Immigrants and refugees face unique challenges navigating the health care system to manage severe arthritis, because of unfamiliarity, lack of awareness of surgical options, or access. The purpose of this study was to assess total knee arthroplasty (TKA) uptake, surgical outcomes, and hospital utilization among immigrants and refugees compared with Canadian-born patients., Methods: We included all adults undergoing primary TKA from January 2011 to December 2020 in Ontario. Cohorts were defined as Canadian-born or immigrants and refugees. We assessed change in yearly TKA utilization for trend. We compared differences in 1-year revision, infection rates, 30-day venous thromboembolism (VTE), presentation to emergency department, and hospital readmission between matched Canadian-born and immigrant and refugee groups., Results: We included 158 031 TKA procedures. A total of 11 973 (7.6%) patients were in the immigrant and refugee group, and 146 058 (92.4%) patients were in the Canadian-born group. The proportion of TKAs in Ontario performed among immigrants and refugees nearly doubled over the 10-year study period ( p < 0.001). After matching, immigrants were at relatively lower risk of 1-year revision (0.9% v. 1.6%, p < 0.001), infection ( p < 0.001), death ( p = 0.004), and surgical complications ( p < 0.001). No differences were observed in rates of 30-day VTE or length of hospital stay. Immigrants were more likely to be discharged to rehabilitation ( p < 0.001) and less likely to present to the emergency department ( p < 0.001) than Canadian-born patients., Conclusion: Compared with Canadian-born patients, immigrants and refugees have favourable surgical outcomes and similar rates of resource utilization after TKA. We observed an underutilization of these procedures in Ontario relative to their proportion of the population. This may reflect differences in perceptions of chronic pain or barriers accessing arthroplasty., Competing Interests: Competing interests:: J. Michael Paterson reports research funding from Arthritis Society Canada and the Canadian Institutes of Health Research. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: The drug toxicity crisis continues to accelerate across Canada, with rapid increases in opioid-related harms following the onset of the COVID-19 pandemic. We sought to describe trends in the burden of opioid-related deaths across Canada throughout the pandemic, comparing these trends by province or territory, age, and sex., Methods: We conducted a repeated cross-sectional analysis of accidental opioid-related deaths between Jan. 1, 2019, and Dec. 31, 2021, across 9 Canadian provinces and territories using aggregated national data. Our primary measure was the burden of premature opioid-related death, measured by potential years of life lost. Our secondary measure was the proportion of all deaths attributable to opioids; we used the Cochrane-Armitage test for trend to compare proportions., Results: Between 2019 and 2021, the annual number of opioid-related deaths increased from 3007 to 6222 and years of life lost increased from 126 115 to 256 336 (from 3.5 to 7.0 yr of life lost per 1000 population). In 2021, the highest number of years of life lost was among males (181 525 yr) and people aged 30-39 years (87 045 yr). In 2019, we found that 1.7% of all deaths among those younger than 85 years were related to opioids, rising to 3.2% in 2021. Significant increases in the proportion of deaths related to opioids were observed across all age groups ( p < 0.001), representing 29.3% and 29.0% of deaths among people aged 20-29 and 30-39 years in 2021, respectively., Interpretation: Across Canada, the burden of premature opioid-related deaths doubled between 2019 and 2021, representing more than one-quarter of deaths among younger adults. The disproportionate loss of life in this demographic group highlights the critical need for targeted prevention efforts., Competing Interests: Competing interests:: David Juurlink is a member of Physicians for Responsible Opioid Prescribing and the American College of Medical Toxicology. Both groups have publicly available positions on this issue. He has also received payment from law firms for lectures and medicolegal opinions regarding the safety and effectiveness of analgesics, including opioids. Mina Tadrous reports consulting fees from Health Canada and the Canadian Agency for Drugs and Technologies in Health (CADTH). Tara Gomes reports funding from the Ontario College of Pharmacists and CADTH, consulting fees from the Province of British Columbia, honoraria from Indigenous Services Canada, and payment for expert testimony from the Office of the Chief Coroner of Ontario. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Purpose: The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients., Methods: Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID., Results: A total of 102,743 patients were included-42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease., Conclusion: The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)