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PURPOSE Continuity of care is broadly associated with better patient health outcomes. The relative contributions of continuity with an individual physician and with a practice, however, have not generally been distinguished. This retrospective observational study examined the impact of continuity of care for patients seen at their main clinic but by different family physicians. METHODS We analyzed linked health administrative data from 2015-2018 from Alberta, Canada to explore the association of physician and clinic continuity with rates of emergency department (ED) visits and hospitalizations across varying levels of patient complexity. Physician continuity was calculated using the known provider of care index and clinic continuity with an analogous measure. We developed zero-inflated negative binomial models to assess the association of each with all-cause ED visits and hospitalizations. RESULTS High physician continuity was associated with lower ED use across all levels of patient complexity and with fewer hospitalizations for highly complex patients. Broadly, no (0%) clinic continuity was associated with increased use and complete (100%) clinic continuity with decreased use, with the largest effect seen for the most complex patients. Levels of clinic continuity between 1% and 50% were generally associated with slightly higher use, and levels of 51% to 99% with slightly lower use. CONCLUSIONS The best health care outcomes (measured by ED visits and hospitalizations) are associated with consistently seeing one's own primary family physician or seeing a clinic partner when that physician is unavailable. The effect of partial clinic continuity appears complex and requires additional research. These results provide some reassurance for part-time and shared practices, and guidance for primary care workforce policy makers. https://doi.org/10.1370/afm.3107, INTRODUCTION The ideal provision of primary care is based on a longitudinal relationship between a patient and a family physician (FP), referred to as relational continuity. (1) Research has shown [...]

Rationale: Existing work suggests that patients with chronic obstructive pulmonary disease (pwCOPD) presented less frequently to the emergency department and were less likely to be hospitalized during the coronavirus disease (COVID-19) pandemic, but it is unclear if this was due to improved health and disease management or to increased barriers and/or avoidance of health care. Objectives: The objective of this study was to determine the impact of the pandemic on inpatient and outpatient healthcare use, disease incidence, and mortality rates in pwCOPD. Methods: A retrospective population-based analysis using linked administrative datasets from Alberta, Canada 18 months before and after March 12, 2020 was conducted to measure hospitalization, emergency department and outpatient visits, and COPD outpatient exacerbations during these time periods. Mortality data were also analyzed before versus after the pandemic, taking confirmed COVID-19 infection within 30 days into account. Subgroup analysis based on COPD exacerbation risk stratification was undertaken to determine if healthcare use differed based on exacerbation risk. Finally, sex-based analysis of healthcare use during the pandemic was also completed. Results: Hospitalization or emergency department visits and outpatient treatment for acute exacerbations of COPD dropped, whereas total outpatient COPD visits, including both virtual and in person, increased during the pandemic for pwCOPD. The mortality rate increased even after adjusting for COVID-19–associated deaths. Sex-based subgroup analysis showed a greater drop in acute care use for females, but the rise in mortality was seen for both sexes, with men experiencing a greater rate of mortality than women. Conclusions: Overall, pwCOPD accessed acute care resources less during the pandemic, which may have contributed to a rise in non–COVID-19 all-cause mortality. [ABSTRACT FROM AUTHOR]

Gender-affirming estrogen therapy (GAET) is commonly used for feminization in transgender and nonbinary (TNB) individuals, yet the optimal rate of change (ROC) in estradiol levels for cardiovascular health is unclear. We examined the association between serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were systematically searched (inception–April 2023) for original articles reporting serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Data extraction was completed in duplicate following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Stratified random effect meta-analyses using serum estradiol ROC (serum estradiolbaseline − serum estradiolfollow-up/study duration) was used to assess longitudinal studies (low, 0 < ROC ≤ 1 pg/mL/mo; moderate, 1 < ROC ≤ 3 pg/mL/mo; high, ROC ≥ 3 pg/mL/mo). Thirty-five studies (13 cross-sectional, 19 cohort, and 3 trials) were included. Two studies collectively reported 50 cardiovascular-related deaths, and four collectively reported 23 adverse cardiovascular events. Nineteen studies reporting cardiovascular risk factors were meta-analyzed by ROC stratum (low = 5; moderate = 6; high = 8), demonstrating an association between moderate [0.40, 95% confidence interval (CI): 0.22, 0.59 kg/m2, I2 = 28.2%] and high (0.46, 95% CI: 0.15, 0.78 kg/m2; I2 = 0.0%) serum estradiol ROC and increased body mass index. High (−6.67, 95% CI: −10.65, −2.68 mg/dL; I2 = 0.0%) serum estradiol ROC was associated with decreased low-density lipoproteins. Low (−7.05, 95% CI: −10.40, −3.70 mmHg; I2 = 0.0%) and moderate (−3.69, 95% CI: −4.93, −2.45 mmHg; I2 = 0.0%) serum estradiol ROCs were associated with decreases in systolic blood pressure. In TNB adults using GAET, serum estradiol ROC may influence cardiovascular risk factors, which may have implications for clinical cardiovascular outcomes. NEW & NOTEWORTHY: In this systematic review and meta-analysis of 35 studies involving 7,745 participants, high rates of serum estradiol change were associated with small increases in body mass index. Moderate to high rates of change were associated with decreases in low-density lipoprotein. Low rates of change were associated with small decreases in systolic blood pressure. Rate of serum estradiol change in adults using gender-affirming estrogen therapy may influence cardiovascular risk factors, though further research is warranted. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/serum-estradiol-and-cardiovascular-health-among-transgender-and-nonbinary-adults-using-gender-affirming-estrogen-therapy/. [ABSTRACT FROM AUTHOR]

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis. La medecine perioperatoire evolue rapidement, ce qui est propice a l'amelioration des modeles de soins actuels et a leur integration au systeme de sante. Les modeles de soins perioperatoires sont des approches structurees ou conceptuelles a l'intention des patients de chirurgie avant, durant et apres leur intervention. Les modeles de soins perioperatoires, tels que les approches PSH (Perioperative Surgical Home) et ERAS (Enhanced Recovery After Surgery) sont de plus en plus utilises pour orienter la structure et la prestation des soins perioperatoires dans le but d'ameliorer les resultats et l'experience des patients dans les milieux de soins au Canada. Dans la presente syn-these narrative, nous retracons l'origine de ces modeles de soins perioperatoires. Ils sont fondamentalement differents aux plans de leur portee et de leur niveau de preuves. Mais leur deploiement a grande echelle dans nos systemes de sante comporte des avantages et des inconvenients potentiels. Dans l'etat actuel de leur developpe-ment, les 2 modeles ont une applicabilite limitee pour les patients atteints de maladies chroniques. Nous discutons de la facon dont ils peuvent etre utilises pour developper des approches horizontales et verticales integrees au contexte canadien. Cette integration est une solution envisageable qui ameliorera leur application aux patients atteints de maladies complexes, a une epoque ou les systemes de sante sont sous pression. Nous decrivons cette approche en prenant l'exemple des insuffisants renaux dialyses., Although the field of perioperative medicine is growing and evolving, a widely accepted current definition is the 'integrated, multi-disciplinary medical care of patients from the moment of contemplation of surgery [...]

IntroductionEffective chronic disease care is dependent on well-organised quality improvement (QI) strategies that monitor processes of care and outcomes for optimal care delivery. Although healthcare is provincially/territorially structured in Canada, there are national networks such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) as important facilitators for national QI-based studies to improve chronic disease care. The goal of our study is to improve the understanding of how patients with chronic kidney disease (CKD) are managed in primary care and the variation across practices and provinces and territories to drive improvements in care delivery.Methods and analysisThe CPCSSN database contains anonymised health information from the electronic medical records for patients of participating primary care practices (PCPs) across Canada (n=1200). The dataset includes information on patient sociodemographics, medications, laboratory results and comorbidities. Leveraging validated algorithms, case definitions and guidelines will help define CKD and the related processes of care, and these enable us to: (1) determine prevalent CKD burden; (2) ascertain the current practice pattern on risk identification and management of CKD and (3) study variation in care indicators (eg, achievement of blood pressure and proteinuria targets) and referral pattern for specialist kidney care. The process of care outcomes will be stratified across patients' demographics as well as provider and regional (provincial/territorial) characteristics. The prevalence of CKD stages 3-5 will be presented as age-sex standardised prevalence estimates stratified by province and as weighted averages for population rates with 95% CIs using census data. For each PCP, age-sex standardised prevalence will be calculated and compared with expected standardised prevalence estimates. The process-based outcomes will be defined using established methods.Ethics and disseminationThe CPCSSN is committed to high ethical standards when dealing with individual data collected, and this work is reviewed and approved by the Network Scientific Committee. The results will be published in peer-reviewed journals and presented at relevant national and international scientific meetings.

Objective: The objective of this study was to explore the longitudinal relationship between anxiety and depressive symptoms and migraine outcomes in children and adolescents. Background: Children and adolescents with migraine experience more anxiety and depressive symptoms than their peers without migraine, but it is unknown if these symptoms are associated with differential migraine outcomes. Methods: In this prospective clinical cohort study, children and adolescents aged 8.0–18.0 years with migraine completed headache questionnaires and validated measures of anxiety and depressive symptoms (Patient‐Reported Outcomes Measurement Information System) at an initial consultation and at their first follow‐up visit with a neurologist. Changes in monthly headache frequency and changes in migraine‐related disability (Pediatric Migraine Disability Assessment) were tracked at each time point. The relationships between these migraine outcomes and anxiety and depressive symptoms were estimated using models controlling for sex, age, headache frequency, and treatment type. Results: There were 123 consenting participants. In models adjusted for age, sex, baseline disability score, and treatment type, baseline anxiety and depressive symptom levels were not significantly associated with change in headache frequency (for anxiety symptoms: β = −0.05, 95% confidence interval [CI] = −0.268 to 0.166, p = 0.639; for depressive symptoms: β = 0.14, 95% CI = −0.079 to 0.359, p = 0.209). Similarly, in models adjusted for age, sex, baseline headache frequency, and treatment type, the change in disability was not associated with baseline anxiety (β = −0.45, 95% CI = −1.69 to 0.78, p = 0.470), nor with baseline depressive symptom scores (β = 0.16, 95% CI = −1.07 to 1.40, p = 0.796). In post hoc exploratory analyses (N = 84 with anxiety and N = 82 with depressive symptom data at both visits), there were also no significant associations between change in mental health symptoms and change in headache frequency (for anxiety symptoms: β = −0.084, 95% CI = −0.246 to 0.078, p = 0.306; for depressive symptoms: β = −0.013, 95% CI = −0.164 to 0.138, p = 0.865). Similarly, the change in disability scores between visits was not related to the change in anxiety (β = 0.85, 95% CI = −0.095 to 1.78, p = 0.077) nor depressive symptom scores (β = 0.32, 95% CI = −0.51 to 1.15, p = 0.446). Conclusion: Baseline anxiety and depressive symptom levels were not associated with longitudinal migraine outcomes and neither were longitudinal changes in anxiety and depressive symptom levels; this contradicts popular clinical belief that mental health symptoms predict or consistently change in tandem with migraine outcomes. Plain Language Summary: Youth with migraine are at a higher risk of having anxiety and depression compared to their peers, but it is not known if anxiety and depressive symptoms impact how migraine disease changes over time. We examined whether the level of anxiety and depressive symptoms in 123 youth with migraine was linked with how their migraine attack frequency and migraine‐related disability changed between first and second visits with a neurologist. Anxiety and depressive symptoms did not predict how youths' migraine disease changed between visits. [ABSTRACT FROM AUTHOR]

Context: Primary aldosteronism (PA) is one of the most common causes of secondary hypertension, but the comparative outcomes of targeted treatment remain unclear. Objective: To compare the clinical outcomes in patients treated for primary aldosteronism over time. Methods: Medline and EMBASE were searched. Original studies reporting the incidence of mortality, major adverse cardiovascular outcomes (MACE), progression to chronic kidney disease, or diabetes following adrenalectomy vs medical therapy were selected. Two reviewers independently abstracted data and assessed study quality. Standard meta-analyses were conducted using random-effects models to estimate relative differences. Time to benefit meta-analyses were conducted by fitting Weibull survival curves to estimate absolute risk differences and pooled using random-effects models. Results: 15 541 patients (16 studies) with PA were included. Surgery was consistently associated with an overall lower risk of death (hazard ratio [HR] 0.34, 95% CI 0.22-0.54) and MACE (HR 0.55, 95% CI 0.36-0.84) compared with medical therapy. Surgery was associated with a significantly lower risk of hospitalization for heart failure (HR 0.48 95% CI 0.34-0.70) and progression to chronic kidney disease (HR 0.62 95% CI 0.39-0.98), and nonsignificant reductions in myocardial infarction and stroke. In absolute terms, 200 patients would need to be treated with surgery instead of medical therapy to prevent 1 death after 12.3 (95% CI 3.1-48.7) months. Conclusion: Surgery is associated with lower all-cause mortality and MACE than medical therapy for PA. For most patients, the long-term surgical benefits outweigh the short-term perioperative risks. [ABSTRACT FROM AUTHOR]

Background There are no consensus definitions for evaluating kidney function recovery after acute kidney injury (AKI) and acute kidney disease (AKD), nor is it clear how recovery varies across populations and clinical subsets. We present a federated analysis of four population-based cohorts from Canada, Denmark and Scotland, 2011–18. Methods We identified incident AKD defined by serum creatinine changes within 48 h, 7 days and 90 days based on KDIGO AKI and AKD criteria. Separately, we applied changes up to 365 days to address widely used e-alert implementations that extend beyond the KDIGO AKI and AKD timeframes. Kidney recovery was based on resolution of AKD and a subsequent creatinine measurement below 1.2× baseline. We evaluated transitions between non-recovery, recovery and death up to 1 year; within age, sex and comorbidity subgroups; between subset AKD definitions; and across cohorts. Results There were 464 868 incident cases, median age 67–75 years. At 1 year, results were consistent across cohorts, with pooled mortalities for creatinine changes within 48 h, 7 days, 90 days and 365 days (and 95% confidence interval) of 40% (34%–45%), 40% (34%–46%), 37% (31%–42%) and 22% (16%–29%) respectively, and non-recovery of kidney function of 19% (15%–23%), 30% (24%–35%), 25% (21%–29%) and 37% (30%–43%), respectively. Recovery by 14 and 90 days was frequently not sustained at 1 year. Older males and those with heart failure or cancer were more likely to die than to experience sustained non-recovery, whereas the converse was true for younger females and those with diabetes. Conclusion Consistently across multiple cohorts, based on 1-year mortality and non-recovery, KDIGO AKD (up to 90 days) is at least prognostically similar to KDIGO AKI (7 days), and covers more people. Outcomes associated with AKD vary by age, sex and comorbidities such that older males are more likely to die, and younger females are less likely to recover. [ABSTRACT FROM AUTHOR]