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Mihan A, Muldoon L, Leider H, Tehfe H, Fitzgerald M, Fournier K, Kendall CE. Social accountability in undergraduate medical education: A narrative review. EDUCATION FOR HEALTH (ABINGDON, ENGLAND) 2022; 35:3-8. [PMID: 36367022 DOI: 10.4103/efh.efh_305_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medical schools have been increasingly called upon to augment and prioritize their social accountability (SA). Approaches to increasing SA may include reorienting and focusing curricular activities on the priority health needs of the region that they serve. To inform the undergraduate medical education (UGME) curriculum renewal at our school, we examined how SA has been expressed in medical education across several countries and the impacts of SA activities on medical student experience and community-level outcomes. METHODS We conducted a narrative literature review using two electronic databases and searched for studies that reported on SA UGME activities implemented in Canada, Australia, New Zealand, the United States, and the United Kingdom. Studies were screened for inclusion based on predetermined eligibility criteria. RESULTS We included 40 studies for descriptive analysis and categorized UGME activities into five categories: (1) distributed medical education and community-specific placements/services (32; 80%), (2) community engagement and advocacy activities (23; 58%), (3) international elective preparation and experiences (8; 20%), (4) classroom-based learning of SA-related concepts (17; 43%), and (5) student engagement in SA UGME activities (6; 15%). We categorized impact into four main outcomes: student experience (21; 53%), student competencies (11; 28%), future career choice/practice setting (15; 38%), and community feedback (7; 18%). Student experience was most frequently examined, followed by future career choice/practice setting. DISCUSSION SA was primarily expressed in UGME activities through placement/service activities and most frequently assessed through student experiences. Student experiences of SA UGME activities have been reported to be largely positive, with benefits also reported for student competencies and influences on future career choice/practice setting. The expression of SA through community engagement in the development of curricular activities indicates a positive shift from social responsibility to SA, but a highly socially accountable curriculum would increasingly consider measures of community impact.
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Shoemaker ES, Saiyin T, Smith S, Loutfy M, Darling L, Walker M, Hawken S, Begum J, Bibeau C, Bertozzi B, Fraleigh A, Kwaramba G, Johnson K, Cousineau A, Kendall CE. Patterns of cesarean birth among women living with HIV in Ontario: A cross-sectional, population-level study. Birth 2021; 48:357-365. [PMID: 33733473 DOI: 10.1111/birt.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/10/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In Canada, as is found globally, women of reproductive age are a growing demographic of persons living with HIV. Combination antiretroviral therapy (cART) treatment enables women living with HIV (WLWH) to become pregnant without perinatal transmission, and they are increasingly planning to become pregnant. Since 2014, Canadian guidelines no longer recommend routine elective cesarean birth (CB) for women who are virally suppressed and receiving cART. It is unknown whether their obstetric care has changed since this update. Our objective was to describe trends in cesarean births among WLWH in Ontario, Canada, over a 12-year period. METHODS Our research is co-led and codesigned with WLWH. We conducted a retrospective population-level cohort study using linked health administrative databases at ICES (formally, the Institute for Clinical and Evaluative Sciences). Participants were all women who gave birth in Ontario, between 2006/07 and 2017/18. We assessed their intrapartum characteristics and used multivariable regression to determine an association between HIV status and CB, controlling for sociodemographic and clinical variables. RESULTS Since 2014, the overall proportion of CB among WLWH remained stable and was higher than among women without HIV (39.9% vs 29.0%, P < 0.001). In addition, the proportion of primary CB decreased between 2006 and 2010 and between 2014 and 2018 (28.5%-19.3%), whereas the proportion of repeat CB increased (13.1%-20.5%, P = 0.013). CONCLUSIONS Because of decreasing HIV-related indications for CB, more practitioners may be following the guidelines for first-time mothers. Currently, no guidelines exist for care of WLWH with a previous CB, and opportunities for vaginal birth may be missed in this population.
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Rowlands Snyder EC, Boucher LM, Bayoumi AM, Martin A, Marshall Z, Boyd R, LeBlanc S, Tyndall M, Kendall CE. A cross-sectional study of factors associated with unstable housing among marginalized people who use drugs in Ottawa, Canada. PLoS One 2021; 16:e0253923. [PMID: 34197552 PMCID: PMC8248707 DOI: 10.1371/journal.pone.0253923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Housing affects an individual’s physical and mental health, particularly among people who use substances. Understanding the association between individual characteristics and housing status can inform housing policy and help optimize the care of people who use drugs. The objective of this study was to explore the factors associated with unstable housing among people who use drugs in Ottawa. Methods This is a cross-sectional analysis of data from 782 participants in the Participatory Research in Ottawa: Understanding Drugs (PROUD) Study. PROUD is a prospective cohort study of people who use drugs in Ottawa. Between March and December 2013, participants were recruited through peer-based recruitment on the streets and in social services settings and completed a peer-administered questionnaire that explored socio-demographic information, drug use patterns, community integration, experiences with police and incarceration, and access to health care and harm reduction services. Eligibility criteria included age of 16 years or older, self-reported illicit drug use within the past 12 months and having lived in Ottawa for at least 3 months. Housing status was determined by self-report. “Stable housing” was defined as residence in a house or apartment and “unstable housing” was defined as all other residence types. Exploratory multivariable logistic regression analyses of the association between characteristics of people who use drugs and their housing status were conducted. Results Factors that were associated with unstable housing included: recent incarceration; not having a regular doctor; not having received support from a peer worker; low monthly income; income source other than public disability support payments; and younger age. Gender, language, ethnicity, education level, opioid use and injection drug use were not independently associated with housing status. Conclusions People who use drugs face significant barriers to stable housing. These results highlight key areas to address in order to improve housing stability among this community.
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Zygmunt A, Kendall CE, James P, Lima I, Tuna M, Tanuseputro P. Avoidable Mortality Rates Decrease but Inequity Gaps Widen for Marginalized Neighborhoods: A Population-Based Analysis in Ontario, Canada from 1993 to 2014. J Community Health 2021; 45:579-597. [PMID: 31722048 DOI: 10.1007/s10900-019-00778-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Avoidable mortality (AM) is a health indicator used to examine trends in avoidable deaths amenable to public health and medical interventions. AM is more likely amongst marginalized populations. Our objective was to examine trends in AM rates by level of neighborhood marginalization. Decedents under age 75 years in Ontario from 1993 to 2014 (n = 691,453) were assigned to a quintile-level of each Ontario Marginalization (ON-Marg) Index dimension: material deprivation, residential instability, dependency, and ethnic concentration. We calculated ON-Marg Index dimension and quintile specific age- and sex-standardized AM incidence rates. We then calculated annual AM rate ratios between the most (Q5) and least (Q1) marginalized quintiles for each ON-Marg dimension. To describe the inequity gap in AM over time we calculated the absolute difference in the Q5/Q1 rate ratio between 2014 and 1993 for each dimension. AM rates in Ontario were almost halved (48.6%) from 1993 to 2014 (216 vs. 111 per 100,000 population). This decline was greater for treatable AM (75 vs. 36 per 100,000 population) than preventable AM (128 vs. 88 per 100,000 population). The inequity gap in AM Q5/Q1 rate ratios (RR) between 1993 and 2014 widened for all marginalization dimensions: dependency (RR 2.11-2.58), ethnic concentration (RR 0.59-0.48), material deprivation (RR 1.63-2.23), and residential instability (RR 2.01-2.43). To attain further declines in AM, policymakers and governments must address AM due to preventable deaths in neighborhoods highly marginalized by dependency, material deprivation, and residential instability.
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Kendzerska T, Zhu DT, Gershon AS, Edwards JD, Peixoto C, Robillard R, Kendall CE. The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review. Risk Manag Healthc Policy 2021; 14:575-584. [PMID: 33623448 PMCID: PMC7894869 DOI: 10.2147/rmhp.s293471] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions. METHODS A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021. FINDINGS During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed. INTERPRETATION Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Lignes directrices de pratique clinique pour les personnes sans-abri, logées précairement, ou ayant connu l’itinérance. CMAJ 2020; 192:E1225-E1241. [PMID: 33051325 PMCID: PMC7588247 DOI: 10.1503/cmaj.190777-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Kendall CE, Boucher LM, Donelle J, Martin A, Marshall Z, Boyd R, Oickle P, Diliso N, Pineau D, Renaud B, LeBlanc S, Tyndall M, Bayoumi AM. Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada. BMC Health Serv Res 2020; 20:837. [PMID: 32894114 PMCID: PMC7487534 DOI: 10.1186/s12913-020-05670-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD. METHODS The Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March-December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care. RESULTS Characteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0-10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)). CONCLUSIONS Despite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.
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Andermann A, Bloch G, Goel R, Brcic V, Salvalaggio G, Twan S, Kendall CE, Ponka D, Pottie K. Caring for patients with lived experience of homelessness. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:563-570. [PMID: 32817028 PMCID: PMC7430777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. SOURCES OF INFORMATION The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient's Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. MAIN MESSAGE Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. CONCLUSION Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.
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Andermann A, Bloch G, Goel R, Brcic V, Salvalaggio G, Twan S, Kendall CE, Ponka D, Pottie K. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:e204-e212. [PMID: 32817047 PMCID: PMC7430794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Objectif Guider les médecins de famille de divers types de pratique familiale quant à la façon de dispenser des soins et du soutien aux patients logés précairement ou qui vivent l’itinérance. Sources d’information L’approche intègre les recommandations tirées des lignes directrices cliniques fondées sur les données probantes, l’opinion des personnes avec une expérience vécue de l’itinérance, les principes théoriques du cadre de travail du Centre de médecine de famille et des leçons pratiques provenant de médecins de famille qui travaillent dans des contextes cliniques variés. Message principal Les médecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinérants ou logés précairement; franchir les premières étapes pour faciliter l’accès au logement, à l’aide financière, à la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel à des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les médecins de famille ont un solide pouvoir de plaidoyer et peuvent s’associer aux organisations communautaires locales et aux personnes ayant vécu l’itinérance pour revendiquer des réformes politiques qui tiennent compte des iniquités sociales. Conclusion Les médecins de famille ont la capacité de répondre directement aux besoins sociaux et aux besoins en matière de santé physique et de santé mentale des patients itinérants ou logés précairement. En outre, ils peuvent promouvoir les programmes d’approche et d’intégration qui aident les personnes avec une expérience vécue de l’itinérance à accéder aux centres de médecine de famille et peuvent militer pour l’adoption de mesures générales visant à contrer les causes structurelles sous-jacentes de l’itinérance.
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Mandel E, E Kendall C, Mason K, Guyton M, Lettner B, Broad J, Altenberg J, Donelle J, Powis J. Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto. CANADIAN LIVER JOURNAL 2020. [DOI: 10.3138/canlivj-2019-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: The majority of new hepatitis C (HCV) cases occur among people who inject drugs. In recent years, multidisciplinary models of HCV treatment have emerged that demonstrate successful treatment outcomes for this population, as well as broad positive individual- and system-level impacts. Our objective was to evaluate changes in health care use among a cohort of people living with HCV before and after engagement with one such program. Methods: Program data were uniquely linked to provincial health administrative databases. Rates of emergency department (ED) visits and hospital admissions of clients from 2011 through 2015 ( N = 103) were evaluated using linkages with administrative data for the 2 years before and after program initiation. Data were evaluated using negative binomial regression models with a covariance structure to account for within-individual correlations. Results: Of participants, 72.8% were men (mean age 47 years), and 38% experienced high rates of physical and mental health comorbidity (Aggregated Diagnosis Group score ≥10). Female clients had significantly fewer ED visits 2 years after program initiation (5.04 versus 3.12; risk ratio [RR] 0.61 [95% CI 0.44% to 0.86%]). ED visits for infectious diseases and soft tissue injury were significantly lower for the cohort overall (RRs 0.58 0.51 [95% CIs 0.35% to 0.95% and 0.29% to 0.90%], respectively). Conclusion: Co-locating HCV treatment within comprehensive primary care and harm reduction services appears to have benefits beyond HCV, including a reduction in ED visits among women and a decrease in ED visits for soft tissue infections for all participants.
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Mandel E, E Kendall C, Mason K, Guyton M, Lettner B, Broad J, Altenberg J, Donelle J, Powis J. Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto. CANADIAN LIVER JOURNAL 2020; 3:203-211. [DOI: 10.3138/canlivj.2019-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/14/2019] [Indexed: 11/20/2022]
Abstract
Background: The majority of new hepatitis C (HCV) cases occur among people who inject drugs. In recent years, multidisciplinary models of HCV treatment have emerged that demonstrate successful treatment outcomes for this population, as well as broad positive individual- and system-level impacts. Our objective was to evaluate changes in health care use among a cohort of people living with HCV before and after engagement with one such program. Methods: Program data were uniquely linked to provincial health administrative databases. Rates of emergency department (ED) visits and hospital admissions of clients from 2011 through 2015 ( N = 103) were evaluated using linkages with administrative data for the 2 years before and after program initiation. Data were evaluated using negative binomial regression models with a covariance structure to account for within-individual correlations. Results: Of participants, 72.8% were men (mean age 47 years), and 38% experienced high rates of physical and mental health comorbidity (Aggregated Diagnosis Group score ≥10). Female clients had significantly fewer ED visits 2 years after program initiation (5.04 versus 3.12; risk ratio [RR] 0.61 [95% CI 0.44% to 0.86%]). ED visits for infectious diseases and soft tissue injury were significantly lower for the cohort overall (RRs 0.58 0.51 [95% CIs 0.35% to 0.95% and 0.29% to 0.90%], respectively). Conclusion: Co-locating HCV treatment within comprehensive primary care and harm reduction services appears to have benefits beyond HCV, including a reduction in ED visits among women and a decrease in ED visits for soft tissue infections for all participants.
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Kendall CE, Fitzgerald M, Donelle J, Kwong JC, Galanakis C, Boyd R, Cooper CL. A cross-sectional study of prolonged disengagement from clinic among people with HCV receiving care in a low-threshold, multidisciplinary clinic. CANADIAN LIVER JOURNAL 2020; 3:212-223. [DOI: 10.3138/canlivj.2019-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/22/2019] [Indexed: 11/20/2022]
Abstract
Background: Disengagement from care can affect treatment outcomes of patients with hepatitis C virus (HCV). We assessed the extent and determinants of disengagement among HCV patients receiving care at the Ottawa Hospital Viral Hepatitis Program (TOHVHP). Methods: We linked clinical data of adult patients, categorized as ever or never disengaged from clinic (no TOHVHP encounters over 18 months), receiving care between April 1, 2002, and October 1, 2015, to provincial health administrative databases and calculated primary care use in the year after disengagement. We used adjusted Cox proportional hazards models to analyze variables associated with disengagement. Results: Those disengaged from care ( n = 657) were younger at presentation (46.6 [SD 11.1] versus 51.9 [SD 11.0] years), p < 0.001) and had lower comorbidity. After multivariable adjustment, we observed lower hazards of disengagement among those with higher compared with lower fibrosis scores (F3, hazard ratio [HR] 0.21 [95% CI 0.08–0.57]; F4, HR 0.32 [95% CI 0.19–0.55]) and those treated compared with never treated (received direct-acting antivirals [DAAs], HR 0.71 [95% CI 0.58–0.88]; received interferon but not DAA, HR 0.66 [95% CI 0.55–0.80]). We found no association with mental health or substance use disorders. In the year after disengagement, 74.3% ( n = 488), 37.1% ( n = 244), and 17.7% ( n = 116) had at least one family physician visit, emergency department visit, and hospitalization, respectively. Conclusions: Better integration of HCV specialty and primary care could improve disengagement rates among people with HCV.
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Shoemaker ES, Kendall CE, Mathew C, Crispo S, Welch V, Andermann A, Mott S, Lalonde C, Bloch G, Mayhew A, Aubry T, Tugwell P, Stergiopoulos V, Pottie K. Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: A Delphi consensus study. PLoS One 2020; 15:e0231758. [PMID: 32298388 PMCID: PMC7162520 DOI: 10.1371/journal.pone.0231758] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 04/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. Methods We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys. Findings Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. Interpretation The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. CMAJ 2020; 192:E240-E254. [PMID: 32152052 PMCID: PMC7062440 DOI: 10.1503/cmaj.190777] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Zygmunt A, Tanuseputro P, James P, Lima I, Tuna M, Kendall CE. Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study. Canadian Journal of Public Health 2019; 111:169-181. [PMID: 31828730 DOI: 10.17269/s41997-019-00270-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the impact of neighbourhood marginalization on avoidable mortality (AM) from preventable and treatable causes of death. METHODS All premature deaths between 1993 and 2014 (N = 691,453) in Ontario, Canada, were assigned to quintiles of neighbourhood marginalization using the four dimensions of the Ontario Marginalization Index: dependency, ethnic concentration, material deprivation, and residential instability. We conducted two multivariate logistic regressions to examine the association between neighbourhood marginalization, first with AM compared with non-AM as the outcome, and second with AM from preventable causes compared with treatable causes as the outcome. All models were adjusted for decedent age, sex, urban/rural location, and level of comorbidity. RESULTS A total of 463,015 deaths were classified as AM and 228,438 deaths were classified as non-AM. Persons living in the most materially deprived (OR, 1.24; 95% CI, 1.22 to 1.27) and residentially unstable neighbourhoods (OR, 1.13; 95% CI, 1.11 to 1.15) had greater odds of AM, particularly from preventable causes. Those living in the most dependent (OR, 0.91; 95% CI, 0.89 to 0.93) and ethnically concentrated neighbourhoods (OR, 0.93; 95% CI, 0.91 to 0.93) had lower odds of AM, although when AM occurred, it was more likely to arise from treatable causes. CONCLUSION Different marginalization dimensions have unique associations with AM. By identifying how different aspects of neighbourhood marginalization influence AM, these results may have important implications for future public health efforts to reduce inequities in avoidable deaths.
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Cooper CL, Galanakis C, Donelle J, Kwong JC, Boyd R, Boucher L, Kendall CE. Correction to: HCV-infected individuals have higher prevalence of comorbidity and multimorbidity: a retrospective cohort study. BMC Infect Dis 2019; 19:889. [PMID: 31651290 PMCID: PMC6813993 DOI: 10.1186/s12879-019-4579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
After publication of the original article [1], we were notified that an author's name has been incorrectly spelled. Jeff Kwong's full name is Jeffery C. Kwong.
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Kendall CE, Porter JE, Shoemaker ES, Seoyeon Kang R, Fitzgerald M, Keely E, Afkham A, Crowe L, MacPherson P, Rosenes R, Lundrigan P, Bibeau C, Liddy C. Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service. MDM Policy Pract 2019; 4:2381468319868216. [PMID: 31453365 PMCID: PMC6699006 DOI: 10.1177/2381468319868216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 06/17/2019] [Indexed: 11/28/2022] Open
Abstract
Background. Electronic consultation (eConsultation) is a potential
strategy to improve access to specialist expertise and facilitate collaborative
care models. The Champlain BASE eConsult service allows for asynchronous
communication between primary care providers (PCP) and specialists on a secure,
web-based system. HIV experts accessible include HIV physician specialists, HIV
pharmacists, and social workers with expertise in HIV. Objective.
This study aims to describe the use, value, and utility of this eConsultation
service in the care of people living with HIV and to characterize the common
question types and clinical topics asked by PCPs. Methods. We
analyzed the data from eConsults sent to the HIV specialty group in Ontario’s
Champlain Local Health Integration Network between February 2015 and December
2017. Usage data and close-out survey responses were analyzed using descriptive
statistics, eConsults were classified using a predefined list of validated
taxonomy, and a thematic analysis was performed on the consultation logs to
identify common clinical themes. Results. Among the 46 eConsults,
the most common question type related to drug treatment (58.7%,
n = 27) and management (19.6%, n = 9). The
main clinical themes involved the care of significant complexities in people
living with HIV, such as comorbidities and drug interactions, and suggestions of
coordinated patient care. As well, eConsult was used for advice regarding
pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection.
PCPs highly valued the eConsult service (average rating 4.8/5).
Conclusion. Overall, this study demonstrates that eConsult
provides an efficient and valuable service to PCPs caring for patients living
with or at risk for HIV by improving access to HIV specialists and facilitating
the delivery of team-based comprehensive care.
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Shoemaker ES, Becker ML, Liddy CE, McClarty LM, Asghari S, Hurd J, Rourke SB, Shaw SY, Bibeau C, Rosenes R, Lundrigan P, Crowe L, Ireland L, Loeppky C, Kendall CE. Creating Clinical Cohorts: Challenges Encountered in Two Canadian Provinces. Healthc Policy 2019; 15:10-18. [PMID: 31629452 PMCID: PMC7008696 DOI: 10.12927/hcpol.2019.25942] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In 2013, the Living with HIV (LHIV) Innovation team established clinical cohorts of people living with HIV in Manitoba and Newfoundland and Labrador, and they linked the data to provincial health administrative databases. Access to these data enabled researchers to conduct studies across provincial borders; contribute to a national dialogue on HIV health system performance; and give recommendations for evidence-based healthcare, health policy and public health. However, research funding is episodic; maintaining cohorts requires stable funding. We support the establishment of a cross-jurisdictional approach to facilitate streamlined data collection and linkage without interruption and to allow for meaningful analysis in order to inform national policies.
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Boucher LM, O'Brien KK, Baxter LN, Fitzgerald ML, Liddy CE, Kendall CE. Healthy aging with HIV: The role of self-management support. PATIENT EDUCATION AND COUNSELING 2019; 102:1565-1569. [PMID: 30827568 DOI: 10.1016/j.pec.2019.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/19/2019] [Accepted: 02/19/2019] [Indexed: 06/09/2023]
Abstract
People living with HIV on antiretroviral treatment have significantly improved longevity, but as a result may also face increasing multimorbidity due to aging and long-term medication use. Thus, care needs for this population have evolved to require a chronic disease management approach in which self-management plays a central role. Here we highlight the importance of expanding self-management support options for people living with HIV, and discuss strategies for implementing and evaluating self-management interventions, outlining potential opportunities, challenges and solutions. We contend that standardized programs such as those offered through the Self-Management Resource Centre provide a rich opportunity to build the evidence base regarding the potential effectiveness of self-management support among people living with HIV. Thus we recommend enhancing self-management support through meaningful community-level collaboration with people with lived experience, careful assessment of process and outcome factors including who does not participate and why, attention to stigma and the specific needs of HIV priority groups, and consideration of how to extend engagement with services to address social and material needs beyond self-management program participation. We hope this reflection will serve as an aide for researchers and program managers to improve the array of evidence-based self-management support options available to people living with HIV.
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Liddy C, Moroz I, Keely E, Taljaard M, Deri Armstrong C, Afkham A, Kendall CE. Understanding the impact of a multispecialty electronic consultation service on family physician referral rates to specialists: a randomized controlled trial using health administrative data. Trials 2019; 20:348. [PMID: 31182123 PMCID: PMC6558850 DOI: 10.1186/s13063-019-3393-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 05/04/2019] [Indexed: 12/03/2022] Open
Abstract
Background Electronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult’s impact on family physicians’ referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care. Methods In this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data. Results One hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03). Conclusions Our randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials. Trial registration Clinicaltrials.gov, ID: NCT02053467. Registered prospectively on 3 February 2014.
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Masindi KI, Jembere N, Kendall CE, Burchell AN, Bayoumi AM, Loutfy M, Raboud J, Rourke SB, Luyombya H, Antoniou T. Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV. J Immigr Minor Health 2019; 20:536-545. [PMID: 29209931 DOI: 10.1007/s10903-017-0681-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.
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Boucher LM, Bayoumi AM, Mark AE, Cooper C, Martin A, Marshall Z, Boyd R, Oickle P, Diliso N, Pineau D, Renaud B, LeBlanc S, Tyndall M, Lee OM, Kendall CE. Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study. Subst Use Misuse 2019; 54:18-30. [PMID: 29932800 DOI: 10.1080/10826084.2018.1485699] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services. METHODS We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment. RESULTS Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.
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Burchell AN, Raboud J, Donelle J, Loutfy MR, Rourke SB, Rogers T, Rosenes R, Liddy C, Kendall CE. Cause-specific mortality among HIV-infected people in Ontario, 1995-2014: a population-based retrospective cohort study. CMAJ Open 2019; 7:E1-E7. [PMID: 30622108 PMCID: PMC6350837 DOI: 10.9778/cmajo.20180159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Risk factors for cause-specific mortality have not been widely studied among people with HIV infection. Our objectives were to estimate rates of and risk factors for all-cause and cause-specific mortality from 1995 to 2014 among HIV-infected people in Ontario. METHODS We conducted a population-based retrospective cohort study using provincial health databases of people with HIV infection who were aged 16 years or more, were residents of Ontario between 1995 and 2014, and had HIV infection according to a previously validated algorithm. We used International Classification of Diseases codes to classify the underlying cause of death and estimated age-adjusted mortality rates per 100 person-years for 1995 to 2014. We used descriptive statistics to characterize the cohort at baseline and calculated adjusted mortality rate ratios (RRs) using generalized estimating equations. RESULTS Among 23 043 people, the all-cause mortality rate declined from 6.69 to 1.53 per 100 person-years over the study period, and the rate of death from HIV/AIDS declined from 4.75 to 0.46 per 100 person-years. Concomitantly, the proportions of deaths due to cancer, cardiovascular disease and other noncommunicable diseases rose; however, rates remained constant or declined. Compared to males, females had higher mortality due to cardiovascular disease (adjusted RR 1.36, 95% confidence interval [CI] 1.04-1.77), noncommunicable causes (adjusted RR 1.75, 95% CI 1.39-2.20) and, by 2010-2014, any cause (adjusted RR 1.19, 95% CI 1.02-1.38). Residing in a low-income neighbourhood was associated with increased risk for most causes, including HIV/AIDS (adjusted RR in 2010-2014 1.86, 95% CI 1.49-2.31). Rural residence was associated with increased mortality due to malignant disease (adjusted RR 1.60, 95% CI 1.10-2.34) and noncommunicable disease (adjusted RR 1.86, 95% CI 1.25-2.77). Being an immigrant was associated with lower risk of death from all causes. INTERPRETATION Over the study period, death was increasingly due to common chronic conditions rather than to HIV infection itself. Care should incorporate the prevention and management of these conditions, especially among females and those residing in rural and low-income areas.
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Kendall CE, Raboud J, Donelle J, Loutfy M, Rourke SB, Kroch A, Liddy C, Rosenes R, Burchell AN. Lost but not forgotten: A population-based study of mortality and care trajectories among people living with HIV who are lost to follow-up in Ontario, Canada. HIV Med 2018; 20:88-98. [PMID: 30474908 PMCID: PMC9292000 DOI: 10.1111/hiv.12682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/27/2022]
Abstract
Objectives Selection as a consequence of volunteer participation in, and loss to follow‐up from, cohort studies may bias estimates of mortality and other health outcomes. To quantify this potential, we estimated mortality and health service use among people living with HIV (PLWH) who were lost to cohort follow‐up (LTCFU) from a volunteer clinical HIV‐infected cohort, and compared these to mortality and health service use in active cohort participants and non‐cohort‐participants living with HIV in Ontario, Canada. Methods We analysed population‐based provincial health databases from 1995 to 2014, identifying PLWH ≥ 18 years old; these included data from participants in the Ontario HIV Treatment Network Cohort Study (OCS), a volunteer, multi‐site clinical HIV‐infected cohort. We calculated all‐cause mortality, hospitalization and emergency department (ED) visit rates per 100 person‐years (PY) and estimated hazard ratios (HRs) of mortality, adjusting for age, sex, income, rurality, and immigration status. Results Among 23 043 PLWH, 5568 were OCS participants. Compared with nonparticipants, participants were younger and less likely to be female, to be an immigrant and to reside in a major urban centre, and had lower comorbidity. Mortality among active participants, participants LTCFU and nonparticipants was 2.52, 3.30 and 2.20 per 100 PY, respectively. After adjustment for covariates, mortality risk was elevated among participants LTCFU compared with active participants (HR 2.26; 95% confidence interval 1.91, 2.68). Age‐adjusted hospitalization rates and ED visit rates were highest among participants LTCFU. Conclusions Mortality risk and use of health care resources were lower among active cohort participants. Our findings may inform health outcome estimates based on volunteer cohorts, as well as quantitative bias adjustment to correct for such biases.
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Wilton J, Light L, Gardner S, Rachlis B, Conway T, Cooper C, Cupido P, Kendall CE, Loutfy M, McGee F, Murray J, Lush J, Rachlis A, Wobeser W, Bacon J, Kroch AE, Gilbert M, Rourke SB, Burchell AN. Late diagnosis, delayed presentation and late presentation among persons enrolled in a clinical HIV cohort in Ontario, Canada (1999-2013). HIV Med 2018; 20:110-120. [PMID: 30430742 DOI: 10.1111/hiv.12686] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Timely HIV diagnosis and presentation to medical care are important for treatment and prevention. Our objective was to measure late diagnosis, delayed presentation and late presentation among individuals in the Ontario HIV Treatment Network Cohort Study (OCS) who were newly diagnosed in Ontario. METHODS The OCS is a multi-site clinical cohort study of people living with HIV in Ontario, Canada. We measured prevalence of late diagnosis [CD4 count < 350 cells/μL or an AIDS-defining condition (ADC) within 3 months of HIV diagnosis], delayed presentation (≥ 3 months from HIV diagnosis to presentation to care), and late presentation (CD4 count < 350 cells/μL or ADC within 3 months of presentation). We identified characteristics associated with these outcomes and explored their overlap. RESULTS A total of 1819 OCS participants were newly diagnosed in Ontario from 1999 to 2013. Late diagnosis (53.0%) and presentation (54.0%) were common, and a quarter (23.1%) of participants were delayed presenters. In multivariable models, the participants of delayed presentation decreased over calendar time, but that of late diagnosis/presentation did not. Late diagnosis contributed to the majority (> 87%) of late presentation, and the prevalence of delayed presentation was similar among those diagnosed late versus early (13.4 versus 13.4%, respectively; P = 0.99). Characteristics associated with higher odds of late diagnosis/presentation in multivariable analyses included older age at diagnosis/presentation; African, Caribbean and Black race/ethnicity; Indigenous race/ethnicity; female sex; and being a male who did not report sex with men. There were lower odds of late diagnosis/presentation among participants who had ever injected drugs. In contrast, delayed presentation risk factors included younger age at diagnosis and having ever injected drugs. CONCLUSIONS Late presentation is common in Ontario, as it is in other high-income countries. Our findings suggest that efforts to reduce late presentation should focus on facilitating earlier diagnosis for the populations identified in this analysis.
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