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Alruwaili A, King JA, Deighton K, Kelly BM, Liao Z, Innes A, Henson J, Yates T, Johnson W, Thivel D, Metz L, Thackray AE, Tolfrey K, Stensel DJ, Willis SA. The association of smoking with different eating and dietary behaviours: A cross-sectional analysis of 80 296 United Kingdom adults. Addiction 2024; 119:1737-1750. [PMID: 38884138 DOI: 10.1111/add.16584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/20/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND AND AIMS Smokers typically have a lower body mass index (BMI) than non-smokers, while smoking cessation is associated with weight gain. In pre-clinical research, nicotine in tobacco smoking suppresses appetite and influences subsequent eating behaviour; however, this relationship is unclear in humans. This study measured the associations of smoking with different eating and dietary behaviours. DESIGN A cross-sectional analysis of data from health assessments conducted between 2004 and 2022. SETTING An independent healthcare-based charity within the United Kingdom. PARTICIPANTS A total of 80 296 men and women (mean ± standard deviation [SD]: age, 43.0 ± 10.4 years; BMI, 25.7 ± 4.2 kg/m2; 62.5% male) stratified into two groups based on their status as a smoker (n = 6042; 7.5%) or non-smoker (n = 74 254; 92.5%). MEASUREMENTS Smoking status (self-report) was the main exposure, while the primary outcomes were selected eating and dietary behaviours. Age, sex and socioeconomic status (index of multiple deprivation [IMD]) were included as covariates and interaction terms, while moderate-to-vigorous exercise and sleep quality were included as covariates only. FINDINGS Smokers had lower odds of snacking between meals and eating food as a reward or out of boredom versus non-smokers (all odds ratio [OR] ≤ 0.82; P < 0.001). Furthermore, smokers had higher odds of skipping meals, going more than 3 h without food, adding salt and sugar to their food, overeating and finding it hard to leave something on their plate versus non-smokers (all OR ≥ 1.06; P ≤ 0.030). Additionally, compared with non-smokers, smoking was associated with eating fried food more times per week (rate ratio [RR] = 1.08; P < 0.001), eating fewer meals per day, eating sweet foods between meals and eating dessert on fewer days per week (all RR ≤ 0.93; P < 0.001). Several of these relationships were modified by age, sex and IMD. CONCLUSIONS Smoking appears to be associated with eating and dietary behaviours consistent with inhibited food intake, low diet quality and altered food preference. Several of these relationships are moderated by age, sex and socioeconomic status.
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Affiliation(s)
- Arwa Alruwaili
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - James A King
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
| | - Kevin Deighton
- Nuffield Health Research Group, Nuffield Health, Epsom, Surrey, United Kingdom
| | - Benjamin M Kelly
- Nuffield Health Research Group, Nuffield Health, Epsom, Surrey, United Kingdom
- Department of Health Professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, United Kingdom
| | - Zhining Liao
- Nuffield Health Research Group, Nuffield Health, Epsom, Surrey, United Kingdom
| | - Aidan Innes
- Nuffield Health Research Group, Nuffield Health, Epsom, Surrey, United Kingdom
| | - Joseph Henson
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Thomas Yates
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - William Johnson
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
| | - David Thivel
- Clermont Auvergne University, EA 3533, Laboratory of the Metabolic Adaptations to Exercise under Physiological and Pathological Conditions (AME2P), CRNH, Clermont-Ferrand, France
- International Research Chair Health in Motion, Clermont Auvergne University Foundation, Clermont-Ferrand, France
| | - Lore Metz
- Clermont Auvergne University, EA 3533, Laboratory of the Metabolic Adaptations to Exercise under Physiological and Pathological Conditions (AME2P), CRNH, Clermont-Ferrand, France
- International Research Chair Health in Motion, Clermont Auvergne University Foundation, Clermont-Ferrand, France
| | - Alice E Thackray
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
| | - Keith Tolfrey
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - David J Stensel
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
- Faculty of Sport Sciences, Waseda University, Shinjuku, Japan
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Sha Tin, Hong Kong, China
| | - Scott A Willis
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
- NIHR Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and the University of Leicester, Leicester, United Kingdom
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Kiadaliri A, Englund M. Uncovering sociodemographic disparities in temporal trends of osteoarthritis incidence and age-at-diagnosis, 2006-2019. Scand J Public Health 2024:14034948241265427. [PMID: 39152739 DOI: 10.1177/14034948241265427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
AIM To describe sociodemographic disparities in temporal trends of incidence and age distributions of first registered osteoarthritis (OA) diagnosis in southern Sweden. METHODS We identified all Skåne residents aged 35+ who had lived in the region at any point during the period 2006-2019 with no previous OA diagnosis (ICD-10 codes M15-M19) for 8 years prior to inclusion in the study (n = 849,061). We calculated person-years from inclusion until OA diagnosis, death, emigration, or 31 December 2019, whichever occurred first. Combining sex (female, male), education (low, medium, high) and nativity (Swedish, immigrant), we created a variable with 12 strata. Average annual percent changes in age-standardized incidence rates were estimated using joinpoint regression. Changes in the median age-at-diagnosis (year of diagnosis minus birth year), weighted to the mid-2005 Swedish population, were explored. RESULTS Cumulative age-standardized incidence rates ranged from 116 (95% CI: 111, 121) per 10,000 person-years for immigrant males with low education to 205 (95% CI: 200, 210) for immigrant females with medium education. The estimated average annual percent changes (ranging from 3.4% to 6.1%) were generally similar, with slightly greater variations among immigrants than Swedes. The weighted median age-at-diagnosis was higher for Swedes and low educated people. Immigrant females with low education were the only stratum with a reduction (3 years) in the weighted median age-at-diagnosis over time. Sociodemographic patterns in knee OA incidence were different from patterns for hip OA. CONCLUSIONS There were few sociodemographic disparities in temporal trends of OA incidence and age-at-diagnosis, suggesting persistent sociodemographic disparities in OA burden in southern Sweden.
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Affiliation(s)
- Ali Kiadaliri
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund University, Sweden
| | - Martin Englund
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund University, Sweden
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Weir DL, Bai YQ, Thavorn K, Guilcher S, Kanji S, Mulpuru S, Wodchis W. Non-adherence to COPD medications and its association with adverse events: A longitudinal population based cohort study of older adults. Ann Epidemiol 2024; 96:88-96. [PMID: 38141744 DOI: 10.1016/j.annepidem.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE To determine the association between non-adherence to long term chronic obstructive pulmonary disease (COPD) medications and COPD related emergency department (ED) visits and hospitalizations in patients with incident COPD, utilizing time varying measures of adherence as well as accounting for time-varying confounding impacted by prior adherence. STUDY DESIGN AND SETTING We conducted a population-based retrospective cohort study between 2007-2017 among individuals aged 66 years and older with incident COPD using multiple linked administrative health databases from the province of Ontario, Canada. Adherence to COPD medications was measured using time varying proportion of days covered based on insurance claims for medications dispensed at community pharmacies. The parametric g-formula was used to assess the association between time-varying adherence (in the last 90-days) to COPD medications and risk of COPD related hospitalizations and ED visits while accounting for time varying confounding by COPD severity. RESULTS Overall, 60,251 individuals with incident COPD were included; mean age was 76 (SD 7) and 59% were male. Mean adherence over the entire follow-up was 23% (SD 0.3). There were 7248 (12%) COPD related ED visits (2.8 events per 100 person years [PY]) and 9188 (15%) COPD related hospitalizations (3.5 events per 100 PY). Compared to those with 0% 90-day adherence, those with adherence between 1-33% had a 19% decreased risk of COPD related ED visits (adjusted risk ratio[aRR]:0.81, 95% confidence interval [CI]:0.78-0.83), those with adherence between 34%-67% had a 18% decreased risk (aRR: 0.82, 95% CI: 0.77-0.85) while those with 68%-100% 90-day adherence had a 63% increased risk of COPD related ED visits (aRR: 1.63, 95% CI: 1.47-1.78). Nearly identical results were obtained for COPD specific hospitalizations. CONCLUSION After accounting for time varying confounding by COPD severity, the highest time varying 90-days adherence was associated with an increased risk of both COPD related ED visits and hospitalizations compared to the lowest adherence categories. Differences in COPD severity between adherence categories, perception of need for medication management in the higher adherence categories, and potential residual confounding makes it difficult to disentangle the independent effects of adherence from the severity of the condition itself.
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Affiliation(s)
- Daniala L Weir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Utrecht Institute of Pharmaceutical Sciences, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.
| | - Yu Qing Bai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sara Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Walter Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Davis LE, Strumpf EC, Patel SV, Mahar AL. Income differences in time to colon cancer diagnosis. Cancer Med 2024; 13:e6999. [PMID: 39096087 PMCID: PMC11297540 DOI: 10.1002/cam4.6999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/24/2024] [Accepted: 01/31/2024] [Indexed: 08/04/2024] Open
Abstract
INTRODUCTION People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval. METHODS This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis. RESULTS A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest. CONCLUSION These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.
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Affiliation(s)
- Laura E. Davis
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealCanada
- ICESTorontoCanada
| | - Erin C. Strumpf
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealCanada
- Department of EconomicsMcGill UniversityMontrealCanada
| | | | - Alyson L. Mahar
- ICESTorontoCanada
- School of NursingQueen's UniversityKingstonCanada
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Zhao N, Smargiassi A, Chen H, Widdifield J, Bernatsky S. Fine Particulate Matter Components and Risk of Rheumatoid Arthritis: A Large General Canadian Open Cohort Study. Arthritis Care Res (Hoboken) 2024. [PMID: 39014888 DOI: 10.1002/acr.25403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE Exposure to fine particulate matter (PM2.5) has been linked to many diseases. However, it remains unclear which PM2.5 chemical components for these diseases, including rheumatoid arthritis (RA), are more harmful. This study aimed to assess potential associations between PM2.5 components and RA and quantify the individual effects of each chemical component on RA risk. METHODS An open cohort of 11,696,930 Canadian adults was assembled using Ontario administrative health data from January 2007 onward. Individuals were followed until RA onset, death, emigration from Ontario, or the end of the study (December 2019). Incident RA cases were defined by physician billing and hospitalization discharge diagnostic codes. The average levels of PM2.5 components (ammonium, black carbon, mineral dust, nitrate, organic matter, sea salt, and sulfate) for 5 years before cohort entry were assigned to participants based on residential postal codes. A quantile g-computation and Cox proportional hazard models for time to RA onset were developed for the mixture of PM2.5 components and environmental overall PM2.5, respectively. RESULTS We identified 67,676 new RA cases across 130,934,256 person-years. The adjusted hazard ratios for the time to RA onset were 1.027 and 1.023 (95% confidence intervals 1.021-1.033 and 1.017-1.029) per every decile increase in exposures to all seven components and per 1 μg/m3 increase in the overall PM2.5, respectively. Ammonium contributed the most to RA onset in the seven components. CONCLUSION Exposure to PM2.5 components was modestly associated with RA risk. Public health efforts focusing on specific components (eg, ammonium) may be a more efficient way to reduce RA burden.
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Affiliation(s)
- Naizhuo Zhao
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Hong Chen
- Health Canada, Ottawa, Institute for Clinical Evaluative Sciences, Toronto, Public Health Ontario, Toronto, and University of Toronto, Toronto, Ontario, Canada
| | - Jessica Widdifield
- Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada
| | - Sasha Bernatsky
- McGill University Health Centre and McGill University, Montreal, Quebec, Canada
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Askgaard G, Jepsen P, Jensen MD, Kann AE, Morling J, Kraglund F, Card T, Crooks C, West J. Population-Based Study of Alcohol-Related Liver Disease in England in 2001-2018: Influence of Socioeconomic Position. Am J Gastroenterol 2024; 119:1337-1345. [PMID: 38299583 PMCID: PMC11208057 DOI: 10.14309/ajg.0000000000002677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/28/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION England has seen an increase in deaths due to alcohol-related liver disease (ALD) since 2001. We studied the influence of socioeconomic position on the incidence of ALD and the mortality after ALD diagnosis in England in 2001-2018. METHODS This was an observational cohort study based on health records contained within the UK Clinical Practice Research Datalink covering primary care, secondary care, cause of death registration, and deprivation of neighborhood areas in 18.8 million residents. We estimated incidence rate and incidence rate ratios of ALD and hazard ratios of mortality. RESULTS ALD was diagnosed in 57,784 individuals with a median age of 54 years and of whom 43% had cirrhosis. The ALD incidence rate increased by 65% between 2001 and 2018 in England to reach 56.1 per 100,000 person-years in 2018. The ALD incidence was 3-fold higher in those from the most deprived quintile vs those from the least deprived quintile (incidence rate ratio 3.30, 95% confidence interval 3.21-3.38), with reducing inequality at older than at younger ages. For 55- to 74-year-olds, there was a notable increase in the incidence rate between 2001 and 2018, from 96.1 to 158 per 100,000 person-years in the most deprived quintile and from 32.5 to 70.0 in the least deprived quintile. After ALD diagnosis, the mortality risk was higher for patients from the most deprived quintile vs those from the least deprived quintile (hazard ratio 1.22, 95% confidence interval 1.18-1.27), and this ratio did not change during 2001-2018. DISCUSSION The increasing ALD incidence in England is a greater burden on individuals of low economic position compared with that on those of high socioeconomic position. This finding highlights ALD as a contributor to inequality in health.
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Affiliation(s)
- Gro Askgaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Section of Gastroenterology and Hepatology, Medical Department, Zealand University Hospital, Køge, Denmark
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Morten Daniel Jensen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anna Emilie Kann
- Section of Gastroenterology and Hepatology, Medical Department, Zealand University Hospital, Køge, Denmark
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Denmark
| | - Joanne Morling
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Frederik Kraglund
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Tim Card
- Nottingham University Hospitals NHS Trust and the University of Nottingham, NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, United Kingdom
| | - Colin Crooks
- Nottingham University Hospitals NHS Trust and the University of Nottingham, NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, United Kingdom
- Translational Medical Sciences, School of Medicine, University of Nottingham, United Kingdom
| | - Joe West
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Translational Medical Sciences, School of Medicine, University of Nottingham, United Kingdom
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Nasiri N, Hu M, Hajizadeh M. Trends in socioeconomic inequalities in breast cancer mortality in Canada: 1992-2019. Breast Cancer Res Treat 2024; 205:533-543. [PMID: 38502420 DOI: 10.1007/s10549-024-07277-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE Breast cancer is the second leading cause of death from cancer among Canadian females. This study aimed to quantify and assess trends in education and income inequalities in the mortality rate of breast cancer in Canada from 1992 to 2019. METHODS We constructed a census division-level dataset pooled from the Canadian Vital Death Statistics Database (CVSD), the Canadian Census of the Population (CCP), and the National Household Survey (NHS) to examine trends in education and income inequalities in the mortality rate of breast cancer in Canada over the study period. The age-standardized Concentration index (C) was used to quantify income and education inequalities in breast cancer mortality over time. RESULTS The national crude mortality rate of breast cancer has decreased in Canada from 1992 to 2019, with Alberta, British Columbia, Manitoba, Ontario, Prince Edward Island, and Quebec having the greatest decreases in mortality rate. The age-standardized C for education and income inequalities were always negative for all the study years, meaning that the mortality rate of breast cancer was higher among less-educated and poorer females. Moreover, the results indicate a growing trend in the concentration of breast cancer mortality among females with lower income and education from 1992 to 2019. CONCLUSION The increasing concentration of breast cancer mortality among low socioeconomic status females remains a challenge in Canada. Continuous efforts are needed within Canadian healthcare system to improve the prevention and treatment of breast cancer for this population.
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Affiliation(s)
- Nazanin Nasiri
- School of Health and Human Performance, Dalhousie University, Halifax, Canada
| | - Min Hu
- Department of Economics, Philosophy, and Political Science, University of British Columbia, Okanagan Campus, Kelowna, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2Nd Floor, Halifax, NS, B3H 4R2, Canada.
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Hetherington E, Darling E, Harper S, Nguyen F, Schummers L, Norman WV. Inequalities in access to prenatal care during the COVID-19 pandemic: Analysis of a population-based cohort. Paediatr Perinat Epidemiol 2024; 38:291-301. [PMID: 38339962 DOI: 10.1111/ppe.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Before the COVID-19 pandemic, access to prenatal care was lower among some socio-demographic groups. This pandemic caused disruptions to routine preventative care, which could have increased inequalities. OBJECTIVES To investigate if the COVID-19 pandemic increased inequalities in access to prenatal care among those who are younger, live in rural areas, have a lower socio-economic situation (SES) and are recent immigrants. METHODS We used linked administrative datasets from ICES to identify a population-based cohort of 455,245 deliveries in Ontario from January 2018 to December 2021. Our outcomes were first-trimester prenatal visits, first-trimester ultrasound and adequacy of prenatal care. We used joinpoint analysis to examine outcome time trends and identify trend change points. We stratified analyses by age, rural residence, SES and recent immigration, and examined risk differences (RD) with 95% confidence intervals (CI) between groups at the beginning and end of the study period. RESULTS For all outcomes, we noted disruptions to care beginning in March or April 2020 and returning to previous trends by November 2020. Inequalities were stable across groups, except recent immigrants. In July 2017, 65.0% and 69.8% of recent immigrants and non-immigrants, respectively, received ultrasounds in the first trimester (RD -4.8%, 95% CI -8.0, -1.5). By October 2020, this had increased to 75.4%, with no difference with non-immigrants (RD 0.4%, 95% CI -2.4, 3.2). Adequacy of prenatal care showed more intensive care as of November 2020, reflecting a higher number of visits. CONCLUSIONS We found no evidence that inequalities between socio-economic groups that existed prior to the pandemic worsened after March 2020. The pandemic may be associated with increased access to care for recent immigrants. The introduction of virtual visits may have resulted in a higher number of prenatal care visits.
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Affiliation(s)
- Erin Hetherington
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Quebec, Canada
- ICES McMaster, Hamilton, Ontario, Canada
| | - Elizabeth Darling
- ICES McMaster, Hamilton, Ontario, Canada
- McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sam Harper
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Quebec, Canada
| | | | - Laura Schummers
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
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Nantais J, Baxter NN, Saskin R, Calzavara A, Gomez D. Short- and long-term outcomes of acute diverticulitis in patients with transplanted kidneys. Colorectal Dis 2024; 26:734-744. [PMID: 38459424 DOI: 10.1111/codi.16941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/09/2024] [Accepted: 01/30/2024] [Indexed: 03/10/2024]
Abstract
AIM The safety of nonoperative treatment for patients with transplanted kidneys who develop acute diverticulitis is unclear. Our primary aim was to examine the long-term sequelae of nonoperative management in this group. METHOD We performed a population-based retrospective cohort study using linked administrative databases housed at ICES in Ontario, Canada. We included adult (≥18 years) patients admitted with acute diverticulitis between April 2002 and December 2019. Patients with a functioning kidney transplant were compared with those without a transplant. The primary outcome was failure of conservative management (operation, drainage procedure or death due to acute diverticulitis) beyond 30 days. The cumulative incidence function and a Fine-Grey subdistribution hazard model were used to evaluate this outcome accounting for competing risks. RESULTS We examined 165 patients with transplanted kidneys and 74 095 without. Patients with transplanted kidneys were managed conservatively 81% of the time at the index event versus 86% in nontransplant patients. Short-term outcomes were comparable, but cumulative failure of conservative management at 5 years occurred in 5.6% (95% CI 2.3%-11.1%) of patients with transplanted kidneys versus 2.1% (95% CI 2.0%-2.3%) in those without. Readmission for acute diverticulitis was also higher in transplanted patients at 5 years at 16.7% (95% CI 10.1%-24.7%) versus 11.6% (95% CI 11.3%-11.9%). Adjusted analyses showed increased failure of conservative management [subdistribution hazard ratio (sHR) 3.24, 95% CI 1.69-6.22] and readmissions (sHR 1.55, 95% CI 1.02-2.36) for patients with transplanted kidneys. CONCLUSION Most patients with transplanted kidneys are managed conservatively for acute diverticulitis. Although long-term readmission and failure of conservative management is higher for this group than the nontransplant population, serious outcomes are infrequent, substantiating the safety of this approach.
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Affiliation(s)
- Jordan Nantais
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Section of General Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - David Gomez
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Division of General Surgery, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Xia M, An J, Safford MM, Colantonio LD, Sims M, Reynolds K, Moran AE, Zhang Y. Cardiovascular Risk Associated With Social Determinants of Health at Individual and Area Levels. JAMA Netw Open 2024; 7:e248584. [PMID: 38669015 PMCID: PMC11053380 DOI: 10.1001/jamanetworkopen.2024.8584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/28/2024] [Indexed: 04/29/2024] Open
Abstract
Importance The benefit of adding social determinants of health (SDOH) when estimating atherosclerotic cardiovascular disease (ASCVD) risk is unclear. Objective To examine the association of SDOH at both individual and area levels with ASCVD risks, and to assess if adding individual- and area-level SDOH to the pooled cohort equations (PCEs) or the Predicting Risk of CVD Events (PREVENT) equations improves the accuracy of risk estimates. Design, Setting, and Participants This cohort study included participants data from 4 large US cohort studies. Eligible participants were aged 40 to 79 years without a history of ASCVD. Baseline data were collected from 1995 to 2007; median (IQR) follow-up was 13.0 (9.3-15.0) years. Data were analyzed from September 2023 to February 2024. Exposures Individual- and area-level education, income, and employment status. Main outcomes and measures ASCVD was defined as the composite outcome of nonfatal myocardial infarction, death from coronary heart disease, and fatal or nonfatal stroke. Results A total of 26 316 participants were included (mean [SD] age, 61.0 [9.1] years; 15 494 women [58.9%]; 11 365 Black [43.2%], 703 Chinese American [2.7%], 1278 Hispanic [4.9%], and 12 970 White [49.3%]); 11 764 individuals (44.7%) had at least 1 adverse individual-level SDOH and 10 908 (41.5%) had at least 1 adverse area-level SDOH. A total of 2673 ASCVD events occurred during follow-up. SDOH were associated with increased risk of ASCVD at both the individual and area levels, including for low education (individual: hazard ratio [HR], 1.39 [95% CI, 1.25-1.55]; area: HR, 1.31 [95% CI, 1.20-1.42]), low income (individual: 1.35 [95% CI, 1.25-1.47]; area: HR, 1.28 [95% CI, 1.17-1.40]), and unemployment (individual: HR, 1.61 [95% CI, 1.24-2.10]; area: HR, 1.25 [95% CI, 1.14-1.37]). Adding area-level SDOH alone to the PCEs did not change model discrimination but modestly improved calibration. Furthermore, adding both individual- and area-level SDOH to the PCEs led to a modest improvement in both discrimination and calibration in non-Hispanic Black individuals (change in C index, 0.0051 [95% CI, 0.0011 to 0.0126]; change in scaled integrated Brier score [IBS], 0.396% [95% CI, 0.221% to 0.802%]), and improvement in calibration in White individuals (change in scaled IBS, 0.274% [95% CI, 0.095% to 0.665%]). Adding individual-level SDOH to the PREVENT plus area-level social deprivation index (SDI) equations did not improve discrimination but modestly improved calibration in White participants (change in scaled IBS, 0.182% [95% CI, 0.040% to 0.496%]), Black participants (0.187% [95% CI, 0.039% to 0.501%]), and women (0.289% [95% CI, 0.115% to 0.574%]). Conclusions and Relevance In this cohort study, both individual- and area-level SDOH were associated with ASCVD risk; adding both individual- and area-level SDOH to the PCEs modestly improved discrimination and calibration for estimating ASCVD risk for Black individuals, and adding individual-level SDOH to PREVENT plus SDI also modestly improved calibration. These findings suggest that both individual- and area-level SDOH may be considered in future development of ASCVD risk assessment tools, particularly among Black individuals.
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Affiliation(s)
- Mengying Xia
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Monika M. Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Mario Sims
- Department of Social Medicine, Population, and Public Health, University of California, Riverside
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Andrew E. Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yiyi Zhang
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York
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11
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Branion-Calles M, Winters M, Rothman L, Harris MA. Risk Factors and Inequities in Transportation Injury and Mortality in the Canadian Census Health and Environment Cohorts (CanCHECs). Epidemiology 2024; 35:252-262. [PMID: 38290144 PMCID: PMC10836781 DOI: 10.1097/ede.0000000000001696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/21/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Road traffic injury contributes substantially to morbidity and mortality. Canada stands out among developed countries in not conducting a national household travel survey, leading to a dearth of national transportation mode data and risk calculations that have appropriate denominators. Since traffic injuries are specific to the mode of travel used, these risk calculations should consider travel mode. METHODS Census data on mode of commute is one of the few sources of these data for persons aged 15 and over. This study leveraged a national data linkage cohort, the Canadian Census Health and Environment Cohorts, that connects census sociodemographic and commute mode data with records of deaths and hospitalizations, enabling assessment of road traffic injury associations by indicators of mode of travel (commuter mode). We examined longitudinal (1996-2019) bicyclist, pedestrian, and motor vehicle occupant injury and fatality risk in the Canadian Census Health and Environment Cohorts by commuter mode and sociodemographic characteristics using Cox proportional hazards models within the working adult population. RESULTS We estimated positive associations between commute mode and same mode injury and fatality, particularly for bicycle commuters (hazard ratios for bicycling injury was 9.1 and for bicycling fatality was 11). Low-income populations and Indigenous people had increased injury risk across all modes. CONCLUSIONS This study shows inequities in transportation injury risk in Canada and underscores the importance of adjusting for mode of travel when examining differences between population groups.
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Affiliation(s)
- Michael Branion-Calles
- From the School of Occupational and Public Health, Faculty of Community Services, Toronto Metropolitan University, Toronto, Ontario, Canada
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Meghan Winters
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Linda Rothman
- From the School of Occupational and Public Health, Faculty of Community Services, Toronto Metropolitan University, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - M. Anne Harris
- From the School of Occupational and Public Health, Faculty of Community Services, Toronto Metropolitan University, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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12
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Mahmud FH, Clarke ABM, Elia Y, Curtis J, Benitez-Aguirre P, Cameron FJ, Chiesa ST, Clarson C, Couper JJ, Craig ME, Dalton RN, Daneman D, Davis EA, Deanfield JE, Donaghue KC, Jones TW, Marshall SM, Neil A, Marcovecchio ML. Socioeconomic representativeness of Australian, Canadian and British cohorts from the paediatric diabetes AdDIT study: comparisons to regional and national data. BMC Med 2023; 21:506. [PMID: 38124088 PMCID: PMC10734126 DOI: 10.1186/s12916-023-03222-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Given limited data regarding the involvement of disadvantaged groups in paediatric diabetes clinical trials, this study aimed to evaluate the socioeconomic representativeness of participants recruited into a multinational clinical trial in relation to regional and national type 1 diabetes reference populations. METHODS Retrospective, cross-sectional evaluation of a subset of adolescent type 1 diabetes cardiorenal intervention trial (AdDIT) participants from Australia (n = 144), Canada (n = 312) and the UK (n = 173). Validated national measures of deprivation were used: the Index of Relative Socioeconomic Disadvantage (IRSD) 2016 (Australia), the Material Resources (MR) dimension of the Canadian Marginalisation index 2016 (Canada) and the Index of Multiple Deprivation (IMD) 2015 (UK). Representativeness was assessed by comparing the AdDIT cohort's distribution of deprivation quintiles with that of the local paediatric type 1 diabetes population (regional), and the broader type 1 diabetes population for which the trial's intervention was targeted (national). RESULTS Recruited study cohorts from each country had higher proportions of participants with higher SES, and significant underrepresentation of lower SES, in relation to their national references. The socioeconomic make-up in Australia mirrored that of the regional population (p = 0.99). For Canada, the 2nd least deprived (p = 0.001) and the most deprived quintiles (p < 0.001) were over- and under-represented relative to the regional reference, while the UK featured higher regional and national SES bias with over-representation and under-representation from the least-deprived and most-deprived quintiles (p < 0.0001). CONCLUSIONS Significant national differences in trial participation of low SES participants were observed, highlighting limitations in access to clinical research and the importance of reporting sociodemographic representation in diabetes clinical trials. TRIAL REGISTRATION NCT01581476. Registered on 20 April 2012.
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Affiliation(s)
- Farid H Mahmud
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, RM 5446 Black Wing, Toronto, ON, M5G 1X8, Canada.
| | - Antoine B M Clarke
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, RM 5446 Black Wing, Toronto, ON, M5G 1X8, Canada
| | - Yesmino Elia
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, RM 5446 Black Wing, Toronto, ON, M5G 1X8, Canada
| | - Jacqueline Curtis
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, RM 5446 Black Wing, Toronto, ON, M5G 1X8, Canada
| | - Paul Benitez-Aguirre
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Fergus J Cameron
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Scott T Chiesa
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Jennifer J Couper
- Departments of Endocrinology and Diabetes and Medical Imaging, Women's and Children's Hospital, Adelaide, Australia
| | - Maria E Craig
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, University of Sydney, Sydney, Australia
- Discipline of Paediatrics & Child Health, School of Clinical Medicine, University of New South Wales Medicine & Health, Sydney, Australia
| | - R Neil Dalton
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Denis Daneman
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, 555 University Avenue, RM 5446 Black Wing, Toronto, ON, M5G 1X8, Canada
| | - Elizabeth A Davis
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - John E Deanfield
- Institute of Cardiovascular Science, University College London, London, UK
| | - Kim C Donaghue
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Timothy W Jones
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Sally M Marshall
- Faculty of Clinical Medical Sciences, Diabetes Research Group, Translational and Clinical Research Institute, Newcastle University, 4Th Floor William Leech Building, Framlington Place, Newcastle Upon Tyne, UK
| | - Andrew Neil
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, UK
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13
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Tope P, Morais S, El-Zein M, Franco EL, Malagón T. Differences in site-specific cancer incidence by individual- and area-level income in Canada from 2006 to 2015. Int J Cancer 2023; 153:1766-1783. [PMID: 37493243 DOI: 10.1002/ijc.34661] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023]
Abstract
Income, a component of socioeconomic status, influences cancer risk as a social determinant of health. We evaluated the independent associations between individual- and area-level income and site-specific cancer incidence in Canada. We used data from the 2006 and 2011 Canadian Census Health and Environment Cohorts, which are probabilistically linked datasets constituted by 5.9 million and 6.5 million respondents of the 2006 Canadian long-form census and 2011 National Household Survey, respectively. Individuals were linked to the Canadian Cancer Registry through 2015. Individual-level income was derived using after-tax household income adjusted for household size. Annual tax return postal codes were used to assign area-level income quintiles to individuals for each year of follow-up. We calculated age-standardized incidence rates (ASIR) and rate ratios for cancers overall and by site. We conducted multivariable negative binomial regression to adjust these rates for other demographic and socioeconomic variables. Individuals of lower individual- and area-level income had higher ASIRs compared to those in the wealthiest income quintile for head and neck, oropharyngeal, esophageal, stomach, colorectal, anal, liver, pancreas, lung, cervical and kidney and renal pelvis cancers. Conversely, individuals of wealthier individual- and area-level income had higher ASIRs for melanoma, leukemia, Hodgkin's lymphoma, non-Hodgkin's lymphoma, breast, uterine, prostate and testicular cancers. Most differences in site-specific incidence by income quintile remained after adjustment. Although Canada's publicly funded healthcare system provides universal coverage, inequalities in cancer incidence persist across individual- and area-level income gradients. Our estimates suggest that individual- and area-level income affect cancer incidence through independent mechanisms.
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Affiliation(s)
- Parker Tope
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Samantha Morais
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Mariam El-Zein
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Eduardo L Franco
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Talía Malagón
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
- St. Mary's Research Centre, Montréal West Island CIUSSS, Montreal, Quebec, Canada
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14
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Luo Z, Dong X, Wang C, Cao W, Zheng Y, Wu Z, Xu Y, Zhao L, Wang F, Li J, Ren J, Shi J, Chen W, Li N. Association Between Socioeconomic Status and Adherence to Fecal Occult Blood Tests in Colorectal Cancer Screening Programs: Systematic Review and Meta-Analysis of Observational Studies. JMIR Public Health Surveill 2023; 9:e48150. [PMID: 37906212 PMCID: PMC10646673 DOI: 10.2196/48150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Screening adherence is important in reducing colorectal cancer (CRC) incidence and mortality. Disparity in CRC screening adherence was observed in populations of different socioeconomic status (SES), but the direction and strength of the association remained unclear. OBJECTIVE We aimed to systematically review all the observational studies that have analyzed the association between SES and adherence to organized CRC screening based on fecal occult blood tests. METHODS We systematically reviewed the studies in PubMed, Embase, and Web of Science and reference lists of relevant reviews from the inception of the database up until June 7, 2023. Individual SES, neighborhood SES, and small-area SES were included, while any SES aggregated by geographic areas larger than neighbors were excluded. Studies assessing SES with any index or score combining indicators of income, education, deprivation, poverty, occupation, employment, marital status, cohabitation, and others were included. A random effect model meta-analysis was carried out for pooled odds ratios (ORs) and relative risks for adherence related to SES. RESULTS Overall, 10 studies, with a total of 3,542,379 participants and an overall adherence rate of 64.9%, were included. Compared with low SES, high SES was associated with higher adherence (unadjusted OR 1.73, 95% CI 1.42-2.10; adjusted OR 1.53, 95% CI 1.28-1.82). In the subgroup of nonindividual-level SES, the adjusted association was significant (OR 1.57, 95% CI 1.26-1.95). However, the adjusted association was insignificant in the subgroup of individual-level SES (OR 1.46, 95% CI 0.98-2.17). As for subgroups of the year of print, not only was the unadjusted association significantly stronger in the subgroup of early studies (OR 1.97, 95% CI 1.59-2.44) than in the subgroup of late studies (OR 1.43, 95% CI 1.31-1.56), but also the adjusted one was significantly stronger in the early group (OR 1.86, 95% CI 1.43-2.42) than in the late group (OR 1.26, 95% CI 1.14-1.39), which was consistent and robust. Despite being statistically insignificant, the strength of the association seemed lower in studies that did not adjust for race and ethnicity (OR 1.31, 95% CI 1.21-1.43) than the overall estimate (OR 1.53, 95% CI 1.28-1.82). CONCLUSIONS The higher-SES population had higher adherence to fecal occult blood test-based organized CRC screening. Neighborhood SES, or small-area SES, was more competent than individual SES to be used to assess the association between SES and adherence. The disparity in adherence between the high SES and the low SES narrowed along with the development of interventions and the improvement of organized programs. Race and ethnicity were probably important confounding factors for the association.
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Affiliation(s)
- Zilin Luo
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuesi Dong
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenran Wang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Cao
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yadi Zheng
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Wu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjie Xu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang Zhao
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Wang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jibin Li
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiansong Ren
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jufang Shi
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wanqing Chen
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ni Li
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Epidemiology and Biostatistics, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
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15
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Lix LM, Renoux C, Moriello C, Choi KL, Dormuth CR, Fisher A, Dahl M, Wu F, Asaf A, Paterson JM. Validity of diagnoses of SARS-CoV-2 infection in Canadian administrative health data: a multiprovince, population-based cohort study. CMAJ Open 2023; 11:E790-E798. [PMID: 37669811 PMCID: PMC10482491 DOI: 10.9778/cmajo.20220152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Accurate coding of diagnoses of SARS-CoV-2 infection in administrative data benefits population-based studies about the epidemiology, treatment and outcomes of COVID-19. We describe the validity of diagnoses of SARS-CoV-2 infection recorded in hospital discharge abstracts, emergency department records and outpatient physician service claims from 3 Canadian provinces. METHODS In this cohort study, population-based inpatient, emergency department and outpatient records were linked to SARS-CoV-2 polymerase chain reaction (PCR; reference standard) test results from British Columbia, Manitoba and Ontario for Apr. 1, 2020, to Mar. 31, 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of diagnoses of SARS-CoV-2 infection were estimated for each quarter in the study period, overall and by province, age group and sex. RESULTS Our study encompassed more than 13 million SARS-CoV-2 PCR test results. Specificity and NPV of diagnoses of SARS-CoV-2 infection were consistently high (i.e., most estimates were > 95%). Overall sensitivity estimates were 86.2%, 60.4% and 20.3% in the first quarter for inpatient, emergency department and outpatient cohorts, and 66.2%, 47.5% and 25.0% in the last quarter, respectively. For inpatients, overall PPV estimates ranged from 50.0% to 66.4%. For emergency department patients, overall PPV estimates were 76.9% and 68.3% in the first and last quarters, respectively. For outpatients, PPV estimates were 6.8% and 29.1% in the first and last quarters, respectively. INTERPRETATION We found variations in the validity of diagnoses for SARS-CoV-2 infection recorded in different health care settings, geographic areas and over time. Our multiprovince validation study provides evidence about the potential use of inpatient and emergency department records as an alternative to population-based laboratory data for identification of patients with SARS-CoV-2 infection, but does not support the use of outpatient claims for this purpose.
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Affiliation(s)
- Lisa M Lix
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont.
| | - Christel Renoux
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Carolina Moriello
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Ko Long Choi
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Colin R Dormuth
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Anat Fisher
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Matthew Dahl
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Fangyun Wu
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - Ayesha Asaf
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
| | - J Michael Paterson
- Department of Community Health Sciences (Lix), University of Manitoba, Winnipeg, Man.; Lady Davis Institute (Renoux, Moriello); Departments of Neurology and Neurosurgery, and Epidemiology, Biostatistics and Occupational Health (Renoux), McGill University, Montréal, Que.; George & Fay Yee Centre for Healthcare Innovation (Choi), University of Manitoba, Winnipeg, Man.; Department of Anesthesiology, Pharmacology & Therapeutics (Dormuth, Fisher), University of British Columbia, Vancouver, BC; Manitoba Centre for Health Policy (Dahl), University of Manitoba, Winnipeg, Man.; ICES Central (Wu, Asaf, Paterson), Toronto, Ont
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Bayoumi I, Glazier RH, Jaakkimainen L, Premji K, Kiran T, Frymire E, Khan S, Green ME. Trends in attachment to a primary care provider in Ontario, 2008-2018: an interrupted time-series analysis. CMAJ Open 2023; 11:E809-E819. [PMID: 37669813 PMCID: PMC10482493 DOI: 10.9778/cmajo.20220167] [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: 09/07/2023] Open
Abstract
BACKGROUND Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care. METHODS Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models. RESULTS Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16). INTERPRETATION Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.
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Affiliation(s)
- Imaan Bayoumi
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont.
| | - Richard H Glazier
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Liisa Jaakkimainen
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Kamila Premji
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Tara Kiran
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Eliot Frymire
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Shahriar Khan
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Michael E Green
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
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Hosseini-Moghaddam SM, Shepherd FA, Swayze S, Kwong JC, Chan KKW. SARS-CoV-2 Infection, Hospitalization, and Mortality in Adults With and Without Cancer. JAMA Netw Open 2023; 6:e2331617. [PMID: 37651139 PMCID: PMC10472189 DOI: 10.1001/jamanetworkopen.2023.31617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/18/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Patients with cancer are at increased risk of SARS-CoV-2-associated adverse outcomes. Objective To determine the associations of tumor type with SARS-CoV-2 infection, hospitalization, intensive care unit (ICU) admission, and death. Design, Setting, and Participants This retrospective, population-based cohort study included community-dwelling adults aged at least 18 years in Ontario, Canada, ICES-linked provincial health databases from January 1, 2020, to November 30, 2021. Data were analyzed from December 1, 2021, to November 1, 2022. Exposures Cancer diagnosis. Main Outcomes and Measures The primary outcome was SARS-CoV-2 infection, and secondary outcomes included all-cause 14-day hospitalization, 21-day ICU admission, and 28-day death following SARS-CoV-2 infection. Cox proportional hazards models were used to obtain adjusted hazard ratios (aHRs) and 95% CIs. Results Of 11 732 108 people in the ICES-linked health databases, 279 287 had cancer (57.2% female; mean [SD] age, 65.9 [16.1] years) and 11 452 821 people did not have cancer (45.7% female; mean [SD] age, 65.9 [16.0] years). Overall, 464 574 individuals (4.1%) developed SARS-CoV-2 infection. Individuals with hematologic malignant neoplasms (33 901 individuals) were at increased risk of SARS-CoV-2 infection (aHR, 1.19; 95% CI, 1.13-1.25), 14-day hospitalization (aHR, 1.75; 95% CI, 1.57-1.96), and 28-day mortality (aHR, 2.03; 95% CI, 1.74-2.38) compared with the overall population, while individuals with solid tumors (245 386 individuals) were at lower risk of SARS-CoV-2 infection (aHR, 0.93; 95% CI, 0.91-0.95) but increased risk of 14-day hospitalization (aHR, 1.11; 95% CI, 1.05-1.18) and 28-day mortality (aHR, 1.31; 95% CI, 1.19-1.44). The 28-day mortality rate was high in hospitalized patients with hematologic malignant neoplasms (163 of 321 hospitalized patients [50.7%]) or solid tumors (486 of 1060 hospitalized patients [45.8%]). However, the risk of 21-day ICU admission in patients with hematologic malignant neoplasms (aHR, 1.14; 95% CI, 0.93-1.40) or solid tumors (aHR, 0.93; 95% CI, 0.82-1.05) was not significantly different from that among individuals without cancer. The SARS-CoV-2 infection risk decreased stepwise with increasing numbers of COVID-19 vaccine doses received (1 dose: aHR, 0.63; 95% CI, 0.62-0.63; 2 doses: aHR, 0.16; 95% CI, 0.16-0.16; 3 doses: aHR, 0.05; 95% CI, 0.04-0.06). Conclusions and Relevance These findings highlight the importance of prioritization strategies regarding ICU access to reduce the mortality risk in increased-risk populations, such as patients with cancer.
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Affiliation(s)
- Seyed M. Hosseini-Moghaddam
- ICES, Toronto, Ontario, Canada
- Transplant-Oncology Infectious Diseases, Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frances A. Shepherd
- Divisions of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Caner Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Jeffrey C. Kwong
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K. W. Chan
- ICES, Toronto, Ontario, Canada
- Divisions of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Odette Caner Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Rosella LC, Negatu E, Kornas K, Chu C, Zhou L, Buajitti E. Multimorbidity at time of death among persons with type 2 diabetes: a population-based study in Ontario, Canada. BMC Endocr Disord 2023; 23:127. [PMID: 37264336 DOI: 10.1186/s12902-023-01362-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 05/04/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVE Individuals with Type 2 Diabetes are likely to experience multimorbidity and accumulate multiple chronic conditions over their life. We aimed to identify causes of death and chronic conditions at the time of death in a population-based cohort, and to analyze variations in the presence of diabetes at the time of death overall and across income and immigrant status. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 2,199,801 adult deaths from 1992 to 2017 in Ontario, Canada. We calculated the proportion of decedents with chronic conditions at time of death and causes of death. The risk of diabetes at the time of death was modeled across sociodemographic variables with a log binomial regression adjusting for sex, age, immigrant status, area-level income. comorbiditiesand time. RESULTS The leading causes of death in the cohort were cardiovascular and cancer. Decedents with diabetes had a higher prevalence of most chronic conditions than decedents without diabetes, including hypertension, osteo and other arthritis, chronic coronary syndrome, mood disorder, and congestive heart failure. The risk of diabetes at the time of death was 19% higher in immigrants (95%CI 1.18-1.20) and 15% higher in refugees (95%CI 1.12-1.18) compared to long-term residents, and 19% higher in the lowest income quintile (95%CI 1.18-1.20) relative to the highest income quintile, after adjusting for other covariates. CONCLUSIONS Individuals with diabetes have a greater multimorbidity burden at the time of death, underscoring the importance of multiple chronic disease management among those living with diabetes and further considerations of the social determinants of health.
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Affiliation(s)
- Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 6th floor, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- ICES, Toronto, ON, Canada.
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.
- Temerty Faculty of Medicine, Toronto, Canada.
| | - Ednah Negatu
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 6th floor, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 6th floor, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Casey Chu
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | | | - Emmalin Buajitti
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 6th floor, 155 College Street, Toronto, ON, M5T 3M7, Canada
- ICES, Toronto, ON, Canada
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19
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Khan AM, Lin P, Kamdar N, Mahmoudi E, Clarke P. Continuity of Care in Adults Aging with Cerebral Palsy and Spina Bifida: The Importance of Community Healthcare and Socioeconomic Context. DISABILITIES (BASEL, SWITZERLAND) 2023; 3:295-306. [PMID: 38223395 PMCID: PMC10786460 DOI: 10.3390/disabilities3020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Continuity of care is considered a key metric of quality healthcare. Yet, continuity of care in adults aging with congenital disability and the factors that contribute to care continuity are largely unknown. Using data from a national private administrative health claims database in the United States (2007-2018). we examined continuity of care in 8596 adults (mean age 48.6 years) with cerebral palsy or spina bifida. Logistic regression models analyzed how proximity to health care facilities, availability of care providers, and community socioeconomic context were associated with more continuous care. We found that adults aging with cerebral palsy or spina bifida saw a variety of different physician specialty types and generally had discontinuous care. Individuals who lived in areas with more hospitals and residential care facilities received more continuous care than those with limited access to these resources. Residence in more affluent areas was associated with receiving more fragmented care. Findings suggest that over and above individual factors, community healthcare resources and socioeconomic context serve as important factors to consider in understanding continuity of care patterns in adults aging with cerebral palsy or spina bifida.
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Affiliation(s)
- Anam M. Khan
- Institute for Social Research, University of Michigan, Ann Arbor, MI 48106, USA
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Center for Disability Health and Wellness, University of Michigan, Ann Arbor, MI 48108, USA
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Elham Mahmoudi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Philippa Clarke
- Institute for Social Research, University of Michigan, Ann Arbor, MI 48106, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Center for Disability Health and Wellness, University of Michigan, Ann Arbor, MI 48108, USA
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20
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Siu SC, Lee DS, Fang J, Austin PC, Silversides CK. New Hypertension After Pregnancy in Patients With Heart Disease. J Am Heart Assoc 2023; 12:e029260. [PMID: 37158089 PMCID: PMC10227309 DOI: 10.1161/jaha.122.029260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/11/2023] [Indexed: 05/10/2023]
Abstract
Background After pregnancy, patients with preexisting heart disease are at high risk for cardiovascular complications. The primary objective was to compare the incidence of new hypertension after pregnancy in patients with and without heart disease. Methods and Results This was a retrospective matched-cohort study comparing the incidence of new hypertension after pregnancy in 832 patients who are pregnant with congenital or acquired heart disease to a comparison group of 1664 patients who are pregnant without heart disease; matching was by demographics and baseline risk for hypertension at the time of the index pregnancy. We also examined whether new hypertension was associated with subsequent death or cardiovascular events. The 20-year cumulative incidence of hypertension was 24% in patients with heart disease, compared with 14% in patients without heart disease (hazard ratio [HR], 1.81 [95% CI, 1.44-2.27]). The median follow-up time at hypertension diagnosis in the heart disease group was 8.1 years (interquartile range, 4.2-11.9 years). The elevated rate of new hypertension was observed not only in patients with ischemic heart disease, but also in those with left-sided valve disease, cardiomyopathy, and congenital heart disease. Pregnancy risk prediction methods can further stratify risk of new hypertension. New hypertension was associated with an increased rate of subsequent death or cardiovascular events (HR, 1.54 [95% CI, 1.05-2.25]). Conclusions Patients with heart disease are at higher risk for developing hypertension in the decades after pregnancy when compared with those without heart disease. New hypertension in this young cohort is associated with adverse cardiovascular events highlighting the importance of systematic and lifelong surveillance.
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Affiliation(s)
- Samuel C. Siu
- Division of CardiologyUniversity of Toronto Pregnancy and Heart Disease ProgramTorontoCanada
- Maternal Cardiology Program, Division of CardiologyDepartment of MedicineSchulich School of Medicine and DentistryLondonOntarioCanada
- ICESTorontoOntarioCanada
- Division of CardiologyDepartment of MedicineMount Sinai Hospital and University Health NetworkUniversity of TorontoOntarioCanada
| | - Douglas S. Lee
- ICESTorontoOntarioCanada
- Division of CardiologyDepartment of MedicineMount Sinai Hospital and University Health NetworkUniversity of TorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoOntarioCanada
| | | | - Peter C. Austin
- ICESTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoOntarioCanada
| | - Candice K. Silversides
- Division of CardiologyUniversity of Toronto Pregnancy and Heart Disease ProgramTorontoCanada
- Division of CardiologyDepartment of MedicineMount Sinai Hospital and University Health NetworkUniversity of TorontoOntarioCanada
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21
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Davis LE, Mahar AL, Strumpf EC. Agreement between individual and neighborhood income measures in patients with colorectal cancer in Canada. J Natl Cancer Inst 2023; 115:514-522. [PMID: 36708004 PMCID: PMC10165486 DOI: 10.1093/jnci/djad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION With increasing interest in income-related differences in cancer outcomes, accurate measurement of income is imperative. Misclassification of income can result in wrong conclusions as to the presence of income inequalities. We determined misclassification between individual- and neighborhood-level income and their association with overall survival among colorectal cancer (CRC) patients. METHODS The Canadian Census Health and Environment Cohorts were used to identify CRC patients diagnosed from 1992 to 2017. We used neighborhood income quintiles from Statistics Canada and created individual income quintiles from the same data sources to be as similar as possible. Agreement between individual and neighborhood income quintiles was measured using cross-tabulations and weighted kappa statistics. Cox proportional hazards and Lin semiparametric hazards models were used to determine the effects of individual and neighborhood income independently and jointly on survival. Analyses were also stratified by rural residence. RESULTS A total of 103 530 CRC patients were included in the cohort. There was poor agreement between individual and neighborhood income with only 17% of respondents assigned to the same quintile (weighted kappa = 0.18). Individual income had a greater effect on relative and additive survival than neighborhood income when modeled separately. The interaction between individual and neighborhood income demonstrated that the most at risk for poor survival were those in the lowest individual and neighborhood income quintiles. Misclassification was more likely to occur for patients residing in rural areas. CONCLUSION Cancer researchers should avoid using neighborhood income as a proxy for individual income, especially among patients with cancers with demonstrated inequalities by income.
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Affiliation(s)
- Laura E Davis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Alyson L Mahar
- Faculty of Health Sciences, School of Nursing, Queens University, Kingston, Canada
| | - Erin C Strumpf
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Department of Economics, McGill University, Montreal, Canada
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Rosella LC, Kornas K, Negatu E, Zhou L. Variations in all-cause mortality, premature mortality and cause-specific mortality among persons with diabetes in Ontario, Canada. BMJ Open Diabetes Res Care 2023; 11:11/3/e003378. [PMID: 37130629 PMCID: PMC10163552 DOI: 10.1136/bmjdrc-2023-003378] [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: 02/27/2023] [Accepted: 04/15/2023] [Indexed: 05/04/2023] Open
Abstract
INTRODUCTION Patients with diabetes have a higher risk of mortality compared with the general population. Large population-based studies that quantify variations in mortality risk for patients with diabetes among subgroups in the population are lacking. This study aimed to examine the sociodemographic differences in the risk of all-cause mortality, premature mortality, and cause-specific mortality in persons diagnosed with diabetes. RESEARCH DESIGN AND METHODS We conducted a population-based cohort study of 1 741 098 adults diagnosed with diabetes between 1994 and 2017 in Ontario, Canada using linked population files, Canadian census, health administrative and death registry databases. We analyzed the association between sociodemographics and other covariates on all-cause mortality and premature mortality using Cox proportional hazards models. A competing risk analysis using Fine-Gray subdistribution hazards models was used to analyze cardiovascular and circular mortality, cancer mortality, respiratory mortality, and mortality from external causes of injury and poisoning. RESULTS After full adjustment, individuals with diabetes who lived in the lowest income neighborhoods had a 26% (HR 1.26, 95% CI 1.25 to 1.27) increased hazard of all-cause mortality and 44% (HR 1.44, 95% CI 1.42 to 1.46) increased risk of premature mortality, compared with individuals with diabetes living in the highest income neighborhoods. In fully adjusted models, immigrants with diabetes had reduced risk of all-cause mortality (HR 0.46, 95% CI 0.46 to 0.47) and premature mortality (HR 0.40, 95% CI 0.40 to 0.41), compared with long-term residents with diabetes. Similar HRs associated with income and immigrant status were observed for cause-specific mortality, except for cancer mortality, where we observed attenuation in the income gradient among persons with diabetes. CONCLUSIONS The observed mortality variations suggest a need to address inequality gaps in diabetes care for persons with diabetes living in the lowest income areas.
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Affiliation(s)
- Laura C Rosella
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Kathy Kornas
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ednah Negatu
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Zhao N, Smargiassi A, Chen H, Widdifield J, Bernatsky S. Systemic autoimmune rheumatic diseases and multiple industrial air pollutant emissions: A large general population Canadian cohort analysis. ENVIRONMENT INTERNATIONAL 2023; 174:107920. [PMID: 37068387 DOI: 10.1016/j.envint.2023.107920] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/13/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Past investigations of air pollution and systemic autoimmune rheumatic diseases (SARDs) typically focused on individual (not mixed) and overall environmental emissions. We assessed mixtures of industrial emissions of fine particulate matter (PM2.5), nitrogen dioxide (NO2), and sulfur dioxide (SO2) and SARDs onset in Ontario, Canada. METHODS We assembled an open cohort of over 12 million adults (without SARD diagnoses at cohort entry) based on provincial health data for 2007-2020 and followed them until SARD onset, death, emigration, or end of study (December 2020). SARDs were identified using physician billing and hospitalization diagnostic codes for systemic lupus, scleroderma, myositis, undifferentiated connective tissue disease, and Sjogren's. Rheumatoid arthritis and vasculitis were not included. Average PM2.5, NO2, and SO2 industrial emissions from 2002 to one year before SARDs onset or end of study were assigned using residential postal codes. A quantile g-computation model for time to SARD onset was developed for the industrial emission mixture, adjusting for sex, age, income, rurality index, chronic obstructive pulmonary disease (as a proxy for smoking), background (environmental overall) PM2.5, and calendar year. We conducted stratified analyses across age, sex, and rurality. RESULTS We identified 43,931 new SARD diagnoses across 143,799,564 person-years. The adjusted hazard ratio for SARD onset for an increase in all emissions by one decile was 1.018 (95% confidence interval 1.013-1.022). Similar positive associations between SARDs and the mixed emissions were observed in most stratified analyses. Industrial PM2.5 contributed most to SARD risk. CONCLUSIONS Industrial air pollution emissions were associated with SARDs risk.
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Affiliation(s)
- Naizhuo Zhao
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Audrey Smargiassi
- Département de Santé Environnementale et Santé au Travail, School of Public Health, Université de Montréal, Montréal, QC, Canada; Institut National de Santé Publique du Québec, Montréal, QC, Canada; Centre of Public Health Research, University of Montreal and CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, QC, Canada
| | - Hong Chen
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada; ICES, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jessica Widdifield
- ICES, Toronto, ON, Canada; Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sasha Bernatsky
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Divisions of Rheumatology and Clinical Epidemiology, Department of Medicine, McGill University, Montreal, QC, Canada.
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Gomez D, Acuna SA, Joseph Kim S, Nantais J, Santiago R, Calzavara A, Saskin R, Baxter NN. Incidence and Mortality of Emergency General Surgery Conditions Among Solid Organ Transplant Recipients in Ontario, Canada: A Population-based Analysis. Transplantation 2023; 107:753-761. [PMID: 36117253 DOI: 10.1097/tp.0000000000004299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) conditions and their outcomes are perceived to be disproportionately high among solid organ transplant recipients (SOTRs). However, this has not been adequately investigated at a population level. We characterized the incidence and mortality of EGS conditions among SOTRs compared with nontransplant patients. METHODS Data were collected through linked administrative population-based databases in Ontario, Canada. We included all adult SOTRs (kidney, liver, heart, and lung) who underwent transplantation between 2002 and 2017. We then identified posttransplantation emergency department visits for EGS conditions (appendicitis, cholecystitis, choledocolithiasis, perforated diverticulitis, incarcerated/strangulated hernias, small bowel obstruction, and perforated peptic ulcer). Age-, sex-, and year-standardized incidence rate ratios (SIRRs) were generated. Logistic regression models were used to evaluate association between transplantation status and 30 d mortality after adjusting for demographics, year, and comorbidities. RESULTS Ten thousand seventy-three SOTRs and 12 608 135 persons were analyzed. SOTRs developed 881 EGS conditions (non-SOTRs: 552 194 events). The incidence of all EGS conditions among SOTR was significantly higher compared with the nontransplant patients [SIRR 3.56 (95% confidence interval [CI] 3.32-3.82)], even among those with high Aggregated Diagnosis Groups scores ( > 10) [SIRR 2.76 (95% CI 2.53-3.00)]. SOTRs were 1.4 times more likely to die at 30 d [adjusted odds ratio 1.44 (95% CI 1.08-1.91)] after an EGS event compared with nontransplant patients, predominantly amongst lung transplant recipients [adjusted odds ratio 3.28 (95% CI 1.72-6.24)]. CONCLUSIONS The incidence of EGS conditions is significantly higher in SOTRs even after stratifying by comorbidity burden. This is of particular importance as SOTRs also have a higher likelihood of death after an EGS condition, especially lung transplant recipients.
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Affiliation(s)
- David Gomez
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Division of General Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Sergio A Acuna
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - S Joseph Kim
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
- Department of Medicine, University of Toronto and Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jordan Nantais
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Robin Santiago
- Canadian Institute of Health Information, Ottawa, ON, Canada
| | | | | | - Nancy N Baxter
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Gomez D, Stukel TA, Baxter NN, Acuna SA, Wilton AS, Treleaven D, Ordon M, Kim SJ. A Population-Based Analysis of the Impact of the COVID-19 Pandemic on Solid Organ Transplantation in Ontario, Canada: Policy Response and Changes in Volume and 90-Day Outcomes. ANNALS OF SURGERY OPEN 2023; 4:e230. [PMID: 37600867 PMCID: PMC10431431 DOI: 10.1097/as9.0000000000000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/04/2022] [Indexed: 01/07/2023] Open
Abstract
Objectives To evaluate the impact of the COVID-19 pandemic on solid organ transplantation. Background COVID-19 caused unprecedented disruption to solid organ transplantation (kidney, liver, heart, lung). Concerns about safety and decreases in deceased donors due to pandemic lockdowns have been described as potential causes. Methods We report population-based rates of transplantation during the first 3 waves of COVID-19 in Ontario, Canada (March 1, 2020-July 3, 2021) versus a pre-COVID-19 baseline period (January 1, 2017-February 29, 2020). Poisson models were used to predict transplantation rates during COVID-19, based on pre-COVID-19 rates, and generate observed to expected rate ratios (RRs). Ninety-day transplant outcomes (mortality, retransplantation, transplant nephrectomy) were captured. Results A 34.4% decrease (RR, 0.656; 95% confidence interval [CI], 0.586-0.734) in transplant rates was observed, coinciding with wave 1 and the deployment of a provincial transplant triaging system. Transplants decreased by 14.6% in wave 2 (RR, 0.854; 95% CI, 0.770-0.947) and 23.1% in wave 3 (RR, 0.769; 95% CI, 0.690-0.857) despite the triaging system not being activated. Overall, there was a 24.3% decrease (RR, 0.757; 95% CI, 0.679-0.844) in transplant rates, equivalent to 409 fewer transplants. No sustained changes were observed in heart or liver but sustained and large decreases were seen for lung (RR, 0.664; 95% CI, 0.482-0.915) and kidney (RR, 0.721; 95% CI, 0.602-0.863) transplantation. A low prevalence (1.7%) of COVID-19 infection within 90 days of transplantation was seen. No differences were observed in other 90-day outcomes. Conclusions Early safety concerns limited transplantation to immediate life-saving procedures; however, the reductions in kidney and lung transplants continued for the rest of the pandemic, where no restrictions were in place.
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Affiliation(s)
- David Gomez
- From the Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Therese A. Stukel
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nancy N. Baxter
- From the Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sergio A. Acuna
- From the Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Darin Treleaven
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, ON, Canada
| | - Michael Ordon
- From the Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - S. Joseph Kim
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto and the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Control del asma en niños, desigualdad socioeconómica y asistencia sanitaria. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Harish V, Buajitti E, Burrows H, Posen J, Bogoch II, Corbeil A, Gubbay JB, Rosella LC, Morris SK. Geographic clustering of travel-acquired infections in Ontario, Canada, 2008-2020. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001608. [PMID: 36963058 PMCID: PMC10022755 DOI: 10.1371/journal.pgph.0001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/20/2023] [Indexed: 03/19/2023]
Abstract
As the frequency of international travel increases, more individuals are at risk of travel-acquired infections (TAIs). In this ecological study of over 170,000 unique tests from Public Health Ontario's laboratory, we reviewed all laboratory-reported cases of malaria, dengue, chikungunya, and enteric fever in Ontario, Canada between 2008-2020 to identify high-resolution geographical clusters for potential targeted pre-travel prevention. Smoothed standardized incidence ratios (SIRs) and 95% posterior credible intervals (CIs) were estimated using a spatial Bayesian hierarchical model. High- and low-incidence areas were described using data from the 2016 Census based on the home forward sortation area of patients testing positive. A second model was used to estimate the association between drivetime to the nearest travel clinic and incidence of TAI within high-incidence areas. There were 6,114 microbiologically confirmed TAIs across Ontario over the study period. There was spatial clustering of TAIs (Moran's I = 0.59, p<0.0001). Compared to low-incidence areas, high-incidence areas had higher proportions of immigrants (p<0.0001), were lower income (p = 0.0027), had higher levels of university education (p<0.0001), and less knowledge of English/French languages (p<0.0001). In the high-incidence Greater Toronto Area (GTA), each minute increase in drive time to the closest travel clinic was associated with a 3% reduction in TAI incidence (95% CI 1-6%). While urban neighbourhoods in the GTA had the highest burden of TAIs, geographic proximity to a travel clinic in the GTA was not associated with an area-level incidence reduction in TAI. This suggests other barriers to seeking and adhering to pre-travel advice.
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Affiliation(s)
- Vinyas Harish
- MD/PhD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Emmalin Buajitti
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Holly Burrows
- Yale School of Public Health, Yale University, New Haven, CT, United States of America
| | - Joshua Posen
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, Canada
| | - Isaac I. Bogoch
- Division of Infectious Diseases, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Jonathan B. Gubbay
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura C. Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Shaun K. Morris
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- * E-mail:
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Clarke P, Khan AM, Kamdar N, Seiler K, Latham-Mintus K, Peterson MD, Meade MA, Ehrlich JR. Risk of type 2 diabetes mellitus among adults aging with vision impairment: The role of the neighborhood environment. Disabil Health J 2023; 16:101371. [PMID: 36130856 PMCID: PMC9772041 DOI: 10.1016/j.dhjo.2022.101371] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/14/2022] [Accepted: 08/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vision impairment (VI) affects approximately 1 in 28 Americans over the age of 40 and the prevalence increases sharply with age. However, experiencing vision loss with aging can be very different from aging with VI acquired earlier in life. People aging with VI may be at increased risk for diabetes due to environmental barriers in accessing health care, healthy food, and recreational resources that can facilitate positive health behaviors. OBJECTIVE This study examined the relationship between neighborhood characteristics and incident type 2 diabetes mellitus (T2DM) among a cohort of 22,719 adults aging with VI. METHODS Data are from Optum® Clinformatics® DataMart, a private administrative claims database (2008-2017). Individuals 18 years of age and older at the time of their initial VI diagnosis were eligible for analysis. VI was determined using vision impairment, low vision, and blindness codes (ICD-9-CM, ICD-10-CM). Covariates included age, sex, and comorbidities. Cox models estimated adjusted hazard ratios (HRs) for incident T2DM. Stratified models examined differences in those aging with (age 18-64) and aging into (age 65+) vision impairment. RESULTS Residence in neighborhoods with greater intersection density (HR = 1.26) and high-speed roads (HR = 1.22) were associated with increased risk of T2DM among older adults with VI. Living in neighborhoods with broadband internet access (HR = 0.67), optical stores (HR = 0.62), supermarkets (HR = 0.78), and gyms/fitness centers (HR = 0.63) was associated with reduced risk of T2DM for both younger and older adults with VI. CONCLUSIONS Findings emphasize the importance of neighborhood context for mitigating the adverse consequences of vision loss for health.
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Affiliation(s)
- Philippa Clarke
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; University of Michigan Center for Disability Health and Wellness, Ann Arbor, MI, USA.
| | - Anam M Khan
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; University of Michigan Center for Disability Health and Wellness, Ann Arbor, MI, USA
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; University of Michigan Center for Disability Health and Wellness, Ann Arbor, MI, USA; Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kristian Seiler
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Kenzie Latham-Mintus
- Department of Sociology, Indiana University School of Liberal Arts, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Mark D Peterson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; University of Michigan Center for Disability Health and Wellness, Ann Arbor, MI, USA; Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michelle A Meade
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; University of Michigan Center for Disability Health and Wellness, Ann Arbor, MI, USA; Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Joshua R Ehrlich
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; University of Michigan Center for Disability Health and Wellness, Ann Arbor, MI, USA; Department of Ophthalmology & Visual Sciences, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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29
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Russell O, Lester S, Black RJ, Hill CL. Socioeconomic Status and Medication Use in Rheumatoid Arthritis: A Scoping Review. Arthritis Care Res (Hoboken) 2023; 75:92-100. [PMID: 36106932 PMCID: PMC10100498 DOI: 10.1002/acr.25024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/22/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Socioeconomic status (SES) influences disease outcomes in rheumatoid arthritis (RA) patients. Differences in medication use may partly explain this association. A scoping review was used to identify research conducted on this topic and determine what knowledge gaps remain. METHODS Medline, Embase, and PsychInfo were searched from their inception until February 2022 for studies that assessed SES and medication use as an outcome variable. Data was extracted on the use of specific SES measures, medication use, and whether differences in SES variables were associated with differences in medication use. RESULTS We identified 2,103 studies, of which 81 were selected for inclusion. Included studies originated most frequently from the US (42%); the mean ± SD age of participants was 55.9 ± 6.8 years, and most were female (75%). Studies measured a median of 4 SES variables (interquartile range 3-6), with educational, area-level SES, and income being the most frequent measurements used. Patients' race and/or ethnicity were documented by 34 studies. Studies primarily assessed the likelihood of prescription of disease-modifying antirheumatic drugs or dispensation, medication adherence, or treatment delays. A majority of studies documented at least 1 SES measure associated with a difference in medication use. CONCLUSION There is some evidence that SES affects use of medications in patients with RA; however, multiple definitions of SES have been utilized, making comparisons between studies difficult. Prospective studies with consistently defined SES will be needed to determine whether differences in medication use accounts for the poorer outcomes experienced by patients of lower SES.
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Affiliation(s)
- Oscar Russell
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Susan Lester
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rachel J Black
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and Adelaide Medical School, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Catherine L Hill
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia, and Adelaide Medical School, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Tweel M, Johnston GM, Hajizadeh M. Trends in Socioeconomic Inequalities in Breast Cancer Incidence Among Women in Canada. Cancer Control 2023; 30:10732748231197580. [PMID: 37608582 PMCID: PMC10467209 DOI: 10.1177/10732748231197580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Breast cancer is the most common cancer among females in Canada. This study examines trends in socioeconomic inequalities in the incidence of breast cancer in Canada over time from 1992 to 2010. METHODS A census division level dataset was constructed using the Canadian Cancer Registry, Canadian Census of the Population and National Household Survey. A summary measure of the Concentration index (C), which captures inequality across socioeconomic groups, was used to measure income and education inequalities in breast cancer incidence over the 19-year period. RESULTS The crude breast cancer incidence increased in Canada between 1992 and 2010. Age-standardized C values indicated no income or education inequalities in breast cancer incidence in the years from 1992 to 2004. However, the incidence was significantly concentrated among females in high income and highly educated neighbourhoods almost half the time in the 6 most recent years (2005-2010). The trend analysis indicated an increase in breast cancer incidence among females living in high income and highly educated neighbourhoods. CONCLUSION Breast cancer incidence in Canada was associated with increased socioeconomic status in some more recent years. Our study findings provide previously unavailable empirical evidence to inform discussions on socioeconomic inequalities in breast incidence.
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Affiliation(s)
- Madeline Tweel
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Grace M. Johnston
- School of Health Administration, Dalhousie University, Halifax, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Halifax, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, Canada
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Kim U, Koroukian SM, Stange KC, Spilsbury JC, Dong W, Rose J. Describing and assessing a new method of approximating categorical individual-level income using community-level income from the census (weighting by income probabilities). Health Serv Res 2022; 57:1348-1360. [PMID: 35832029 PMCID: PMC9643096 DOI: 10.1111/1475-6773.14026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess a new approach (weighting by "income probabilities [IP]") that uses US Census data from the patients' communities to approximate individual-level income, an important but often missing variable in health services research. DATA SOURCES Community (census tract level) income data came from the 2017 5-year American Community Survey (ACS). The patient data included those diagnosed with cancer in 2017 in Ohio (n = 65,759). The reference population was the 2017 5-year ACS Public Use Microdata Sample (n = 564,357 generalizing to 11,288,350 Ohioans). STUDY DESIGN/METHODS We applied the traditional approach of income approximation using median census tract income along with two IP based approaches to estimate the proportions in the patient data with incomes of 0%-149%, 150%-299%, 300%-499%, and 500%+ of the federal poverty level (FPL) ("class-relevant income grouping") or 0%-138%, 139%-249%, 250%-399%, and 400%+ FPL ("policy-relevant income grouping"). These estimated income distributions were then compared with the known income distributions of the reference population. DATA COLLECTION/EXTRACTION METHODS The patient data came from Ohio's cancer registry. The other data were publicly available. PRINCIPAL FINDINGS Both IP based approaches consistently outperformed the traditional approach overall and in subgroup analyses, as measured by the weighted average absolute percentage point differences between the proportions of each of the income categories of the reference population and the estimated proportions generated by the income approximation approaches ("average percent difference," or APD). The smallest APD for an IP based method, 0.5%, was seen in non-Hispanic White females in the class-relevant income grouping (compared with 16.5% for the conventional method), while the largest APD, 7.1%, was seen in non-Hispanic Black females in the policy-relevant income grouping (compared with 18.0% for the conventional method). CONCLUSIONS Weighting by IP substantially outperformed the conventional approach of estimating the distribution of incomes in patient data.
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Affiliation(s)
- Uriel Kim
- Center for Community Health IntegrationCase Western Reserve University School of MedicineClevelandOhioUSA
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOhioUSA
- Department of Population and Quantitative Health SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
- Kellogg School of ManagementNorthwestern UniversityEvanstonILUSA
| | - Siran M. Koroukian
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOhioUSA
- Department of Population and Quantitative Health SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
- Population Cancer Analytics Shared ResourceCase Comprehensive Cancer CenterClevelandOhioUSA
| | - Kurt C. Stange
- Center for Community Health IntegrationCase Western Reserve University School of MedicineClevelandOhioUSA
| | - James C. Spilsbury
- Department of Population and Quantitative Health SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
| | - Weichuan Dong
- Department of Population and Quantitative Health SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
- Population Cancer Analytics Shared ResourceCase Comprehensive Cancer CenterClevelandOhioUSA
| | - Johnie Rose
- Center for Community Health IntegrationCase Western Reserve University School of MedicineClevelandOhioUSA
- Case Comprehensive Cancer CenterCase Western Reserve University School of MedicineClevelandOhioUSA
- Population Cancer Analytics Shared ResourceCase Comprehensive Cancer CenterClevelandOhioUSA
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van Ingen T, Brown KA, Buchan SA, Akingbola S, Daneman N, Warren CM, Smith BT. Neighbourhood-level socio-demographic characteristics and risk of COVID-19 incidence and mortality in Ontario, Canada: A population-based study. PLoS One 2022; 17:e0276507. [PMID: 36264984 PMCID: PMC9584389 DOI: 10.1371/journal.pone.0276507] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/07/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES We aimed to estimate associations between COVID-19 incidence and mortality with neighbourhood-level immigration, race, housing, and socio-economic characteristics. METHODS We conducted a population-based study of 28,808 COVID-19 cases in the provincial reportable infectious disease surveillance systems (Public Health Case and Contact Management System) which includes all known COVID-19 infections and deaths from Ontario, Canada reported between January 23, 2020 and July 28, 2020. Residents of congregate settings, Indigenous communities living on reserves or small neighbourhoods with populations <1,000 were excluded. Comparing neighbourhoods in the 90th to the 10th percentiles of socio-demographic characteristics, we estimated the associations between 18 neighbourhood-level measures of immigration, race, housing and socio-economic characteristics and COVID-19 incidence and mortality using Poisson generalized linear mixed models. RESULTS Neighbourhoods with the highest proportion of immigrants (relative risk (RR): 4.0, 95%CI:3.5-4.5) and visible minority residents (RR: 3.3, 95%CI:2.9-3.7) showed the strongest association with COVID-19 incidence in adjusted models. Among individual race groups, COVID-19 incidence was highest among neighbourhoods with the high proportions of Black (RR: 2.4, 95%CI:2.2-2.6), South Asian (RR: 1.9, 95%CI:1.8-2.1), Latin American (RR: 1.8, 95%CI:1.6-2.0) and Middle Eastern (RR: 1.2, 95%CI:1.1-1.3) residents. Neighbourhoods with the highest average household size (RR: 1.9, 95%CI:1.7-2.1), proportion of multigenerational families (RR: 1.8, 95%CI:1.7-2.0) and unsuitably crowded housing (RR: 2.1, 95%CI:2.0-2.3) were associated with COVID-19 incidence. Neighbourhoods with the highest proportion of residents with less than high school education (RR: 1.6, 95%CI:1.4-1.8), low income (RR: 1.4, 95%CI:1.2-1.5) and unaffordable housing (RR: 1.6, 95%CI:1.4-1.8) were associated with COVID-19 incidence. Similar inequities were observed across neighbourhood-level sociodemographic characteristics and COVID-19 mortality. CONCLUSIONS Neighbourhood-level inequities in COVID-19 incidence and mortality were observed in Ontario, with excess burden experienced in neighbourhoods with a higher proportion of immigrants, racialized populations, large households and low socio-economic status.
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Affiliation(s)
| | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sarah A. Buchan
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Brendan T. Smith
- Public Health Ontario, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Measuring disadvantage in the early years in the UK: A systematic scoping review. SSM Popul Health 2022; 19:101206. [PMID: 36105560 PMCID: PMC9465426 DOI: 10.1016/j.ssmph.2022.101206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/14/2022] [Accepted: 08/10/2022] [Indexed: 11/20/2022] Open
Abstract
Background The relationship between disadvantage and child health in the early years is well established. For this evidence base to most helpfully inform services, we need to better understand how disadvantage is conceptualised and measured in the literature. We aimed to conceptualise disadvantage measured in child health literature and explore the associations between disadvantage and child health using these measures. Method We conducted a scoping review using systematic methods to identify key concepts of disadvantage used in empirical child health literature. We searched MEDLINE, Scopus, and grey literature for studies exploring the association between disadvantage and child health outcomes for children aged 0–5 in the United Kingdom. We extracted and analysed data from 86 studies. Results We developed a framework describing two domains, each with two attributes conceptualising disadvantage: level of disadvantage indicator (individual and area) and content of disadvantage indicator (social and economic). Individual-level measures of disadvantage tended to identify stronger associations between disadvantage and child health compared with area-level measures. Conclusion The choice of disadvantage indicators, particularly whether individual- or area-level, can affect the inferences made about the relationship between disadvantage and child health. Better access to individual-level disadvantage indicators in administrative data could support development and implementation of interventions aimed at reducing child health inequalities in the early years. Measurement of disadvantage in child health is wide-ranging and multi-dimensional. Social, economic, individual, and area-level are key concepts of disadvantage. Area-level measures underestimate the association between disadvantage and child health. Individual-level disadvantage indicators are needed in administrative data. Policymakers planning child health interventions should measure disadvantage carefully.
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Khodayari Moez E, Maximova K, Sim S, Senthilselvan A, Pabayo R. Developing a Socioeconomic Status Index for Chronic Disease Prevention Research in Canada. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:7800. [PMID: 35805461 PMCID: PMC9265839 DOI: 10.3390/ijerph19137800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 01/27/2023]
Abstract
Capturing socioeconomic inequalities in relation to chronic disease is challenging since socioeconomic status (SES) encompasses many aspects. We constructed a comprehensive individual-level SES index based on a broad set of social and demographic indicators (gender, education, income adequacy, occupational prestige, employment status) and examined its relationship with smoking, a leading chronic disease risk factor. Analyses were based on baseline data from 17,371 participants of Alberta’s Tomorrow Project (ATP), a prospective cohort of adults aged 35−69 years with no prior personal history of cancer. To construct the SES index, we used principal component analysis (PCA) and to illustrate its utility, we examined the association with smoking intensity and smoking history using multiple regression models, adjusted for age and gender. Two components were retained from PCA, which explained 61% of the variation. The SES index was best aligned with educational attainment and occupational prestige, and to a lesser extent, with income adequacy. In the multiple regression analysis, the SES index was negatively associated with smoking intensity (p < 0.001). Study findings highlight the potential of using individual-level SES indices constructed from a broad set of social and demographic indicators in epidemiological research.
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Affiliation(s)
- Elham Khodayari Moez
- School of Public Health, University of Alberta, 3-300 ECHA, 11405 87 Avenue, Edmonton, AB T6G 1C9, Canada; (E.K.M.); (S.S.); (A.S.); (R.P.)
| | - Katerina Maximova
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria St, Toronto, ON M5B 1T8, Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON M5T 3M7, Canada
| | - Shannon Sim
- School of Public Health, University of Alberta, 3-300 ECHA, 11405 87 Avenue, Edmonton, AB T6G 1C9, Canada; (E.K.M.); (S.S.); (A.S.); (R.P.)
| | - Ambikaipakan Senthilselvan
- School of Public Health, University of Alberta, 3-300 ECHA, 11405 87 Avenue, Edmonton, AB T6G 1C9, Canada; (E.K.M.); (S.S.); (A.S.); (R.P.)
| | - Roman Pabayo
- School of Public Health, University of Alberta, 3-300 ECHA, 11405 87 Avenue, Edmonton, AB T6G 1C9, Canada; (E.K.M.); (S.S.); (A.S.); (R.P.)
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Buajitti E, Rosella LC. Neighbourhood socioeconomic improvement, residential mobility and premature death: a population-based cohort study and inverse probability of treatment weighting analysis. Int J Epidemiol 2022; 52:489-500. [PMID: 35656702 PMCID: PMC10114058 DOI: 10.1093/ije/dyac117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/20/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Causal inference using area-level socioeconomic measures is challenging due to risks of residual confounding and imprecise specification of the neighbourhood-level social exposure. By using multi-linked longitudinal data to address these common limitations, our study aimed to identify protective effects of neighbourhood socioeconomic improvement on premature mortality risk. METHODS We used data from the Canadian Community Health Survey, linked to health administrative data, including longitudinal residential history. Individuals aged 25-69, living in low-socioeconomic status (SES) areas at survey date (n = 8335), were followed up for neighbourhood socioeconomic improvement within 5 years. We captured premature mortality (death before age 75) until 2016. We estimated protective effects of neighbourhood socioeconomic improvement exposures using Cox proportional hazards models. Stabilized inverse probability of treatment weights (IPTW) were used to account for confounding by baseline health, social and behavioural characteristics. Separate analyses were carried out for three exposure specifications: any improvement, improvement by residential mobility (i.e. movers) or improvement in place (non-movers). RESULTS Overall, 36.9% of the study cohort experienced neighbourhood socioeconomic improvement either by residential mobility or improvement in place. There were noted differences in baseline health status, demographics and individual SES between exposure groups. IPTW survival models showed a modest protective effect on premature mortality risk of socioeconomic improvement overall (HR = 0.86; 95% CI 0.63, 1.18). Effects were stronger for improvement in place (HR = 0.67; 95% CI 0.48, 0.93) than for improvement by residential mobility (HR = 1.07, 95% 0.67, 1.51). CONCLUSIONS Our study provides robust evidence that specific neighbourhood socioeconomic improvement exposures are important for determining mortality risks.
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Affiliation(s)
- Emmalin Buajitti
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,ICES, Toronto, ON, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Department of Laboratory Medicine & Pathology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Camden A, To T, Ray JG, Gomes T, Bai L, Guttmann A. Categorization of Opioid Use Among Pregnant People and Association With Overdose or Death. JAMA Netw Open 2022; 5:e2214688. [PMID: 35622361 PMCID: PMC9142862 DOI: 10.1001/jamanetworkopen.2022.14688] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/13/2022] [Indexed: 12/12/2022] Open
Abstract
Importance Early identification of people who use opioids in pregnancy may improve health outcomes for pregnant people and infants. However, characterization of diverse circumstances surrounding type of opioid use and indications for opioid use are lacking. Objective To develop clinically distinct groups of people who use opioids in pregnancy and to evaluate their association with drug overdose or death up to 1 year post partum. Design, Setting, and Participants This is a population-based, repeated cross-sectional study conducted in Ontario, Canada, with participants who used opioids in pregnancy who had a live birth or stillbirth between January 1, 2014, and December 31, 2019, identified in health administrative databases. Data were analyzed from August 2020 to January 2021. Exposures Prenatal opioid use. Main Outcomes and Measures Latent class analysis (LCA), based on prenatal opioid use and 19 socioeconomic and medical characteristics, first identified clinically distinct groups of opioid users. Then, within the optimally derived LCA-derived group, adjusted relative risks (aRRs) were generated for the outcome of drug overdose or all-cause death within 1 year post partum, adjusting for birthing parent age and year of delivery. Results The analysis included 31 241 people with prenatal opioid use (mean [SD] age, 30.0 [5.6] years; 86.1% [26 908 individuals] Canadian-born; 30.6% [9574 individuals] lived in low-income neighborhoods). LCA generated a 5-group model that optimally distinguished opioid users in pregnancy as follows: short-term analgesia with low comorbidity (group 1), analgesia in young people (group 2), medication for opioid use disorder or unregulated opioid use (group 3), pain management with comorbidity (group 4), and mixed opioid use plus high social and medical needs (group 5). The overall risk of postpartum drug overdose or death was 1.5%. Using the 5-group model, compared with people in group 1, the aRR of overdose or death was highest among those in group 5 (aRR, 14.0; 95% CI, 10.1-19.5), followed by group 3 (aRR, 4.6; 95% CI, 3.3-6.5), group 2 (aRR, 3.3; 95% CI, 2.2-4.7), and group 4 (aRR, 3.2; 95% CI, 2.3-4.4). Conclusions and Relevance In this cross-sectional study, distinct groups of people with opioid use in pregnancy were associated with increasing degrees of risk of postpartum drug overdose or death. Group characteristics can be used to identify people with high risk and inform harm reduction, home visiting programs, and other interventions.
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Affiliation(s)
- Andi Camden
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Teresa To
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joel G. Ray
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, St Michaels Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin SH Leong Centre, University of Toronto, Toronto, Ontario, Canada
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Atrey A, Pincus D, Khoshbin A, Haddad FS, Ward S, Aktar S, Ladha K, Ravi B. Access to hip arthroplasty and rates of complications in different socioeconomic groups : a review of 111,000 patients in a universal healthcare system. Bone Joint J 2022; 104-B:589-597. [PMID: 35491583 DOI: 10.1302/0301-620x.104b5.bjj-2021-1520.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups. METHODS We conducted a retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, over a 17-year period. Patients were divided into income quintiles based on postal codes as a proxy for personal economic status. Multivariable logistic regression models were then used to primarily assess the relationship between SES and surgical complications within one year of index THA. RESULTS Of 111,359 patients who underwent elective primary THA, those in the lower SES groups had statistically significantly more comorbidities and statistically significantly more postoperative complications. While there was no increase in readmission rates within 90 days, there was a statistically significant difference in the primary and secondary outcomes including all revisions due (with a subset of deep wound infection and dislocation). Results showed that those in the higher SES groups had proportionally more cases performed than those in lower groups. Compared to the highest SES quintile, the lower groups had 61% of the number of hip arthroplasties performed. CONCLUSION Patients in lower socioeconomic groups have more comorbidities, fewer absolute number of cases performed, have their procedures performed in lower-volume centres, and ultimately have higher rates of complications. This lack of access and higher rates of complications is a "double hit" to those in lower SES groups, and indicates that we should be concentrating efforts to improve access to surgeons and hospitals where arthroplasty is routinely performed in high numbers. Even in a universal healthcare system where there are no penalties for complications such as readmission, there seems to be an inequality in the access to THA. Cite this article: Bone Joint J 2022;104-B(5):589-597.
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Affiliation(s)
- Amit Atrey
- Orthopaedics, Saint Michael's Hospital, Toronto, Canada.,Division of Orthopaedics, University of Toronto, Toronto, Canada
| | - Daniel Pincus
- Division of Orthopaedics, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Amir Khoshbin
- Division of Orthopaedics, University of Toronto, Toronto, Canada
| | - Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Sarah Ward
- Division of Orthopaedics, University of Toronto, Toronto, Canada
| | - Suriya Aktar
- Orthopaedics, Saint Michael's Hospital, Toronto, Canada
| | - Karim Ladha
- Orthopaedics, Saint Michael's Hospital, Toronto, Canada.,Division of Orthopaedics, University of Toronto, Toronto, Canada
| | - Bheeshma Ravi
- Division of Orthopaedics, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada
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Williams NG, Gorey KM, Alberton AM. Motor vehicle collision-related injuries and deaths among Indigenous Peoples in Canada: Meta-analysis of geo-structural factors. CANADIAN JOURNAL OF RURAL MEDICINE 2022; 27:51-60. [PMID: 35343182 DOI: 10.4103/cjrm.cjrm_42_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Indigenous Peoples are much more likely than non-Indigenous Peoples to be seriously injured or die in motor vehicle collisions (MVCs). This study updates and extends a previous systematic review, suggesting that future research ought to incorporate social-environmental factors. Methods We conducted a systematic review and meta-analysis of the published and grey literature on MVCs involving Indigenous Peoples in Canada between 2010 and 2020. We focussed on personal (e.g. driving an old vehicle) and community social-environmental-economic factors (e.g. prevalent low socioeconomic status). Results Eleven comparative cohorts that resulted in 23 at minimum, age-standardised, mortality or morbidity rate outcomes were included in our meta-analysis. Indigenous Peoples were twice as likely as non-Indigenous Peoples to be seriously injured (rate ratio [RRpooled] = 2.18) and more than 3 times as likely to die (RRpooled = 3.40) in MVCs. Such great risks to Indigenous Peoples do not seem to have diminished over the past generation. Furthermore, such risks were greater on-reserves and in smaller, rural and remote, places. Conclusion Such places may lack community resources, including fewer transportation and healthcare infrastructural investments, resulting in poorer road conditions in Indigenous communities and longer delays to trauma care. This seems to add further evidence of geo-structural violence (geographical and institutional violence) perpetrated against Indigenous Peoples in yet more structures (i.e. institutions) of Canadian society. Canada's system of highways and roadways and its remote health-care system represent legitimate policy targets in aiming to solve this public health problem.
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Affiliation(s)
| | - Kevin M Gorey
- School of Social Work, University of Windsor, Ontario, Canada
| | - Amy M Alberton
- School of Social Work, Wichita State University, Wichita, Kansas, USA
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de Oliveira C, Mondor L, Wodchis WP, Rosella LC. Looking beyond Administrative Health Care Data: The Role of Socioeconomic Status in Predicting Future High-cost Patients with Mental Health and Addiction. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:140-152. [PMID: 33792407 PMCID: PMC8892069 DOI: 10.1177/07067437211004882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Previous research has shown that the socioeconomic status (SES)-health gradient also extends to high-cost patients; however, little work has examined high-cost patients with mental illness and/or addiction. The objective of this study was to examine associations between individual-, household- and area-level SES factors and future high-cost use among these patients. METHODS We linked survey data from adult participants (ages 18 and older) of 3 cycles of the Canadian Community Health Survey to administrative health care data from Ontario, Canada. Respondents with mental illness and/or addiction were identified based on prior mental health and addiction health care use and followed for 5 years for which we ascertained health care costs covered under the public health care system. We quantified associations between SES factors and becoming a high-cost patient (i.e., transitioning into the top 5%) using logistic regression models. For ordinal SES factors, such as income, education and marginalization variables, we measured absolute and relative inequalities using the slope and relative index of inequality. RESULTS Among our sample, lower personal income (odds ratio [OR] = 2.11, 95% confidence interval [CI], 1.54 to 2.88, for CAD$0 to CAD$14,999), lower household income (OR = 2.11, 95% CI, 1.49 to 2.99, for lowest income quintile), food insecurity (OR = 1.87, 95% CI, 1.38 to 2.55) and non-homeownership (OR = 1.34, 95% CI, 1.08 to 1.66), at the individual and household levels, respectively, and higher residential instability (OR = 1.72, 95% CI, 1.23 to 2.42, for most marginalized), at the area level, were associated with higher odds of becoming a high-cost patient within a 5-year period. Moreover, the inequality analysis suggested pro-high-SES gradients in high-cost transitions. CONCLUSIONS Policies aimed at high-cost patients with mental illness and/or addiction, or those concerned with preventing individuals with these conditions from becoming high-cost patients in the health care system, should also consider non-clinical factors such as income as well as related dimensions including food security and homeownership.
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Affiliation(s)
- Claire de Oliveira
- Centre for Health Economics, University of York, United Kingdom.,Hull York Medical School, University of York, United Kingdom.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Health System Performance Network (HSPN), Toronto, Ontorio, Canada
| | - Luke Mondor
- ICES, Toronto, Ontario, Canada.,Health System Performance Network (HSPN), Toronto, Ontorio, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Health System Performance Network (HSPN), Toronto, Ontorio, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Laura C Rosella
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Ontario, Canada.,Population Health Analytics Laboratory, Toronto, Ontario, Canada.,Public Health Ontario, Toronto, Ontario, Canada
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A Population-based Analysis of the COVID-19 Generated Surgical Backlog and Associated Emergency Department Presentations for Inguinal Hernias and Gallstone Disease. Ann Surg 2022; 275:836-841. [PMID: 35081578 PMCID: PMC9083314 DOI: 10.1097/sla.0000000000005403] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the downstream effects of the COVID-19 generated surgical backlog. BACKGROUND Delayed elective surgeries may result in emergency department (ED) presentations and the need for urgent interventions. METHODS Population-based repeated cross-sectional study utilizing administrative data. We quantified rates of elective cholecystectomy and inguinal hernia repair and rates of ED presentations, urgent interventions, and outcomes during the first and second waves of COVID-19 (March 1, 2020-February 28, 2021) as compared to a 3-year pre-COVID-19 period (January 1, 2017-February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates during COVID-19 based on the pre-COVID-19 period. The ratio of observed (actual events) to expected rates was generated for surgical procedures (SRRs) and ED visits (ED-RRs). RESULTS We identified 74,709 elective cholecystectomies and 60,038 elective inguinal hernia repairs. During the COVID-19 period, elective inguinal hernia repairs decreased by 21% (SRR 0.791; 0.760-0.824) whereas elective cholecystectomies decreased by 23% (SRR 0.773; 0.732-0.816). ED visits for inguinal hernia decreased by 17% (ED-RR 0.829; 0.786-0.874) whereas ED visits for gallstones decreased by 8% (ED-RR 0.922; 0.878-0.967). A higher population rate of urgent cholecystectomy was observed, particularly after the first wave (SRR 1.076; 1.000-1.158). No difference was seen in inguinal hernias. CONCLUSIONS An over 20% reduction in elective surgeries and an increase in urgent cholecystectomies was observed during the COVID-19 period suggesting a rebound effect secondary to the surgical backlog. The COVID-19 generated surgical backlog will have a heterogeneous downstream effect with significant implications for surgical recovery planning.
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Althoff T, Nilforoshan H, Hua J, Leskovec J. Large-scale diet tracking data reveal disparate associations between food environment and diet. Nat Commun 2022; 13:267. [PMID: 35042849 PMCID: PMC8766578 DOI: 10.1038/s41467-021-27522-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 11/18/2021] [Indexed: 02/07/2023] Open
Abstract
An unhealthy diet is a major risk factor for chronic diseases including cardiovascular disease, type 2 diabetes, and cancer1-4. Limited access to healthy food options may contribute to unhealthy diets5,6. Studying diets is challenging, typically restricted to small sample sizes, single locations, and non-uniform design across studies, and has led to mixed results on the impact of the food environment7-23. Here we leverage smartphones to track diet health, operationalized through the self-reported consumption of fresh fruits and vegetables, fast food and soda, as well as body-mass index status in a country-wide observational study of 1,164,926 U.S. participants (MyFitnessPal app users) and 2.3 billion food entries to study the independent contributions of fast food and grocery store access, income and education to diet health outcomes. This study constitutes the largest nationwide study examining the relationship between the food environment and diet to date. We find that higher access to grocery stores, lower access to fast food, higher income and college education are independently associated with higher consumption of fresh fruits and vegetables, lower consumption of fast food and soda, and lower likelihood of being affected by overweight and obesity. However, these associations vary significantly across zip codes with predominantly Black, Hispanic or white populations. For instance, high grocery store access has a significantly larger association with higher fruit and vegetable consumption in zip codes with predominantly Hispanic populations (7.4% difference) and Black populations (10.2% difference) in contrast to zip codes with predominantly white populations (1.7% difference). Policy targeted at improving food access, income and education may increase healthy eating, but intervention allocation may need to be optimized for specific subpopulations and locations.
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Affiliation(s)
- Tim Althoff
- Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA.
| | - Hamed Nilforoshan
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Jenna Hua
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Million Marker Wellness Inc., San Francisco, CA, USA
| | - Jure Leskovec
- Department of Computer Science, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
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van Ingen T, Brown KA, Buchan SA, Akingbola S, Daneman N, Warren CM, Smith BT. Neighbourhood-level socio-demographic characteristics and risk of COVID-19 incidence and mortality in Ontario, Canada: A population-based study. PLoS One 2022; 17:e0276507. [PMID: 36264984 DOI: 10.1101/2021.01.27.21250618] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/07/2022] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVES We aimed to estimate associations between COVID-19 incidence and mortality with neighbourhood-level immigration, race, housing, and socio-economic characteristics. METHODS We conducted a population-based study of 28,808 COVID-19 cases in the provincial reportable infectious disease surveillance systems (Public Health Case and Contact Management System) which includes all known COVID-19 infections and deaths from Ontario, Canada reported between January 23, 2020 and July 28, 2020. Residents of congregate settings, Indigenous communities living on reserves or small neighbourhoods with populations <1,000 were excluded. Comparing neighbourhoods in the 90th to the 10th percentiles of socio-demographic characteristics, we estimated the associations between 18 neighbourhood-level measures of immigration, race, housing and socio-economic characteristics and COVID-19 incidence and mortality using Poisson generalized linear mixed models. RESULTS Neighbourhoods with the highest proportion of immigrants (relative risk (RR): 4.0, 95%CI:3.5-4.5) and visible minority residents (RR: 3.3, 95%CI:2.9-3.7) showed the strongest association with COVID-19 incidence in adjusted models. Among individual race groups, COVID-19 incidence was highest among neighbourhoods with the high proportions of Black (RR: 2.4, 95%CI:2.2-2.6), South Asian (RR: 1.9, 95%CI:1.8-2.1), Latin American (RR: 1.8, 95%CI:1.6-2.0) and Middle Eastern (RR: 1.2, 95%CI:1.1-1.3) residents. Neighbourhoods with the highest average household size (RR: 1.9, 95%CI:1.7-2.1), proportion of multigenerational families (RR: 1.8, 95%CI:1.7-2.0) and unsuitably crowded housing (RR: 2.1, 95%CI:2.0-2.3) were associated with COVID-19 incidence. Neighbourhoods with the highest proportion of residents with less than high school education (RR: 1.6, 95%CI:1.4-1.8), low income (RR: 1.4, 95%CI:1.2-1.5) and unaffordable housing (RR: 1.6, 95%CI:1.4-1.8) were associated with COVID-19 incidence. Similar inequities were observed across neighbourhood-level sociodemographic characteristics and COVID-19 mortality. CONCLUSIONS Neighbourhood-level inequities in COVID-19 incidence and mortality were observed in Ontario, with excess burden experienced in neighbourhoods with a higher proportion of immigrants, racialized populations, large households and low socio-economic status.
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Affiliation(s)
| | - Kevin A Brown
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sarah A Buchan
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Brendan T Smith
- Public Health Ontario, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Hajizadeh M, Whelan A, Johnston GM, Urquhart R. Socioeconomic Gradients in Prostate Cancer Incidence Among Canadian Males: A Trend Analysis From 1992 to 2010. Cancer Control 2021; 28:10732748211055272. [PMID: 34889129 PMCID: PMC8669872 DOI: 10.1177/10732748211055272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Understanding the effects of socioeconomic status on cancer incidence and their trends over time will help inform public health interventions for cancer control. This study sought to investigate trends in socioeconomic inequalities in prostate cancer incidence among Canadian males. Methods Using a census division level dataset (n = 280) constructed from the Canadian Cancer Registry, Canadian Census of Population (1992, 1996, 2001, 2006) and 2011 National Household Survey, we examined the effect of socioeconomic status on prostate cancer incidence among Canadian males between 1992 and 2010. The age-adjusted concentration index was used to quantify education/income-related inequalities in prostate cancer incidence. Results The crude prostate cancer incidence increased from 115 to 137 per 100 000 males in Canada from 1992 to 2010 with a peak in 2007. The rate increased significantly in all but three of four western provinces. The age-adjusted concentration index showed a higher concentration of prostate cancer diagnoses among males living in high-income neighbourhoods in Canada in particular from 1996 to 2005. In contrast, the index was higher among males living in less-educated neighbourhoods in the most recent study years (2006–2010). Conclusions The concentration of new prostate cancer cases among high-income populations in Canada may be explained by the rise of opportunistic screening of asymptomatic males; however, this should be studied in further detail. Since we found a higher incidence rate of prostate cancer among less-educated males in Canada in recent years, risk-benefit investigation of primary prevention and opportunistic screening for less-educated males is advised.
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Affiliation(s)
- Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, 3688Dalhousie University, Halifax, NS, Canada
| | - Ashley Whelan
- 12361Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Grace M Johnston
- Cancer Care Program, and School of Health Administration, 3688Dalhousie University, Halifax, NS, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Faculty of Medicine, 3688Dalhousie University, Halifax, NS, Canada
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Hajizadeh M, Charles M, Johnston GM, Urquhart R. Socioeconomic inequalities in colorectal cancer incidence in Canada: trends over two decades. Cancer Causes Control 2021; 33:193-204. [PMID: 34779993 DOI: 10.1007/s10552-021-01518-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Colorectal cancer is the third most commonly diagnosed cancer in Canada. This study aimed to measure and examine trends in socioeconomic inequalities in the incidence of colorectal cancer in Canada. METHODS This study is a time trend ecological study based on Canadian Census Division level data constructed from the Canadian Cancer Registry, Canadian Census of Population, and National Household Survey. We assessed trends in income and education inequalities in colorectal cancer incidence in Canada from 1992 to 2010. The age-standardized Concentration index ([Formula: see text]), which measures inequality across all socioeconomic groups, was used to quantify socioeconomic inequalities in colorectal cancer incidence in Canada. RESULTS The average crude colorectal cancer incidence was found to be 61.52 per 100,000 population over the study period, with males having a higher incidence rate than females (males: 66.98; females: 56.25 per 100,000 population). The crude incidence increased over time and varied by province. The age-standardized C indicated a higher concentration of colorectal cancer incidence among lower income and less-educated neighborhoods in Canada. Income and education inequalities increased over time among males. CONCLUSION The concentration of colorectal cancer incidence in low socioeconomic neighborhoods in Canada has implications for primary prevention and screening.
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Affiliation(s)
- Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2nd Floor, Halifax, NS, B3H 4R2, Canada.
| | - Marie Charles
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Grace M Johnston
- Cancer Care Program, Nova Scotia Health, School of Health Administration, Dalhousie University, Halifax, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Walker MJ, Meggetto O, Gao J, Espino-Hernández G, Jembere N, Bravo CA, Rey M, Aslam U, Sheppard AJ, Lofters AK, Tammemägi MC, Tinmouth J, Kupets R, Chiarelli AM, Rabeneck L. Measuring the impact of the COVID-19 pandemic on organized cancer screening and diagnostic follow-up care in Ontario, Canada: A provincial, population-based study. Prev Med 2021; 151:106586. [PMID: 34217413 PMCID: PMC9755643 DOI: 10.1016/j.ypmed.2021.106586] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022]
Abstract
It is essential to quantify the impacts of the COVID-19 pandemic on cancer screening, including for vulnerable sub-populations, to inform the development of evidence-based, targeted pandemic recovery strategies. We undertook a population-based retrospective observational study in Ontario, Canada to assess the impact of the pandemic on organized cancer screening and diagnostic services, and assess whether patterns of cancer screening service use and diagnostic delay differ across population sub-groups during the pandemic. Provincial health databases were used to identify age-eligible individuals who participated in one or more of Ontario's breast, cervical, colorectal, and lung cancer screening programs from January 1, 2019-December 31, 2020. Ontario's screening programs delivered 951,000 (-41%) fewer screening tests in 2020 than in 2019 and volumes for most programs remained more than 20% below historical levels by the end of 2020. A smaller percentage of cervical screening participants were older (50-59 and 60-69 years) during the pandemic when compared with 2019. Individuals in the oldest age groups and in lower-income neighborhoods were significantly more likely to experience diagnostic delay following an abnormal breast, cervical, or colorectal cancer screening test during the pandemic, and individuals with a high probability of living on a First Nation reserve were significantly more likely to experience diagnostic delay following an abnormal fecal test. Ongoing monitoring and management of backlogs must continue. Further evaluation is required to identify populations for whom access to cancer screening and diagnostic care has been disproportionately impacted and quantify impacts of these service disruptions on cancer incidence, stage, and mortality. This information is critical to pandemic recovery efforts that are aimed at achieving equitable and timely access to cancer screening-related care.
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Affiliation(s)
- Meghan J Walker
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Olivia Meggetto
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Julia Gao
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | | | | | | | - Michelle Rey
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Usman Aslam
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Amanda J Sheppard
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Aisha K Lofters
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, Ontairo, Canada; IC/ES, Toronto, Ontario, Canada; Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Martin C Tammemägi
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Brock University, St. Catharines, Ontario, Canada
| | - Jill Tinmouth
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; IC/ES, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Kupets
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Division of Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Anna M Chiarelli
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Linda Rabeneck
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; IC/ES, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Saunders N, Guttmann A, Brownell M, Cohen E, Fu L, Guan J, Sarkar J, Mahar A, Gandhi S, Fiksenbaum L, Katz A, Eze N, Stukel TA. Pediatric primary care in Ontario and Manitoba after the onset of the COVID-19 pandemic: a population-based study. CMAJ Open 2021; 9:E1149-E1158. [PMID: 34906990 PMCID: PMC8687490 DOI: 10.9778/cmajo.20210161] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND There were large disruptions to health care services after the onset of the COVID-19 pandemic. We sought to describe the extent to which pandemic-related changes in service delivery and access affected use of primary care for children overall and by equity strata in the 9 months after pandemic onset in Manitoba and Ontario. METHODS We performed a population-based study of children aged 17 years or less with provincial health insurance in Ontario or Manitoba before and during the COVID-19 pandemic (Jan. 1, 2017-Nov. 28, 2020). We calculated the weekly rates of in-person and virtual primary care well-child and sick visits, overall and by age group, neighbourhood material deprivation level, rurality and immigrant status, and assessed changes in visit rates after COVID-19 restrictions were imposed compared to expected baseline rates calculated for the 3 years before pandemic onset. RESULTS Among almost 3 million children in Ontario and more than 300 000 children in Manitoba, primary care visit rates declined to 0.80 (95% confidence interval [CI] 0.77-0.82) of expected in Ontario and 0.82 (95% CI 0.79-0.84) of expected in Manitoba in the 9 months after the onset of the pandemic. Virtual visits accounted for 53% and 29% of visits in Ontario and Manitoba, respectively. The largest monthly decreases in visits occurred in April 2020. Although visit rates increased slowly after April 2020, they had not returned to prerestriction levels by November 2020 in either province. Children aged more than 1 year to 12 years experienced the greatest decrease in visits, especially for well-child care. Compared to prepandemic levels, visit rates were lowest among rural Manitobans, urban Ontarians and Ontarians in low-income neighbourhoods. INTERPRETATION During the study period, the pandemic contributed to rapid, immediate and inequitable decreases in primary care use, with some recovery and a substantial shift to virtual care. Postpandemic planning must consider the need for catch-up visits, and the long-term impacts warrant further study.
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Affiliation(s)
- Natasha Saunders
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man.
| | - Astrid Guttmann
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Marni Brownell
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Eyal Cohen
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Longdi Fu
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Jun Guan
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Joykrishna Sarkar
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Alyson Mahar
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Sima Gandhi
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Lisa Fiksenbaum
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Alan Katz
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Nkiruka Eze
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Therese A Stukel
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
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Roberts A, Hu M, Hajizadeh M. Income and Education Inequalities in Brain and Central Nervous System Cancer Incidence in Canada: Trends over Two Decades. J Cancer Prev 2021; 26:110-117. [PMID: 34258249 PMCID: PMC8249205 DOI: 10.15430/jcp.2021.26.2.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/21/2021] [Accepted: 06/09/2021] [Indexed: 11/06/2022] Open
Abstract
The socioeconomic gradient of brain and central nervous system (CNS) cancer incidence in Canada is poorly understood. This study aimed to measure socioeconomic inequalities in brain and CNS cancer incidence in Canada from 1992 to 2010. Using a unique census division level dataset (n = 280) pooled from the Canadian Cancer Registry (CCR), the Canadian Census of Population and the National Household Survey, we measured brain and CNS cancer incidence in Canada. The age-adjusted concentration index (C) was used to measure income- and education-related inequalities in brain and CNS cancers in Canada, and for men and women, separately. Time trend analyses were conducted to examine the changes in socioeconomic inequalities in brain and CNS cancers in Canada over time. The results indicated that the crude brain and CNS cancer incidence increased from 7.29 to 8.17 per 100,000 (annual percentage change: 0.70) over the study period. The age-adjusted C results suggested that the brain and CNS cancer incidence was not generally significantly different for census division of different income and educational levels. There was insufficient evidence to support changes in income and education-related inequalities over time. Since the incidence of brain and CNS cancers in Canada showed no significant association with socioeconomic status, future cancer control programs should focus on other risk factors for this cancer subset.
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Affiliation(s)
- Alysha Roberts
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Min Hu
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
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Vest JR, Kasthurirathne SN, Ge W, Gutta J, Ben-Assuli O, Halverson PK. Choice of measurement approach for area-level social determinants of health and risk prediction model performance. Inform Health Soc Care 2021; 47:80-91. [PMID: 34106026 DOI: 10.1080/17538157.2021.1929999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: The objective of this paper is to provide empirical guidance by comparing the performance of six different area-level SDoH measurement approaches in predicting patient referral to a social worker and hospital admission after a primary care visit.Methods: We compared the performance of six area-level SDoH measurement approaches in predicting patient referral to a social worker and hospital admission after a primary care visit using random forest classification algorithm. Data came from 209,605 patient encounters at a federally qualified health center. Models with each area-based measurement approach were compared against the patient-level data only model using area under the curve, sensitivity, specificity, and precision.Results: Addition of area-level features to patient-level data improved the overall performance of models predicting need for a social worker referral. Entering area-level measures as individual features resulted in highest model performance.Conclusion: Researchers seeking to include area-level SDoH measures in risk prediction may be able to forego more complex measurement approaches.
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Affiliation(s)
- J R Vest
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, USA
| | - S N Kasthurirathne
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, USA.,Department of Paediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - W Ge
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, USA
| | - J Gutta
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, USA
| | - O Ben-Assuli
- Information Systems Management Department, Ono Academic College, Kiryat Ono, Israel
| | - P K Halverson
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, USA
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49
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Gomez D, Simpson AN, Sue-Chue-Lam C, de Mestral C, Dossa F, Nantais J, Wilton AS, Urbach D, Austin PC, Baxter NN. A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits. CMAJ 2021; 193:E753-E760. [PMID: 34035055 PMCID: PMC8177921 DOI: 10.1503/cmaj.202821] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients. METHODS We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes. RESULTS Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions. INTERPRETATION Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.
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MESH Headings
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/epidemiology
- Abortion, Spontaneous/therapy
- Adult
- Aged
- Appendicitis/diagnosis
- Appendicitis/epidemiology
- Appendicitis/therapy
- COVID-19/epidemiology
- COVID-19/psychology
- Cholecystitis/diagnosis
- Cholecystitis/epidemiology
- Cholecystitis/therapy
- Cross-Sectional Studies
- Emergency Service, Hospital/trends
- Facilities and Services Utilization/trends
- Female
- Genital Diseases, Female/diagnosis
- Genital Diseases, Female/epidemiology
- Genital Diseases, Female/therapy
- Humans
- Male
- Middle Aged
- Ontario/epidemiology
- Pandemics
- Patient Acceptance of Health Care/statistics & numerical data
- Pregnancy
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/epidemiology
- Pregnancy, Ectopic/therapy
- Severity of Illness Index
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Affiliation(s)
- David Gomez
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Andrea N Simpson
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Colin Sue-Chue-Lam
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Charles de Mestral
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Fahima Dossa
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Jordan Nantais
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Andrew S Wilton
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - David Urbach
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Peter C Austin
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
| | - Nancy N Baxter
- Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia
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50
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McPhail J, Loitz CC, Zaychkowsky C, Valeroso G, McNeil DA, McDonald SW, Edwards SA. Opportunistic postpartum depression symptom screening at well-child clinics in Alberta, 2012-2016. Canadian Journal of Public Health 2021; 112:938-946. [PMID: 34021493 DOI: 10.17269/s41997-021-00521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/29/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The study objective was to assess the reach and delivery of opportunistic postpartum depression (PPD) symptom screening at well-child clinic (WCC) immunization appointments in Alberta. The relationship between socio-demographic factors and PPD symptom screening status, and PPD symptom scores was explored. METHOD In this retrospective population-based cohort study, administrative health data from WCC immunization appointments were used to assess the PPD symptom screening delivery and scores from January 1, 2012 to December 31, 2016. The associations with maternal age and area-level material deprivation were determined by multivariable statistics. RESULTS The number of births ranged from 51,537 to 55,787 annually. The percentage of mothers screened for PPD symptoms using the Edinburgh Postnatal Depression Scale decreased between 2012 and 2016, from 80.1% to 69.7%. Of those screened, 3-3.2% of the mothers were identified to be at high risk for PPD, annually. Screening status varied according to maternal age: mothers ≤29 years were more likely to be screened than mothers 30-34 years, while mothers ≥35 years were the least likely to be screened. Logistic regression analyses, adjusting for age, found the odds of not being screened increased with increases in area-level material deprivation. Language/cultural barriers were the most commonly reported reasons for not screening. CONCLUSION Opportunistic PPD symptom screening at WCCs can be an efficient method to identify mothers who need postpartum support and to inform population-level public health surveillance. Additional work is needed to further understand barriers to PPD symptom screening, especially language, cultural, and socio-demographic factors.
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Affiliation(s)
- Juliana McPhail
- Public Health and Social Policy, University of Victoria, 3800 Finnerty Rd, Victoria, BC, V8P 5C2, Canada
| | - Christina C Loitz
- Alberta Health Services, 10909 Jasper Avenue, Edmonton, AB, T5J 4J3, Canada.
| | - Carol Zaychkowsky
- Alberta Health Services, 10101 Southport Road SW, Calgary, AB, T2W 3N2, Canada
| | - Germaeline Valeroso
- Alberta Health Services, 10101 Southport Road SW, Calgary, AB, T2W 3N2, Canada
| | - Deborah A McNeil
- Alberta Health Services, 10101 Southport Road SW, Calgary, AB, T2W 3N2, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada
| | - Sheila W McDonald
- Alberta Health Services, 10101 Southport Road SW, Calgary, AB, T2W 3N2, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Sarah A Edwards
- Alberta Health Services, 10101 Southport Road SW, Calgary, AB, T2W 3N2, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
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