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Cohen E, Quartarone S, Orkin J, Moretti ME, Emdin A, Guttmann A, Willan AR, Major N, Lim A, Diaz S, Osqui L, Soscia J, Fu L, Gandhi S, Heath A, Fayed N. Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial. JAMA Pediatr 2023; 177:461-471. [PMID: 36939728 PMCID: PMC10028546 DOI: 10.1001/jamapediatrics.2023.0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Importance Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care. Objective To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care. Design, Setting, and Participants This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months. Intervention Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care. Main Outcomes and Measures Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost. Results Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01). Conclusions and Relevance The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions. Trial Registration ClinicalTrials.gov Identifier: NCT02928757.
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Affiliation(s)
- Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Quartarone
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Myla E Moretti
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Clinical Trials Unit, Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abby Emdin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sanober Diaz
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Lisa Osqui
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Joanna Soscia
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence M. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
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Emdin A, Boblitz A, Maclagan L, Bethell J, Watt J, Harris D, Maxwell C, Bronskill S. DESCRIBING THE EVOLUTION OF MEDICATION USE OVER TIME IN PEOPLE LIVING WITH DEMENTIA USING NETWORK ANALYSIS. Innov Aging 2022. [DOI: 10.1093/geroni/igac059.2815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Prescribing for community-dwelling older adults living with dementia is complex. Multiple medications may be used to manage symptoms associated with dementia and/or co-existing chronic conditions, and can lead to problematic polypharmacy. Our objective was to use network analysis, a data science method, to provide a comprehensive description of co-prescribed medications in persons with dementia and describe whether these patterns change over time. We created a population-based cohort of community-dwelling older adults (aged 67+ years) in Ontario, Canada, newly diagnosed with dementia (between April 2014 and January 2019), from health administrative data, and developed medication networks at one year prior to, at, and for up to five years following dementia diagnosis. Among 136,292 individuals newly diagnosed with dementia, the mean age was 82.2 years and 59% were female. The most common medication subclasses dispensed at diagnosis were primarily cardiovascular medications: statins (45.6%), proton pump inhibitors (27.3%), beta-blockers (27.0%), calcium blockers (25.1%), and ACE inhibitors (24.6%). Similar proportions of medication subclasses were found at five years after diagnosis, except cholinesterase inhibitors (34.0% at five years were dispensed cholinesterase inhibitors compared to 16.9% at diagnosis). The most frequent co-prescribed medication pairs at diagnosis included statins and beta-blockers (16.0%), proton pump inhibitors (16.0%), and ace inhibitors (15.4%), respectively. Co-prescription was similar at five years, but also included higher frequency of co-prescribing with cholinesterase inhibitors (e.g., 19.4% were prescribed cholinesterase inhibitors and statins). Network diagrams demonstrate the complexity of prescribing in this population and highlight concurrent prescribing which may require careful monitoring or deprescribing.
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Affiliation(s)
- Abby Emdin
- University of Toronto , Toronto, Ontario , Canada
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Maclagan LC, Wang X, Emdin A, Jones A, Jaakkimainen RL, Schull MJ, Sourial N, Vedel I, Swartz RH, Bronskill SE. Visits to the emergency department by community-dwelling people with dementia during the first 2 waves of the COVID-19 pandemic in Ontario: a repeated cross-sectional analysis. CMAJ Open 2022; 10:E610-E621. [PMID: 35790227 PMCID: PMC9262349 DOI: 10.9778/cmajo.20210301] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Community-dwelling people with dementia have been affected by COVID-19 pandemic health risks and control measures that resulted in worsened access to health care and service cancellation. One critical access point in health systems is the emergency department. We aimed to determine the change in weekly rates of visits to the emergency department of community-dwelling people with dementia in Ontario during the first 2 waves of the COVID-19 pandemic compared with historical patterns. METHODS We conducted a population-based repeated cross-sectional study and used health administrative databases to compare rates of visits to the emergency department among community-dwelling people with dementia who were aged 40 years and older in Ontario during the first 2 waves of the COVID-19 pandemic (March 2020-February 2021) with the rates of a historical period (March 2019-February 2020). Weekly rates of visits to the emergency department were evaluated overall, by urgency and by chapter from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. We used Poisson models to compare pandemic and historical rates at the week of the lowest rate during the pandemic period and the latest week. RESULTS We observed large immediate declines in rates of visits to the emergency department during the COVID-19 pandemic (rate ratio [RR] 0.50, 95% confidence interval [CI] 0.47-0.53), which remained below historical levels by the end of the second wave (RR 0.88, 95% CI 0.83-0.92). Rates of both nonurgent (RR 0.33, 95% CI 0.28-0.39) and urgent (RR 0.51, 95% CI 0.48-0.55) visits to the emergency department also declined and remained low (RR 0.68, 95% CI 0.59-0.79, RR 0.91, 95% CI 0.86-0.96), respectively. Visits for injuries, and circulatory, respiratory and musculoskeletal diseases declined and remained below historical levels. INTERPRETATION Prolonged reductions in visits to the emergency department among people with dementia during the first 2 pandemic waves raise concerns about patients who delay seeking acute care services. Understanding the long-term effects of these reductions requires further research.
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Affiliation(s)
- Laura C Maclagan
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Xuesong Wang
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Abby Emdin
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Aaron Jones
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - R Liisa Jaakkimainen
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Michael J Schull
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Nadia Sourial
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Isabelle Vedel
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Richard H Swartz
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que
| | - Susan E Bronskill
- ICES Central (Maclagan, Wang, Emdin, Jones, Jaakkimainen, Schull, Swartz, Bronskill); Dalla Lana School of Public Health (Emdin, Schull, Bronskill), Department of Family and Community Medicine (Jaakkimainen) and Division of Neurology (Swartz), Department of Medicine, University of Toronto; Sunnybrook Research Institute (Jaakkimainen, Schull, Bronskill), Sunnybrook Health Sciences Centre, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Swartz), McMaster University, Hamilton, Ont.; Department of Health Management, Evaluation and Policy (Sourial), School of Public Health, University of Montreal; Department of Family Medicine (Vedel), McGill University, Montréal, Que.
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Bronskill SE, Maclagan LC, Maxwell CJ, Iaboni A, Jaakkimainen RL, Marras C, Wang X, Guan J, Harris DA, Emdin A, Jones A, Sourial N, Godard-Sebillotte C, Vedel I, Austin PC, Swartz RH. Trends in Health Service Use for Canadian Adults With Dementia and Parkinson Disease During the First Wave of the COVID-19 Pandemic. JAMA Health Forum 2022; 3:e214599. [PMID: 35977228 PMCID: PMC8903126 DOI: 10.1001/jamahealthforum.2021.4599] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/07/2021] [Indexed: 12/15/2022] Open
Abstract
Question Was the COVID-19 pandemic associated with changes in health service use and mortality among community-dwelling persons with dementia and Parkinson disease compared with older adults? Findings In this population-based repeated cross-sectional analysis, large declines in hospital use and nursing home admission were experienced across all cohorts. After the first wave, most services returned to historical levels, with physician visits elevated and mostly virtual, nursing home admissions reduced, and excess all-cause mortality. Meaning The pandemic was associated with meaningful health service disruptions for persons with dementia and Parkinson disease, highlighting that continued support for virtual care is needed to ensure optimal health outcomes. Importance Persons with dementia and Parkinson disease (PD) are vulnerable to disruptions in health care and services. Objective To examine changes in health service use among community-dwelling persons with dementia, persons with PD, and older adults without neurodegenerative disease during the first wave of the COVID-19 pandemic. Design, Setting, and Participants Repeated cross-sectional analysis using population-based administrative data among community-dwelling persons with dementia, persons with PD, and adults 65 years and older at the start of each week from March 1 through the week of September 20, 2020 (pandemic period), and March 3 through the week of September 22, 2019 (historical period), in Ontario, Canada. Exposures COVID-19 pandemic as of March 1, 2020. Main Outcomes and Measures Main outcomes were weekly rates of emergency department visits, hospitalizations, nursing home admissions, home care, virtual and in-person physician visits, and all-cause mortality. Poisson regression models were used to calculate weekly rate ratios (RRs) with 95% CIs comparing pandemic weeks with historical levels. Results Among those living in the community as of March 1, 2020, persons with dementia (n = 131 466; mean [SD] age, 80.1 [10.1] years) were older than persons with PD (n = 30 606; 73.7 [10.2] years) and older adults (n = 2 363 742; 74.0 [7.1] years). While all services experienced declines, the largest drops occurred in nursing home admissions (RR for dementia: 0.10; 95% CI, 0.07-0.15; RR for PD: 0.03; 95% CI, 0.00-0.21; RR for older adults: 0.11; 95% CI, 0.06-0.18) and emergency department visits (RR for dementia: 0.45; 95% CI, 0.41-0.48; RR for PD: 0.40; 95% CI, 0.34-0.48; RR for older adults: 0.45; 95% CI, 0.44-0.47). After the first wave, most services returned to historical levels except physician visits, which remained elevated (RR for dementia: 1.07; 95% CI, 1.05-1.09; RR for PD: 1.10, 95% CI, 1.06-1.13) and shifted toward virtual visits. Older adults continued to experience lower hospitalizations. All-cause mortality was elevated across cohorts. Conclusions and Relevance In this population-based repeated cross-sectional study in Ontario, Canada, those with dementia, those with PD, and older adults sought hospital care far less than usual, were not admitted to nursing homes, and experienced excess mortality during the first wave of the pandemic. Most services returned to historical levels, but virtual physician visits remained a feature of care. While issues of equity and quality of care are still emerging among persons with neurodegenerative diseases, policies to support virtual care are necessary.
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Affiliation(s)
- Susan E. Bronskill
- ICES, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Colleen J. Maxwell
- ICES, Toronto, Ontario, Canada
- Schools of Pharmacy and Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Andrea Iaboni
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - R. Liisa Jaakkimainen
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Connie Marras
- ICES, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson Disease, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | | | - Daniel A. Harris
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Abby Emdin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Jones
- ICES, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montreal, Quebec, Canada
| | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Richard H. Swartz
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
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Emdin A, Strzelecki M, Seto W, Feinstein J, Bogler O, Cohen E, Roth DE. Medications Reconciled at Discharge Versus Admission Among Inpatients at a Children's Hospital. Hosp Pediatr 2021:hpeds.2021-006080. [PMID: 34807980 PMCID: PMC9156657 DOI: 10.1542/hpeds.2021-006080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Discharge prescription practices may contribute to medication overuse and polypharmacy. We aimed to estimate changes in the number and types of medications reported at inpatient discharge (versus admission) at a tertiary care pediatric hospital. METHODS Electronic medication reconciliation data were extracted for inpatient admissions at The Hospital for Sick Children from January 1, 2016, to December 31, 2017 (n = 22 058). Relative changes in the number of medications and relative risks (RRs) of specific types and subclasses of medications at discharge (versus admission) were estimated overall and stratified by the following: sex, age group, diagnosis of a complex chronic condition, surgery, or ICU (PICU) admission. Micronutrient supplements, nonopioid analgesics, cathartics, laxatives, and antibiotics were excluded in primary analyses. RESULTS Medication counts at discharge were 1.27-fold (95% confidence interval [CI]: 1.25-1.29) greater than admission. The change in medications at discharge (versus admission) was increased by younger age, absence of a complex chronic condition, surgery, PICU admission, and discharge from a surgical service. The most common drug subclasses at discharge were opioids (22% of discharges), proton pump inhibitors (18%), bronchodilators (10%), antiemetics (9%), and corticosteroids (9%). Postsurgical patients had higher RRs of opioid prescriptions at discharge (versus admission; RR: 13.3 [95% CI: 11.5-15.3]) compared with nonsurgical patients (RR: 2.38 [95% CI: 2.22-2.56]). CONCLUSIONS Pediatric inpatients were discharged from the hospital with more medications than admission, frequently with drugs that may be discretionary rather than essential. The high frequency of opioid prescriptions in postsurgical patients is a priority target for educational and clinical decision support interventions.
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Affiliation(s)
- Abby Emdin
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health
| | - Marina Strzelecki
- Department of Pharmacy, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Winnie Seto
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pharmacy, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - James Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Eyal Cohen
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation
| | - Daniel E Roth
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health
- Institute of Health Policy, Management and Evaluation
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O'Callaghan K, Shaila S, Fariha F, Harrington J, Mahmud AA, Emdin A, Gernand A, Ahmed T, Abrams S, Moore D, Roth D. Effect of Maternal Prenatal and Postpartum Vitamin D Supplementation on Offspring Bone Mass in Early Childhood: Follow-Up of a Randomized Controlled Trial. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab046_094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Maternal vitamin D status has gained substantial attention as a modifiable contributor to offspring musculoskeletal health, yet there is a paucity of trial-derived data to corroborate effects of prenatal or postpartum vitamin D supplementation on offspring bone mass accrual. Among maternal-infant pairs in Bangladesh, we aimed to examine the hypothesized causal association of early life vitamin D exposure with musculoskeletal health in childhood.
Methods
In a double-blind dose-ranging trial of maternal vitamin D3 supplementation (Maternal Vitamin D for Infant Growth Trial), healthy pregnant women (n = 1300) were recruited at 17–24 weeks’ gestation and randomly assigned to receive a prenatal; postpartum regimen of 0;0,4200;0,16,800;0,28,000;0 or 28,000;28,000 IU vitamin D3/week until 26 weeks postpartum. In a follow-up study of offspring at 4 years of age (n = 642), bone mineral content (BMC) and bone mineral density (BMD) were measured by dual-energy X-ray absorptiometry. Between-group differences were assessed by independent t-tests (28,000 IU/week prenatally vs placebo) and linear regression (each vitamin D treatment group vs placebo) with bootstrapping (1000 replications).
Results
Whole-body (WB), total-body-less-head (TBLH) and head-only BMC were similar in the combined high-dose prenatal and placebo groups (mean difference [95% CI] = 6.81g [−8.70, 22.32], 0.61g [−10.90, 12.13] and 1.71g [−3.54, 6.96], respectively). None of the mean values for WB or TBLH BMC or BMD in each vitamin D group were different from placebo (P > 0.05 for all comparisons). Although head BMD was slightly greater in offspring of women assigned to the 28,000;28,000 IU regimen compared to placebo (mean difference [95% CI] = 0.024g/cm2 [0.0009, 0.047], P = 0.042), the effect was attenuated and no longer significant upon adjustment for child height, weight, and sex (P = 0.11).
Conclusions
In a population with high prevalence of vitamin D deficiency, our findings do not support the use of maternal prenatal vitamin D supplementation, with or without postpartum supplementation, for improvement of child BMC or BMD at 4 years of age.
Funding Sources
Canadian Institutes for Health Research and the Bill and Melinda Gates Foundation.
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Affiliation(s)
- Karen O'Callaghan
- Centre for Global Child Health and SickKids Research Institute, Hospital for Sick Children, Toronto
| | - Shaila Shaila
- Nutrition and Clinical Services Division, International Center for Diarrhoeal Disease Research, Bangladesh
| | - Farzana Fariha
- Nutrition and Clinical Services Division, International Center for Diarrhoeal Disease Research, Bangladesh
| | - Jennifer Harrington
- Department of Paediatrics, Hospital for Sick Children and University of Toronto
| | - Abdullah Al Mahmud
- Nutrition and Clinical Services Division, International Center for Diarrhoeal Disease Research, Bangladesh
| | - Abby Emdin
- Centre for Global Child Health and SickKids Research Institute, Hospital for Sick Children, Toronto
| | - Alison Gernand
- Department of Nutritional Sciences, The Pennsylvania State University
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Center for Diarrhoeal Disease Research, Bangladesh
| | - Steven Abrams
- Dell Medical School at the University of Texas at Austin
| | - Daniel Moore
- Faculty of Kinesiology and Physical Education, University of Toronto
| | - Daniel Roth
- Department of Paediatrics, Hospital for Sick Children and University of Toronto
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7
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McAlpine C, Huang A, Emdin A, Banko N, Beriault D, Shi Y, Werstuck G. Abstract 19: Deletion of Myeloid GSK3α Attenuates Atherosclerosis and Promotes an M2 Macrophage Phenotype. Arterioscler Thromb Vasc Biol 2015. [DOI: 10.1161/atvb.35.suppl_1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Glycogen synthase kinase (GSK)-3α/β has been implicated in the pathogenesis of diseases including diabetes, cancer, Alzheimer’s and atherosclerosis. The tissue and homolog specific functions of GSK3α and β in atherosclerosis are unknown. This study examines the effect of hepatocyte or myeloid cell specific deletion of GSK3α or GSK3β on atherosclerosis in LDLR-/- mice.
Approach and results:
We ablated GSK3α or GSK3β expression in hepatic or myeloid cells of LDLR-/- mice and mice were fed a high fat diet for 10 weeks. GSK3α or GSK3β deficiency in hepatic or myeloid cells did not affect metabolic parameters, including plasma lipid levels. Hepatic deletion of GSK3α or GSK3β did not affect the development of atherosclerosis or hepatic lipid content. Myeloid deletion of GSK3α, but not GSK3β, reduced atherosclerotic lesion volume as well as lesion complexity. Mice lacking GSK3α in myeloid cells had a less inflammatory and more anti-inflammatory plasma cytokine profile. Macrophages within atherosclerotic lesions of myeloid GSK3α deficient mice, but not GSK3β deficient mice, displayed reduced expression of markers associated with M1 macrophage polarization and enhanced expression of the M2 markers. Finally, bone marrow derived macrophages were isolated and differentiated into classical M1 macrophages or alternative M2 macrophages in vitro. GSK3α deletion, but not GSK3β deletion, attenuated the expression of genes associated with M1 polarization while promoting the expression of genes associated with M2 polarization. Mechanistically, GSK3α regulated macrophage polarization by modulating the phosphorylation and activation of STAT transcription factors.
Conclusions:
Our findings suggest that deletion of myeloid GSK3α attenuates the progression of atherosclerosis by regulating STAT activation and promoting an M2 macrophage phenotype.
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Affiliation(s)
| | - Aric Huang
- Medicine, McMaster Univ, Hamilton, Canada
| | - Abby Emdin
- Medicine, McMaster Univ, Hamilton, Canada
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8
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McAlpine CS, Huang A, Emdin A, Banko NS, Beriault DR, Shi Y, Werstuck GH. Deletion of Myeloid GSK3α Attenuates Atherosclerosis and Promotes an M2 Macrophage Phenotype. Arterioscler Thromb Vasc Biol 2015; 35:1113-22. [PMID: 25767272 DOI: 10.1161/atvbaha.115.305438] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/27/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Glycogen synthase kinase (GSK)-3α/β has been implicated in the pathogenesis of diabetes mellitus, cancer, Alzheimer, and atherosclerosis. The tissue- and homolog-specific functions of GSK3α and β in atherosclerosis are unknown. This study examines the effect of hepatocyte or myeloid cell deletion of GSK3α or GSK3β on atherosclerosis in low-density lipoprotein receptor (LDLR)(-/-) mice. APPROACH AND RESULTS We ablated GSK3α or GSK3β expression in hepatic or myeloid cells of LDLR(-/-) mice, and mice were fed a high-fat diet for 10 weeks. GSK3α or GSK3β deficiency in hepatic or myeloid cells did not affect metabolic parameters, including plasma lipid levels. Hepatic deletion of GSK3α or GSK3β did not affect the development of atherosclerosis or hepatic lipid content. Myeloid deletion of GSK3α, but not of GSK3β, reduced atherosclerotic lesion volume and lesion complexity. Mice lacking GSK3α in myeloid cells had a less inflammatory and more anti-inflammatory plasma cytokine profile. Macrophages within atherosclerotic lesions of myeloid GSK3α-deficient mice, but not of GSK3β-deficient mice, displayed reduced expression of markers associated with M1 macrophage polarization and enhanced expression of the M2 markers. Finally, bone marrow-derived macrophages were isolated and differentiated into classical M1 macrophages or alternative M2 macrophages in vitro. GSK3α deletion, but not GSK3β deletion, attenuated the expression of genes associated with M1 polarization while promoting the expression of genes associated with M2 polarization by modulating STAT3 and STAT6 activation. CONCLUSIONS Our findings suggest that deletion of myeloid GSK3α attenuates the progression of atherosclerosis by promoting an M2 macrophage phenotype.
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Affiliation(s)
- Cameron S McAlpine
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada
| | - Aric Huang
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada
| | - Abby Emdin
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada
| | - Nicole S Banko
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada
| | - Daniel R Beriault
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada
| | - Yuanyuan Shi
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada
| | - Geoff H Werstuck
- From the Departments of Medicine (C.S.M., Y.S., G.H.W.), Biochemistry and Biomedical Sciences (N.S.B., D.R.B., G.H.W.), and the Thrombosis and Atherosclerosis Research Institute (C.S.M., A.H., A.E., N.S.B., D.R.B., Y.S., G.H.W.), McMaster University, Hamilton, Ontario, Canada.
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