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Bugeja A, Girard C, Sood MM, Kendall CE, Sweet A, Singla R, Motazedian P, Vinson AJ, Ruzicka M, Hundemer GL, Knoll G, McIsaac DI. Sex-Related Disparities in Cardiovascular Outcomes Among Older Adults With Late-Onset Hypertension. Hypertension 2024. [PMID: 38660798 DOI: 10.1161/hypertensionaha.124.22870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/07/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND It is unclear whether sex-based differences in cardiovascular outcomes exist in late-onset hypertension. METHODS This is a population-based cohort study in Ontario, Canada of 266 273 adults, aged ≥66 years with newly diagnosed hypertension. We determined the incidence of the primary composite cardiovascular outcome (myocardial infarction, stroke, and congestive heart failure), all-cause mortality, and cardiovascular death by sex using Cox proportional hazard models adjusted for demographic factors and comorbidities. RESULTS The mean age of the total cohort was 74 years, and 135 531 (51%) were female. Over a median follow-up of 6.6 (4.7-9.0) years, females experienced a lower crude incidence rate (per 1000 person-years) than males for the primary composite cardiovascular outcome (287.3 versus 311.7), death (238.4 versus 251.4), and cardiovascular death (395.7 versus 439.6), P<0.001. The risk of primary composite cardiovascular outcome was lower among females (adjusted hazard ratio, 0.75 [95% CI, 0.73-0.76]; P<0.001) than in males. This was consistent after adjusting for the competing risk of all-cause death with a subdistributional hazard ratio, 0.88 ([95% CI, 0.86-0.91]; P<0.001). CONCLUSIONS Females had a lower risk of cardiovascular outcomes compared with males within a population characterized by advanced age and new hypertension. Our results highlight that the severity of outcomes is influenced by sex in relation to the age at which hypertension is diagnosed. Further studies are required to identify sex-specific variations in the diagnosis and management of late-onset hypertension due to its high incidence in this group.
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Affiliation(s)
- Ann Bugeja
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
| | - Celine Girard
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
- ICES uOttawa, ON, Canada (C.G., C.E.K., G.L.H., D.I.M.)
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
| | - Claire E Kendall
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Department of Family Medicine, University of Ottawa, ON, Canada. (C.E.K.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
- ICES uOttawa, ON, Canada (C.G., C.E.K., G.L.H., D.I.M.)
| | - Ally Sweet
- Faculty of Medicine, University of Ottawa, ON, Canada. (A.S., R.S.)
| | - Ria Singla
- Faculty of Medicine, University of Ottawa, ON, Canada. (A.S., R.S.)
| | - Pouya Motazedian
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
- University of Ottawa Heart Institute, ON, Canada (P.M.)
| | - Amanda J Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University (A.J.V.)
- Kidney Research Institute Nova Scotia (A.J.V.)
| | - Marcel Ruzicka
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
- ICES uOttawa, ON, Canada (C.G., C.E.K., G.L.H., D.I.M.)
| | - Greg Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada. (A.B., M.M.S., M.R., G.L.H., G.K.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
| | - Daniel I McIsaac
- Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, ON, Canada. (D.I.M.)
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada. (A.B., C.G., M.M.S., C.E.K., P.M., G.L.H., D.I.M.)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (A.B., C.G., M.M.S., C.E.K., P.M., M.R., G.L.H., G.K., D.I.M.)
- ICES uOttawa, ON, Canada (C.G., C.E.K., G.L.H., D.I.M.)
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Greenwald ZR, Werb D, Feld JJ, Austin PC, Fridman D, Bayoumi AM, Gomes T, Kendall CE, Lapointe-Shaw L, Scheim AI, Bartlett SR, Benchimol EI, Bouck Z, Boucher LM, Greenaway C, Janjua NZ, Leece P, Wong WW, Sander B, Kwong JC. Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada. J Clin Epidemiol 2024:111332. [PMID: 38522754 DOI: 10.1016/j.jclinepi.2024.111332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/23/2023] [Revised: 02/12/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada. STUDY DESIGN AND SETTING Data from cohorts of people with recent (past 12 month) injection drug use, including those participating in community-based research studies or seeking drug treatment were linked to health administrative data in Ontario from 1992-2020. We assessed the validity of algorithms to identify injection drug use over varying lookback periods (i.e., all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT). RESULTS Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts, 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, emergency department visit or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity, 94.2% specificity) and recent IDU (using 3 years lookback: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment. CONCLUSION Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of injection drug use in the population in which they are applied.
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Affiliation(s)
- Zoë R Greenwald
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, United States
| | - Jordan J Feld
- Department of Medicine, University of Toronto, Toronto, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada; University Health Network, Toronto, Canada
| | - Peter C Austin
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Ahmed M Bayoumi
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Department of Medicine, University of Toronto, Toronto, Canada; Division of General Internal Medicine, St. Michael's Hospital, Unity Health Toronto,; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto. Canada
| | - Tara Gomes
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto. Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Ontario Drug Policy Research Network, Toronto, Canada
| | - Claire E Kendall
- ICES, Toronto, Canada; Bruyère Research Institute, Ottawa, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Department of Medicine, University of Toronto, Toronto, Canada; University Health Network, Toronto, Canada
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, United States; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Sofia R Bartlett
- British Columbia Centre for Disease Control, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Eric I Benchimol
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Zachary Bouck
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto. Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | | | - Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, Montreal, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Canada; Department of Epidemiology and Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada; Centre for Health Evaluation & Outcome Sciences, St Paul's Hospital Vancouver, Vancouver, Canada
| | - Pamela Leece
- Public Health Ontario, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - William Wl Wong
- ICES, Toronto, Canada; School of Pharmacy, University of Waterloo, Kitchener, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - Beate Sander
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; University Health Network, Toronto, Canada; Public Health Ontario, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; University Health Network, Toronto, Canada; Public Health Ontario, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
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3
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Harrison LD, Dumicho AY, Eddeen AB, Tanuseputro P, Kendall CE, Fiedorowicz JG, Rosic T, Fernando SM, McNaughton CD, Corace K, Kurdyak P, Beckerleg W, Webber C, Gardner W, Sood M, Myran DT. Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol. Acad Emerg Med 2024; 31:220-229. [PMID: 38097531 DOI: 10.1111/acem.14843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/09/2023] [Accepted: 11/26/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND METHODS We conducted a population-based, retrospective cohort study of first-time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all-cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. RESULTS A total of 71,776 AYA had a first-time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First-time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69-3.51). Mortality was associated with age 25-29 years (aHR 3.88, 95% CI 2.56-5.86), being male (aHR 1.98, 95% CI 1.49-2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64-6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96-4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27-3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. CONCLUSION Incident ED visits due to alcohol in AYA are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow-up care in this population.
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Affiliation(s)
- Lyndsay D Harrison
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Asnake Y Dumicho
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anan Bader Eddeen
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Primary Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ontario, Canada
- Lamont Primary Health Care Research Centre, Riverside Campus Family Health Team, Ottawa, Ontario, Canada
| | - Jess G Fiedorowicz
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
| | - Tea Rosic
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Shannon M Fernando
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, Ontario, Canada
| | - Candace D McNaughton
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
| | - Kim Corace
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Kurdyak
- ICES Central, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Weiwei Beckerleg
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - William Gardner
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Manish Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Thomas Myran
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ontario, Canada
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Wiper-Bergeron N, Adam HL, Eady K, Moreau KA, Kennedy CRJ, Kendall CE. Extending social accountability mandates to biomedical research in Canadian faculties of medicine. Can Med Educ J 2024; 15:56-61. [PMID: 38528893 PMCID: PMC10961123 DOI: 10.36834/cmej.75425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Background Social accountability (SA), as defined by Boelen and Heck, is the obligation of medical schools to address the needs of communities through education, research and service activities. While SA is embedded within health profession education frameworks in medicine, they are rarely taught within graduate-level (MSc/PhD) education. Methods As these programs train future medical researchers, we invited first-year graduate students enrolled in a mandatory professionalism class at our institution (n = 111) to complete a survey on their perceptions of the importance of SA in their research, training, and future careers. Results Over 80% (n = 87) of respondents agreed that SA is relevant and felt committed to integrating it into their future research activities, only a limited number of students felt confident and/or supported in their abilities to integrate SA into their research. Conclusions Specific SA training in graduate education is necessary for students to effectively incorporate elements of SA into their research, and as such support the SA mandates of their training institutions. We posit that awareness of SA principles formalizes the professional standards for biomedical researchers and is thus foundational for developing a professionalism curriculum in graduate education programs in medicine. We propose an expansion of the World Health Organization (WHO) partnership pentagon to include partners within the research ecosystem (funding partners, certification bodies) that collaborate with biomedical researchers to make research socially accountable.
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Affiliation(s)
- Nadine Wiper-Bergeron
- Graduate and Postdoctoral Studies, Faculty of Medicine, University of Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Holly L Adam
- Faculty of Education, University of Ottawa, Ontario, Canada
| | - Kaylee Eady
- Faculty of Education, University of Ottawa, Ontario, Canada
| | | | - Christopher RJ Kennedy
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ontario, Canada
- Chronic Disease Program, Kidney Research Center, Ottawa Hospital Research Institute, Ontario, Canada
| | - Claire E Kendall
- Social Accountability, Faculty of Medicine, University of Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Canada
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Vargas ME, Gershon AS, Pugliese M, Gotfrit RJ, Manuel D, Sadatsafavi M, Stukel TA, To T, Kendall CE, Thavorn K, Robillard R, Kendzerska T. Pandemic Effect on Healthcare Use and Death in Adults with Epilepsy: A Population Study. Can J Neurol Sci 2023:1-11. [PMID: 38115804 DOI: 10.1017/cjn.2023.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVES We conducted a population-based study using Ontario health administrative data to describe trends in healthcare utilization and mortality in adults with epilepsy during the first pandemic year (March 2020-March 2021) compared to historical data (2016-2019). We also investigated if changes in outpatient visits and diagnostic testing during the first pandemic year were associated with increased risk for hospitalizations, emergency department (ED) visits, or death. METHODS Projected monthly visit rates (per 100,000 people) for outpatient visits, electroencephalography, magnetic resonance, computed tomography, all-cause ED visits, hospitalizations, and mortality were calculated based on historical data by fitting monthly time series autoregressive integrated moving-average models. Two-way interactions were calculated using Quasi-Poisson models. RESULTS In adults with epilepsy during the first quarter of the pandemic, we demonstrated a reduction in all-cause outpatient visits, diagnostic testing, ED visits and hospitalizations, and a temporary increase in mortality (observed rates of 355.8 vs projected 308.8, 95% CI: 276.3-345.1). By the end of the year, outpatient visits increased (85,535.4 vs 76,620.6, 95% CI: 71,546.9-82,059.4), and most of the diagnostic test rates returned to the projected. The increase in the rate of all-cause mortality during the pandemic, compared to pre-pandemic, was greater during months with the lower frequency of diagnostic tests than months with higher frequency (interaction p-values <.0001). CONCLUSION We described the impact of the pandemic on healthcare utilization and mortality in adults with epilepsy during the first year. We demonstrated that access to relevant diagnostic testing is likely important for this population while planning restrictions on non-urgent health services.
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Affiliation(s)
| | - Andrea S Gershon
- ICES, Ottawa, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Research Institute, The Hospital of Sick Children, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael Pugliese
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
| | - Ryan Jason Gotfrit
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Douglas Manuel
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, Respiratory Evaluation Sciences Program, The University of British Columbia, Vancouver, BC, Canada
| | - Therese A Stukel
- ICES, Ottawa, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Teresa To
- ICES, Ottawa, Toronto, ON, Canada
- Research Institute, The Hospital of Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Claire E Kendall
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Kednapa Thavorn
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | | | - Tetyana Kendzerska
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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6
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Kendzerska T, Zhu DT, Pugliese M, Manuel D, Sadatsafavi M, Povitz M, Stukel TA, To T, Aaron SD, Mulpuru S, Chin M, Kendall CE, Thavorn K, Robillard R, Gershon AS. Trends in outpatient and inpatient visits for separate ambulatory-care-sensitive conditions during the first year of the COVID-19 pandemic: a province-based study. Front Public Health 2023; 11:1251020. [PMID: 38169852 PMCID: PMC10759216 DOI: 10.3389/fpubh.2023.1251020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Background The COVID-19 pandemic led to global disruptions in non-urgent health services, affecting health outcomes of individuals with ambulatory-care-sensitive conditions (ACSCs). Methods We conducted a province-based study using Ontario health administrative data (Canada) to determine trends in outpatient visits and hospitalization rates (per 100,000 people) in the general adult population for seven ACSCs during the first pandemic year (March 2020-March 2021) compared to previous years (2016-2019), and how disruption in outpatient visits related to acute care use. ACSCs considered were chronic obstructive pulmonary disease (COPD), asthma, angina, congestive heart failure (CHF), hypertension, diabetes, and epilepsy. We used time series auto-regressive integrated moving-average models to compare observed versus projected rates. Results Following an initial reduction (March-May 2020) in all types of visits, primary care outpatient visits (combined in-person and virtual) returned to pre-pandemic levels for asthma, angina, hypertension, and diabetes, remained below pre-pandemic levels for COPD, and rose above pre-pandemic levels for CHF (104.8 vs. 96.4, 95% CI: 89.4-104.0) and epilepsy (29.6 vs. 24.7, 95% CI: 22.1-27.5) by the end of the first pandemic year. Specialty visits returned to pre-pandemic levels for COPD, angina, CHF, hypertension, and diabetes, but remained above pre-pandemic levels for asthma (95.4 vs. 79.5, 95% CI: 70.7-89.5) and epilepsy (53.3 vs. 45.6, 95% CI: 41.2-50.5), by the end of the year. Virtual visit rates increased for all ACSCs. Among ACSCs, reductions in hospitalizations were most pronounced for COPD and asthma. CHF-related hospitalizations also decreased, albeit to a lesser extent. For angina, hypertension, diabetes, and epilepsy, hospitalization rates reduced initially, but returned to pre-pandemic levels by the end of the year. Conclusion This study demonstrated variation in outpatient visit trends for different ACSCs in the first pandemic year. No outpatient visit trends resulted in increased hospitalizations for any ACSC; however, reductions in rates of asthma, COPD, and CHF hospitalizations persisted.
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Affiliation(s)
- Tetyana Kendzerska
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
| | - David T. Zhu
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Medical Scientist Training Program, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Michael Pugliese
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
| | - Douglas Manuel
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Marcus Povitz
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Therese A. Stukel
- ICES, Ottawa, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Teresa To
- ICES, Ottawa, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Research Institute, The Hospital of Sick Children, Toronto, ON, Canada
| | - Shawn D. Aaron
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, ON, Canada
| | - Sunita Mulpuru
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, ON, Canada
| | - Melanie Chin
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, ON, Canada
| | - Claire E. Kendall
- ICES, Ottawa, Toronto, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- The Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kednapa Thavorn
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, Toronto, ON, Canada
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | | | - Andrea S. Gershon
- ICES, Ottawa, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Research Institute, The Hospital of Sick Children, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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7
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Scott MM, Ramzy A, Isenberg SR, Webber C, Eddeen AB, Murmann M, Mahdavi R, Howard M, Kendall CE, Klinger C, Marshall D, Sinnarajah A, Ponka D, Buchman S, Bennett C, Tanuseputro P, Dahrouge S, May K, Heer C, Cooper D, Manuel D, Thavorn K, Hsu AT. Nurse practitioner and physician end-of-life home visits and end-of-life outcomes. BMJ Support Palliat Care 2023:spcare-2023-004392. [PMID: 37979954 DOI: 10.1136/spcare-2023-004392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/07/2023] [Accepted: 10/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death. METHODS We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit. RESULTS Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both. CONCLUSIONS Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients' preferences-emphasising the importance of NPs and physicians' role in supporting people near the end of life.
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Affiliation(s)
- Mary M Scott
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amy Ramzy
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anan Bader Eddeen
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Maya Murmann
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Roshanak Mahdavi
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Klinger
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Denise Marshall
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Lakeridge Health, Oshawa, Ontario, Canada
| | - David Ponka
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sandy Buchman
- Division of Palliative Care, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carol Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Simone Dahrouge
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kathryn May
- Emergency Department, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carrie Heer
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Dana Cooper
- Nurse Practitioners' Association, Toronto, Ontario, Canada
| | - Douglas Manuel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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8
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Batista R, Reaume M, Roberts R, Seale E, Rhodes E, Sucha E, Pugliese M, Kendall CE, Bjerre LM, Bouchard L, Prud'homme D, Manuel DG, Tanuseputro P. Prevalence and patterns of multimorbidity among linguistic groups of patients receiving home care in Ontario: a retrospective cohort study. BMC Geriatr 2023; 23:725. [PMID: 37946126 PMCID: PMC10634019 DOI: 10.1186/s12877-023-04267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 08/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Prior studies have demonstrated the negative impact of language barriers on access, quality, and safety of healthcare, which can lead to health disparities in linguistic minorities. As the population ages, those with multiple chronic diseases will require increasing levels of home care and long-term services. This study described the levels of multimorbidity among recipients of home care in Ontario, Canada by linguistic group. METHODS Population-based retrospective cohort of 510,685 adults receiving home care between April 1, 2010, to March 31, 2018, in Ontario, Canada. We estimated and compared prevalence and characteristics of multimorbidity (2 or more chronic diseases) across linguistic groups (Francophones, Anglophones, Allophones). The most common combinations and clustering of chronic diseases were examined. Logistic regression models were used to explore the main predictors of 'severe' multimorbidity (defined as the presence of five or more chronic diseases). RESULTS The proportion of home care recipients with multimorbidity and severe multimorbidity was 92% and 44%, respectively. The prevalence of multimorbidity was slightly higher among Allophones (93.6%) than among Anglophones (91.8%) and Francophones (92.4%). However, Francophones had higher rates of cardiovascular and respiratory disease (64.9%) when compared to Anglophones (60.2%) and Allophones (61.5%), while Anglophones had higher rates of cancer (34.2%) when compared to Francophones (25.2%) and Allophones (24.3%). Relative to Anglophones, Allophones were more likely to have severe multimorbidity (adjusted OR = 1.04, [95% CI: 1.02-1.06]). CONCLUSIONS The prevalence of multimorbidity among Ontarians receiving home care services is high; especially for whose primary language is a language other than English or French (i.e., Allophones). Understanding differences in the prevalence and characteristics of multimorbidity across linguistic groups will help tailor healthcare services to the unique needs of patients living in minority linguistic situations.
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Affiliation(s)
- Ricardo Batista
- Institut du Savoir Montfort, Hôpital Montfort, 202-745A Ch. Montréal Road, Ottawa, ON, K1K 0T1, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael Reaume
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Emily Seale
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Emily Rhodes
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | - Claire E Kendall
- Institut du Savoir Montfort, Hôpital Montfort, 202-745A Ch. Montréal Road, Ottawa, ON, K1K 0T1, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lise M Bjerre
- Institut du Savoir Montfort, Hôpital Montfort, 202-745A Ch. Montréal Road, Ottawa, ON, K1K 0T1, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Louise Bouchard
- Institut du Savoir Montfort, Hôpital Montfort, 202-745A Ch. Montréal Road, Ottawa, ON, K1K 0T1, Canada
- School of Social and Anthropological Studies, University of Ottawa, Ottawa, ON, Canada
| | - Denis Prud'homme
- Institut du Savoir Montfort, Hôpital Montfort, 202-745A Ch. Montréal Road, Ottawa, ON, K1K 0T1, Canada
- Université de Moncton, Nouveau-Brunswick, Canada
| | - Douglas G Manuel
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- ICES uOttawa, Ottawa, ON, Canada.
- Bruyère Research Institute, Ottawa, ON, Canada.
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
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9
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Nicolau IA, Moineddin R, Antoniou T, Brooks JD, Gillis JL, Kendall CE, Cooper C, Cotterchio M, Salters K, Smieja M, Kroch AE, Lindsay JD, Price C, Mohamed A, Burchell AN. Trends in infection-related and infection-unrelated cancer incidence among people with and without HIV infection in Ontario, Canada, 1996-2020: a population-based matched cohort study using health administrative data. CMAJ Open 2023; 11:E894-E905. [PMID: 37816545 PMCID: PMC10569814 DOI: 10.9778/cmajo.20220230] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND People with HIV infection are at higher risk for certain cancers than the general population. We compared trends in infection-related and infection-unrelated cancers among people with and without HIV infection. METHODS We conducted a retrospective population-based matched cohort study of adults with and without HIV infection using linked health administrative databases in Ontario, Canada. Participants were matched on birth year, sex, census division (rurality), neighbourhood income quintile and region of birth. We followed participants from cohort entry until the earliest of date of cancer diagnosis, date of death, Nov. 1, 2020, or date of loss to follow-up. Incident cancers identified from Jan. 1, 1996, to Nov. 1, 2020, were categorized as infection-related or-unrelated. We examined calendar periods 1996-2003, 2004-2011 and 2012-2020, corresponding to the early combination antiretroviral therapy (cART), established cART and contemporary cART eras, respectively. We used competing risk analyses to examine trends in cumulative incidence by calendar period, age and sex, and cause-specific hazard ratios (HRs). RESULTS We matched 20 304 people with HIV infection to 20 304 people without HIV infection. A total of 2437 cancers were diagnosed, 1534 (62.9%) among infected people and 903 (37.0%) among uninfected people. The risk of infection-related cancer by age 65 years for people with HIV infection decreased from 19.0% (95% confidence interval [CI] 15.6%-22.3%) in 1996-2011 to 10.0% (95% CI 7.9%-12.1%) in 2012-2020. Compared to uninfected people, those with HIV infection had similar HRs of infection-unrelated cancer but increased rates of infection-related cancer, particularly among younger age groups (25.1 [95% CI 13.2-47.4] v. 1.9 [95% CI 1.0-3.7] for age 18-39 yr v. ≥ 70 yr); these trends were consistent when examined by sex.Interpretation: We observed significantly higher rates of infection-related, but not infection-unrelated, cancer among people with HIV infection than among uninfected people. The elevated rate of infection-related cancer in 2012-2020 highlights the importance of early and sustained antiretroviral therapy along with cancer screening and prevention measures.
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Affiliation(s)
- Ioana A Nicolau
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Rahim Moineddin
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Tony Antoniou
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Jennifer D Brooks
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Jennifer L Gillis
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Claire E Kendall
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Curtis Cooper
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Michelle Cotterchio
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Kate Salters
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Marek Smieja
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Abigail E Kroch
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Joanne D Lindsay
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Colleen Price
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Anthony Mohamed
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont
| | - Ann N Burchell
- Dalla Lana School of Public Health (Nicolau, Brooks, Cotterchio, Kroch), University of Toronto; Li Ka Shing Knowledge Institute (Nicolau, Antoniou, Lindsay, Mohamed, Burchell), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Moineddin, Antoniou, Burchell), University of Toronto; ICES Central (Moineddin, Antoniou, Burchell); Canadian Cancer Society (Gillis), Toronto, Ont.; Bruyère Research Institute (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute; ICES uOttawa (Kendall); Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University, Hamilton, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; Canadian HIV/AIDS and Chronic Pain Society (Price), Ottawa, Ont.
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10
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Myran D, Milani C, Pugliese M, Hensel JM, Sood M, Kendall CE, Kendzerska T, Tanuseputro P. Physician benzodiazepine self-use prior to and during the COVID-19 pandemic in Ontario, Canada: a population-level cohort study. BMJ Open 2023; 13:e062742. [PMID: 37085307 PMCID: PMC10123848 DOI: 10.1136/bmjopen-2022-062742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES The aim of this study was to investigate physician benzodiazepine (BZD) self-use pre-COVID-19 pandemic and to examine changes in BZD self-use during the first year of the pandemic. DESIGN Population-based retrospective cohort study using linked routinely collected administrative health data comparing the first year of the pandemic to the period before the pandemic. SETTING Province of Ontario, Canada between March 2016 and March 2021. PARTICIPANTS INTERVENTION: Onset of the COVID-19 pandemic in March 2020. OUTCOMES MEASURES The primary outcome measure was the receipt of one or more prescriptions for BZD, which was captured via the Narcotics Monitoring System. RESULTS In a cohort of 30 798 physicians (mean age 42, 47.8% women), we found that during the year before the pandemic, 4.4% of physicians had 1 or more BZD prescriptions. Older physicians (6.8% aged 50+ years), female physicians (5.1%) and physicians with a prior mental health (MH) diagnosis (12.4%) were more likely than younger (3.7% aged <50 years), male physicians (3.8%) and physicians without a prior MH diagnosis (2.9%) to have received 1 or more BZD prescriptions. The first year of the COVID-19 pandemic was associated with a 10.5% decrease (adjusted OR (aOR) 0.85, 95% CI: 0.80 to 0.91) in the number of physicians with 1 or more BZD prescriptions compared with the year before the pandemic. Female physicians were less likely to reduce BZD self-use (aORfemale=0.90, 95% CI: 0.83 to 0.98) compared with male physicians (aORmale=0.79, 95% CI: 0.72 to 0.87, pinteraction=0.046 during the pandemic. Physicians presenting with an incident MH visit had higher odds of filling a BZD prescription during COVID-19 compared with the prior year. CONCLUSIONS Physicians' BZD prescriptions decreased during the first year of the COVID-19 pandemic in Ontario, Canada. These findings suggest that previously reported increases in mental distress and MH visits among physicians during the pandemic did not lead to greater self-use of BZDs.
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Affiliation(s)
- Daniel Myran
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyere Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
| | - Christina Milani
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Michael Pugliese
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
| | | | - Manish Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Claire E Kendall
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tetyana Kendzerska
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Respirology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Division of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
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11
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Abstract
As part of its social accountability mission, the University of Ottawa Faculty of Medicine invited community service learning (CSL) partner organizations to a guided, virtual conversation on April 12, 2021 to contribute to the future strategic directions for our curriculum. Representatives of 15 organizations participated and provided insights into how they perceive CSL students, the Faculty of Medicine, and the process of assessment. This workshop forged stronger bonds between the university and these community organizations and led to recommendations for their greater involvement going forward, an approach that could be considered by other Faculties of Medicine.
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Affiliation(s)
- Laura Muldoon
- Director of Social Medicine, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Craig Campbell
- Curriculum Director, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Claire E Kendall
- Associate Dean, Social Accountability, Faculty of Medicine, University of Ottawa, Ontario, Canada
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12
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Mihan A, Kester N, Fitzgerald M, Fournier K, Kendall CE. Characteristics of Canadian physicians and their associations with practice patterns: a scoping review. Can Med Educ J 2023; 14:61-88. [PMID: 37304623 PMCID: PMC10254117 DOI: 10.36834/cmej.74205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background Physician characteristics such as education and sociodemographic attributes are associated with particular practice patterns, such as practice in rural settings. Understanding the Canadian context of such associations can inform medical school recruitment and health workforce decision-making. Objective The objective of this scoping review was to report the nature and extent of the literature on associations between characteristics of physicians in Canada and physicians' practice patterns. Eligibility criteria: We included studies reporting associations between 1) the education or sociodemographic attributes of practicing physicians or residents in Canada and 2) practice patterns, including career choice, practice setting, and populations served. Methods We searched five electronic databases (MEDLINE (R) ALL, Embase, ERIC, Education Source and Scopus) for quantitative primary studies and reviewed reference lists of included studies for additional studies. Data were extracted using a standardized data charting form. Results Our search yielded 80 studies. Sixty-two examined education, evenly divided between undergraduate and postgraduate. Fifty-eight examined physicians' attributes, most focusing on sex/gender. The majority of studies focused on the outcome of practice setting. We found no studies examining race/ethnicity or socioeconomic status. Conclusion Many studies in our review found positive associations between (i) rural training or rural background and rural practice setting and (ii) location of training or physicians' origin and practice in that location, consistent with previous literature. Associations for sex/gender were mixed, suggesting it may be a less useful target for workforce planning or recruitment aiming to address gaps in health care provision. More research is needed on the association of characteristics, particularly race/ethnicity and socioeconomic status, with career choice and populations served.
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Affiliation(s)
| | | | | | - Karine Fournier
- Health Sciences Library, University of Ottawa, Ontario, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ontario, Canada
- Office of Social Accountability, Faculty of Medicine, University of Ottawa, Ontario, Canada
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13
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Fung OW, Mulholland A, Bondy M, Driedger M, Kendall CE. Implementing experiential learning logs addressing social accountability into undergraduate medical clerkship education. Can Med Educ J 2023; 14:146-149. [PMID: 37304626 PMCID: PMC10254109 DOI: 10.36834/cmej.73907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Medical schools have a responsibility to ensure students meet and advocate for the needs of the community. However, addressing the social determinants of health is not always emphasized in clinical learning objectives. Learning logs are useful tools that can engage students to reflect on clinical encounters and direct students in their learning to target the development of highlighted skills. Despite their efficacy, the use of learning logs in medical education is largely applied towards biomedical knowledge and procedural skills. Thus, students may lack competence to address the psychosocial challenges involved in comprehensive medical care. Social accountability experiential logs were developed for third year medical students at the University of Ottawa to address and intervene on the social determinants of health. Students completed quality improvement surveys and results demonstrated this initiative to be beneficial to their learning and contributed to greater clinical confidence. Experiential logs in clinical training can be adapted across other medical schools and tailored to fit the needs and priorities of each institution's local communities.
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Affiliation(s)
- Oliver W Fung
- Faculty of Medicine, University of Ottawa, Ontario, Canada
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14
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Craig-Neil A, Ho J, Perri M, Gaspar M, Hunter C, Rachlis B, Kendall CE, Rueda S, Burchell AN, Pinto AD. Healthcare system action on employment as a social determinant of health in people living with HIV: A qualitative study. PLoS One 2023; 18:e0282421. [PMID: 37023048 PMCID: PMC10079099 DOI: 10.1371/journal.pone.0282421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/14/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Employment is a key social determinant of health. People living with HIV (PLWH) have higher unemployment rates than the general population. Vocational rehabilitation services have been shown to have significant and positive impact on employment status for PLWH. Understanding whether integrating vocational rehabilitation with health care services is acceptable, from the perspectives of PLWH and their health care providers, is an area that is understudied. METHODS We conducted a qualitative study and collected data from focus groups and interviews to understand the perspectives of stakeholders regarding the potential for vocational rehabilitation and health care integration. We completed five focus groups with 45 health care providers and one-to-one interviews with 23 PLWHs. Participants were sampled from infectious disease, primary care clinics, and AIDS Service Organizations in Toronto and Ottawa, Canada. Interviews were audio-recorded and transcribed. We conducted a reflexive thematic analysis of the transcripts. FINDINGS We found health care providers have little experience assisting patients with employment and PLWH had little experience receiving employment interventions from their health care team. This lack of integration between health care and vocational services was related to uncertainties around drug coverage, physician role and living with an episodic disability. Health care providers thought that there is potential for a larger role for health care clinics in providing employment interventions for PLWH however patients were divided. Some PLWH suggest that health care providers could provide advice on the disclosure of status, work limitations and act as advocates with employers. INTERPRETATION Health care providers and some PLWH recognize the importance of integrating health services with vocational services but both groups have little experience with implementing these types of interventions. Thus, there needs to be more study of such interventions, including the processes entailed and outcomes they aim to achieve.
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Affiliation(s)
- Amy Craig-Neil
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Julia Ho
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Melissa Perri
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Mark Gaspar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Charlotte Hunter
- Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
| | - Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Claire E Kendall
- ICES, Toronto, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
- Institut du Savoir Montfort, Montfort Hospital, Ottawa, Canada
| | - Sergio Rueda
- Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ann N Burchell
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
| | - Andrew D Pinto
- Li Ka Shing Knowledge Institute, Upstream Lab, MAP/Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
- University of Toronto Practice-Based Research Network, Toronto, Canada
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15
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Boucher LM, Shoemaker ES, Liddy CE, Leonard L, MacPherson PA, Presseau J, Martin A, Pineau D, Lalonde C, Diliso N, Lafleche T, Fitzgerald M, Kendall CE. “They’re all struggling as well”: social and economic barriers and facilitators to self-managing chronic illness among marginalized people who use drugs. Int J Qual Stud Health Well-being 2022; 17:2082111. [PMID: 35652801 PMCID: PMC9176359 DOI: 10.1080/17482631.2022.2082111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose Self-management is recommended for addressing chronic conditions, and self-management programmes improve health behaviours and outcomes. However, social and economic factors have been neglected in self-management research, despite their relevance for marginalized groups. Thus, we aimed to explore barriers and facilitators that influence self-management among socioeconomically marginalized people who use drugs (PWUD). Methods Using community-based participatory methods, we developed a qualitative interview guide and conducted peer-led recruitment. Participants were admitted into the study after self-identifying as using non-prescribed drugs, having a chronic health issue, and experiencing socioeconomic marginalization. Data were analysed using reflexive thematic analysis, taking a relational autonomy lens. Results Participants highlighted substantial barriers to managing their health issues, mostly stemming from their social and economic environments, such as unstable housing, low income, lack of supportive social networks, and negative healthcare experiences. Participants also described how their ability to self-manage their chronic conditions benefited from specific aspects of social interactions, including close relationships, community connectedness, and engaging in peer support. Conclusions Our findings suggest that structural interventions are needed to support self-management among marginalized PWUD, especially stable housing. Self-management supports for PWUD would benefit from including a range of low-barrier community-based options, peer work opportunities, and advocacy for needs.
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Affiliation(s)
- Lisa M. Boucher
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Esther S. Shoemaker
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Clare E. Liddy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lynne Leonard
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Paul A. MacPherson
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alana Martin
- Somerset West Community Health Centre, Ottawa, ON, Canada
- Centretown Community Health Centre, Ottawa, ON, Canada
- The CDSM among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Dave Pineau
- The CDSM among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Christine Lalonde
- Centretown Community Health Centre, Ottawa, ON, Canada
- The CDSM among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Nic Diliso
- The CDSM among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Terry Lafleche
- The CDSM among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
- Sandy Hill Community Health Centre, Ottawa, ON, Canada
| | - Michael Fitzgerald
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Claire E. Kendall
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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16
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Chambers C, Samji H, Cooper CL, Costiniuk CT, Janjua NZ, Kroch AE, Arbess G, Benoit AC, Buchan SA, Chung H, Kendall CE, Kwong JC, Langlois MA, Lee SM, Mbuagbaw L, McCullagh J, Moineddin R, Nambiar D, Walmsley S, Anis AH, Burchell AN. Coronavirus disease 2019 vaccine effectiveness among a population-based cohort of people living with HIV. AIDS 2022; 36:F17-F26. [PMID: 36254892 PMCID: PMC9696686 DOI: 10.1097/qad.0000000000003405] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/29/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE People with HIV were underrepresented in coronavirus disease 2019 (COVID-19) vaccine clinical trials. We estimated vaccine effectiveness (VE) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for the BNT162b2, mRNA-1273, and ChAdOx1 vaccines among a population-based cohort of people with HIV in Ontario, Canada. DESIGN Test-negative design. METHODS We identified people with HIV aged ≥19 years who were tested for SARS-CoV-2 by RT-PCR between December 14, 2020 (first availability of COVID-19 vaccines) and November 21, 2021 (pre-Omicron circulation). Outcomes included any infection, symptomatic infection, and COVID-19-related hospitalization/death. We compared the odds of vaccination between test-positive cases and test-negative controls using multivariable logistic regression with adjustment for age, sex, region, calendar time, SARS-CoV-2 test histories, influenza vaccination, comorbidities, and neighborhood-level socio-economic status. VE was derived as (1 - adjusted odds ratio) × 100%. RESULTS Among 21 023 adults living with HIV, there were 801 (8.3%) test-positive cases and 8,879 (91.7%) test-negative controls. 20.1% cases and 47.8% of controls received ≥1 COVID-19 vaccine dose; among two-dose recipients, 93.4% received ≥1 mRNA dose. Two-dose VE ≥7 days before specimen collection was 82% (95% confidence interval [CI] = 74-87%) against any infection, 94% (95% CI = 82-98%) against symptomatic infection, and 97% (95% CI = 85-100%) against hospitalization/death. Against any infection, VE declined from 86% (95% CI = 77-92%) within 7-59 days after the second dose to 66% (95% CI = -15-90%) after ≥180 days; we did not observe evidence of waning protection for other outcomes. CONCLUSION Two doses of COVID-19 vaccine offered substantial protection against symptomatic illness and hospitalization/death in people with HIV prior to the emergence of the Omicron variant. Our findings do not support a broad conclusion that COVID-19 VE is lower among people with HIV in populations that, for the most part, are attending HIV care, taking antiretroviral medication, and are virally suppressed.
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Affiliation(s)
- Catharine Chambers
- Dalla Lana School of Public Health, University of Toronto
- Unity Health Toronto, Toronto, ON
| | - Hasina Samji
- British Columbia Centre for Disease Control, Vancouver
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
| | | | | | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver
- School of Population and Public Health, University of British Columbia
- Canadian HIV Trials Network, Vancouver, BC
| | - Abigail E. Kroch
- Dalla Lana School of Public Health, University of Toronto
- Ontario HIV Treatment Network
- Public Health Ontario
| | - Gordon Arbess
- Unity Health Toronto, Toronto, ON
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto
| | - Anita C. Benoit
- Dalla Lana School of Public Health, University of Toronto
- Department of Health and Society, University of Toronto Scarborough, Scarborough
- Women's College Research Institute, Women's College Hospital
| | - Sarah A. Buchan
- Dalla Lana School of Public Health, University of Toronto
- Public Health Ontario
- ICES (formerly Institute for Clinical Evaluative Sciences)
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto
| | - Hannah Chung
- ICES (formerly Institute for Clinical Evaluative Sciences)
| | - Claire E. Kendall
- ICES (formerly Institute for Clinical Evaluative Sciences)
- Bruyère Research Institute
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa
| | - Jeffrey C. Kwong
- Dalla Lana School of Public Health, University of Toronto
- Public Health Ontario
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto
- ICES (formerly Institute for Clinical Evaluative Sciences)
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto
- University Health Network, Toronto
| | - Marc-André Langlois
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa
| | | | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University
- Department of Anesthesia, Faculty of Health Sciences
- Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | | | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto
| | - Devan Nambiar
- Gay Men's Sexual Health Alliance, Toronto, ON, Canada
| | | | - Aslam H. Anis
- School of Population and Public Health, University of British Columbia
- Canadian HIV Trials Network, Vancouver, BC
| | - Ann N. Burchell
- Dalla Lana School of Public Health, University of Toronto
- Unity Health Toronto, Toronto, ON
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto
- ICES (formerly Institute for Clinical Evaluative Sciences)
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17
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Boucher LM, Dodd Z, Young S, Shahid A, Bayoumi A, Firestone M, Kendall CE. "They have their security, we have our community": Mutual support among people experiencing homelessness in encampments in Toronto during the COVID-19 pandemic. SSM Qual Res Health 2022; 2:100163. [PMID: 36060310 PMCID: PMC9425704 DOI: 10.1016/j.ssmqr.2022.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 01/12/2023]
Abstract
Unaffordable housing is a growing crisis in Canada, exacerbated by the COVID-19 pandemic, yet perspectives of people living outdoors in encampments have primarily gone unheard. We conducted qualitative interviews with encampment residents to explore how mutual support occurred within the social context of encampments. We found that mutually supportive interactions helped residents meet basic survival needs, as well as health and social needs, and reduced common health and safety risks related to homelessness. The homelessness sector should acknowledge that encampment residents form their own positive communities, and ensure policies and services do not isolate people from these beneficial social connections.
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Affiliation(s)
- Lisa M. Boucher
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada,C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St, Annex E, Ottawa, ON, K1N 5C8, Canada,Corresponding author. School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Zoë Dodd
- South Riverdale Community Health Centre, 955 Queen St E, Toronto, ON, M4M 3P3, Canada,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Samantha Young
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada,Division of General Internal Medicine, St. Michael's Hospital, Unity Health Toronto, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Abeera Shahid
- University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Ahmed Bayoumi
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Michelle Firestone
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Claire E. Kendall
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada,C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St, Annex E, Ottawa, ON, K1N 5C8, Canada,Department of Family Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
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18
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Chambers C, Gillis J, Lindsay J, Benoit AC, Kendall CE, Kroch A, Grewal R, Loutfy M, Mah A, O'Brien K, Ogilvie G, Raboud J, Rachlis A, Rachlis B, Yeung A, Yudin MH, Burchell AN. Low human papillomavirus vaccine uptake among women engaged in HIV care in Ontario, Canada. Prev Med 2022; 164:107246. [PMID: 36075492 DOI: 10.1016/j.ypmed.2022.107246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 10/31/2022]
Abstract
Women living with HIV are at higher risk for human papillomavirus (HPV)-related dysplasia and cancers and thus are prioritized for HPV vaccination. We measured HPV vaccine uptake among women engaged in HIV care in Ontario, Canada, and identified socio-demographic, behavioural, and clinical characteristics associated with HPV vaccination. During annual interviews from 2017 to 2020, women participating in a multi-site, clinical HIV cohort responded to a cross-sectional survey on HPV vaccine knowledge and receipt. We used logistic regression to derive age-adjusted odds ratios and 95% confidence intervals (CI) for factors associated with self-reported vaccine initiation (≥1 dose) or series completion (3 doses). Among 591 women (median age = 48 years; interquartile range = 40-56 years), 13.2% (95%CI = 10.5-15.9%) had received ≥1 dose. Of those vaccinated, 64.6% had received 3 doses. Vaccine initiation (≥1 dose) was significantly higher among women aged 20-29 years at 31.0% but fell to 13.9% in those aged 30-49 years and < 10% in those aged ≥50 years. After age adjustment, vaccine initiation was significantly associated with being employed (vs. unemployed but seeking work), income $40,000-$59,999 (vs. <$20,000), being married/common-law (vs. single), living with children, immigrating to Canada >5 years ago (vs. immigrating ≤5 years ago), never smoking (vs. currently smoking), and being in HIV care longer (per 10 years). Similar factors were identified for series completion (3 doses). HPV vaccine uptake remains low among women living with HIV in our cohort despite regular engagement in care. Recommendations for improving uptake include education of healthcare providers, targeted community outreach, and public funding of HPV vaccination.
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Affiliation(s)
- Catharine Chambers
- University of Toronto, Toronto, Canada; St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | | | - Joanne Lindsay
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Anita C Benoit
- University of Toronto, Toronto, Canada; Women's College Research Institute, Toronto, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Canada; ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Abigail Kroch
- University of Toronto, Toronto, Canada; Ontario HIV Treatment Network, Toronto, Canada; Public Health Ontario, Toronto, Canada
| | - Ramandip Grewal
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Public Health Ontario, Toronto, Canada
| | - Mona Loutfy
- Women's College Research Institute, Toronto, Canada
| | - Ashley Mah
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | | | - Gina Ogilvie
- University of British Columbia, Vancouver, Canada
| | - Janet Raboud
- University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | | | - Beth Rachlis
- University of Toronto, Toronto, Canada; ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Canada
| | - Anna Yeung
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Mark H Yudin
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Ann N Burchell
- University of Toronto, Toronto, Canada; St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.
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19
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Hogg W, Kotb A, Chu A, Gozdyra P, Sivaswamy A, Fang J, Kendall CE, Tu J. Patient clustering in primary care settings: Outcomes and quality of care. Can Fam Physician 2022; 68:671-680. [PMID: 36100388 PMCID: PMC9470188 DOI: 10.46747/cfp.6809671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine whether neighbours who share the same family physicians have better cardiovascular and health care outcomes. DESIGN Retrospective cohort study using administrative health databases. SETTING Ontario. PARTICIPANTS The study population included 2,690,482 adult patients cared for by 1710 family physicians. INTERVENTIONS Adult residents of Ontario were linked to their family physicians and the geographic distance between patients in the same panel or list was calculated. Using distance between patients within a panel to stratify physicians into quintiles of panel proximity, physicians and patients from close-proximity practices were compared with those from more-distant-proximity practices. Age- and sex-standardized incidence rates and hazard ratios from cause-specific hazards regression models were determined. MAIN OUTCOME MEASURES The occurrence of a major cardiovascular event during a 5-year follow-up period (2008 to 2012). RESULTS Patients of panels in the closest-proximity quintile lived an average of 3.9 km from the 10 closest patients in their panel compared with 12.4 km for the 10 closest patients of panels in the distant-proximity quintile. After adjusting for various patient and physician characteristics, patients in the most-distant-proximity practices had a 24% higher rate of cardiovascular events (adjusted hazard ratio=1.24 [95% CI 1.20 to 1.28], P<.001) than patients in the closest-proximity practices. Age- and sex-standardized all-cause mortality and total per patient health care costs were also lowest in the closest-proximity quintile. In sensitivity analyses restricted to large urban communities and to White long-term residents, results were similar. CONCLUSION The better cardiovascular outcomes observed in close-proximity panels may be related to a previously unrecognized mechanism of social connectedness that extends the effectiveness of primary care practitioners.
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Affiliation(s)
- William Hogg
- Director of Faculty Affairs in the Department of Family Medicine at the University of Ottawa in Ontario.
| | - Ahmed Kotb
- Family physician and Lecturer at the University of Ottawa
| | - Anna Chu
- Associate Research Methodologist at ICES in Toronto, Ont
| | | | | | | | - Claire E Kendall
- Associate Professor in the Department of Family Medicine and is cross-appointed to the School of Epidemiology and Public Health at the University of Ottawa; Senior Investigator at the Bruyère Research Institute in Ottawa; a practising family physician with the Bruyère Family Health Team; Adjunct Scientist at ICES; Affiliate Investigator in the Clinical Epidemiology Program at the Ottawa Hospital Research Institute; Affiliate Scientist in the Li Ka Shing Knowledge Institute at St Michael's Hospital in Toronto; and Associate Dean of Social Accountability in the Faculty of Medicine at the University of Ottawa
| | - Jack Tu
- Was Professor of Medicine, Health Policy, Management and Evaluation, and Public Health Sciences at the University of Toronto, was an attending physician at Sunnybrook Health Sciences Centre in Toronto, and oversaw the Cardiovascular Research Group at ICES
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20
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Kendzerska T, Zhu DT, Pugliese M, Manuel D, Sadatsafavi M, Povitz M, Stukel TA, To T, Aaron SD, Mulpuru S, Chin M, Kendall CE, Thavorn K, Robillard R, Gershon AS. Trends in all-cause mortality and inpatient and outpatient visits for ambulatory care sensitive conditions during the first year of the COVID-19 pandemic: A population-based study. J Hosp Med 2022; 17:726-737. [PMID: 35929531 PMCID: PMC9539068 DOI: 10.1002/jhm.12920] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The impact of the COVID-19 pandemic on the management of ambulatory care sensitive conditions (ACSCs) remains unknown. OBJECTIVES To compare observed and expected (projected based on previous years) trends in all-cause mortality and healthcare use for ACSCs in the first year of the pandemic (March 2020 to March 2021). DESIGN, SETTING AND PARTICIPANTS We conducted a population-based study using provincial health administrative data on general adul population (Ontario, Canada). OUTCOMES AND MEASURES Monthly all-cause mortality, and hospitalizations, emergency department (ED) and outpatient visit rates (per 100,000 people at-risk) for seven combined ACSCs (asthma, chronic obstructive pulmonary disease, angina, congestive heart failure, hypertension, diabetes, and epilepsy) during the first year were compared with similar periods in previous years (2016-2019) by fitting monthly time series autoregressive integrated moving-average models. RESULTS Compared to previous years, all-cause mortality rates increased at the beginning of the pandemic (observed rate in March to May 2020 of 79.98 vs. projected of 71.24 [66.35-76.50]) and then returned to expected in June 2020-except among immigrants and people with mental health conditions where they remained elevated. Hospitalization and ED visit rates for ACSCs remained lower than projected throughout the first year: observed hospitalization rate of 37.29 versus projected of 52.07 (47.84-56.68); observed ED visit rate of 92.55 versus projected of 134.72 (124.89-145.33). ACSC outpatient visit rates decreased initially (observed rate of 4299.57 vs. projected of 5060.23 [4712.64-5433.46]) and then returned to expected in June 2020.
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Affiliation(s)
- Tetyana Kendzerska
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
- ICESOntarioCanada
| | - David T. Zhu
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of Social and Behavioral SciencesYale School of Public HealthNew HavenConnecticutUSA
| | - Michael Pugliese
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- ICESOntarioCanada
| | - Douglas Manuel
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- ICESOntarioCanada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical SciencesThe University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Marcus Povitz
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Therese A. Stukel
- ICESOntarioCanada
- Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoOntarioCanada
| | - Teresa To
- ICESOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
- Research InstituteThe Hospital of Sick ChildrenTorontoOntarioCanada
| | - Shawn D. Aaron
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
| | - Sunita Mulpuru
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
| | - Melanie Chin
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
| | - Claire E. Kendall
- ICESOntarioCanada
- Bruyère Research InstituteOttawaOntarioCanada
- Department of Family MedicineUniversity of OttawaOttawaOntarioCanada
| | - Kednapa Thavorn
- The Ottawa Hospital Research InstituteOttawaOntarioCanada
- ICESOntarioCanada
- School of Epidemiology and Public Health, Faculty of MedicineUniversity of OttawaOntarioCanada
| | | | - Andrea S. Gershon
- ICESOntarioCanada
- Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
- Research InstituteThe Hospital of Sick ChildrenTorontoOntarioCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
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21
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Seale E, Reaume M, Batista R, Eddeen AB, Roberts R, Rhodes E, McIsaac DI, Kendall CE, Sood MM, Prud'homme D, Tanuseputro P. Patient–physician language concordance and quality and safety outcomes among frail home care recipients admitted to hospital in Ontario, Canada. CMAJ 2022; 194:E899-E908. [PMID: 35817434 PMCID: PMC9328476 DOI: 10.1503/cmaj.212155] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background: When patients and physicians speak the same language, it may improve the quality and safety of care delivered. We sought to determine whether patient–physician language concordance is associated with in-hospital and postdischarge outcomes among home care recipients who were admitted to hospital. Methods: We conducted a population-based study of a retrospective cohort of 189 690 home care recipients who were admitted to hospital in Ontario, Canada, between 2010 and 2018. We defined patient language (obtained from home care assessments) as English (Anglophone), French (Francophone) or other (allophone). We obtained physician language from the College of Physicians and Surgeons of Ontario. We defined hospital admissions as language concordant when patients received more than 50% of their care from physicians who spoke the patients’ primary language. We identified in-hospital (adverse events, length of stay, death) and post-discharge outcomes (emergency department visits, readmissions, death within 30 days of discharge). We used regression analyses to estimate the adjusted rate of mean and the adjusted odds ratio (OR) of each outcome, stratified by patient language, to assess the impact of language-concordant care within each linguistic group. Results: Allophone patients who received language-concordant care had lower risk of adverse events (adjusted OR 0.25, 95% confidence interval [CI] 0.15–0.43) and in-hospital death (adjusted OR 0.44, 95% CI 0.29–0.66), as well as shorter stays in hospital (adjusted rate of mean 0.74, 95% CI 0.66–0.83) than allophone patients who received language-discordant care. Results were similar for Francophone patients, although the magnitude of the effect was smaller than for allophone patients. Language concordance or discordance of the hospital admission was not associated with significant differences in postdischarge outcomes. Interpretation: Patients who received most of their care from physicians who spoke the patients’ primary language had better in-hospital outcomes, suggesting that disparities across linguistic groups could be mitigated by providing patients with language-concordant care.
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Affiliation(s)
- Emily Seale
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Michael Reaume
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Ricardo Batista
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Anan Bader Eddeen
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Rhiannon Roberts
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Emily Rhodes
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Daniel I McIsaac
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Claire E Kendall
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Manish M Sood
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Denis Prud'homme
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
| | - Peter Tanuseputro
- Faculty of Medicine (Seale, Reaume, McIsaac, Kendall, Sood, Tanuseputro), University of Ottawa; Institut du Savoir Montfort (Seale, Reaume, Prud'homme, Tanuseputro), Ottawa, Ont.; Department of Internal Medicine (Reaume), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.; Ottawa Hospital Research Institute (Batista, Roberts, Rhodes, McIsaac, Kendall, Sood, Tanuseputro); ICES uOttawa (Batista, Bader Eddeen, McIsaac, Kendall, Sood, Tanuseputro); Institut du Savoir Montfort (Batista); Department of Anesthesiology and Pain Medicine (McIsaac), The Ottawa Hospital; Bruyère Research Institute (Kendall, Tanuseputro), Ottawa, Ont.; Université de Moncton (Prud'homme), Moncton, NB
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22
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Nicolau IA, Antoniou T, Brooks JD, Moineddin R, Cooper C, Cotterchio M, Gillis JL, Kendall CE, Kroch AE, Lindsay JD, Price C, Salters K, Smieja M, Burchell AN. The burden of cancer among people living with HIV in Ontario, Canada, 1997-2020: a retrospective population-based cohort study using administrative health data. CMAJ Open 2022; 10:E666-E674. [PMID: 35853661 PMCID: PMC9312995 DOI: 10.9778/cmajo.20220012] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 With combination antiretroviral therapy (ART) and increased longevity, cancer is a leading cause of morbidity among people with HIV. We characterized trends in cancer burden among people with HIV in Ontario, Canada, between 1997 and 2020. METHODS We conducted a population-based, retrospective cohort study of adults with HIV using linked administrative health databases from Jan. 1, 1997, to Nov. 1, 2020. We grouped cancers as infection-related AIDS-defining cancers (ADCs), infection-related non-ADCs (NADCs) and infection-unrelated cancers. We calculated age-standardized incidence rates per 100 000 person-years with 95% confidence intervals (CIs) using direct standardization, stratified by calendar period and sex. We also calculated limited-duration prevalence. RESULTS Among 19 403 adults living with HIV (79% males), 1275 incident cancers were diagnosed. From 1997-2000 to 2016- 2020, we saw a decrease in the incidence of all cancers (1113.9 [95% CI 657.7-1765.6] to 683.5 [95% CI 613.4-759.4] per 100 000 person-years), ADCs (403.1 [95% CI 194.2-739.0] to 103.8 [95% CI 79.2-133.6] per 100 000 person-years) and infection-related NADCs (196.6 [95% CI 37.9-591.9] to 121.9 [95% CI 94.3-154.9] per 100 000 person-years). The incidence of infection-unrelated cancers was stable at 451.0 per 100 000 person-years (95% CI 410.3-494.7). The incidence of cancer among females increased over time but was similar to that of males in 2016-2020. INTERPRETATION Over a 24-year period, the incidence of cancer decreased overall, largely driven by a considerable decrease in the incidence of ADC, whereas the incidence of infection-unrelated cancer remained unchanged and contributed to the greatest burden of cancer. These findings could reflect combination ART-mediated changes in infectious comorbidity and increased life expectancy; targeted cancer screening and prevention strategies are needed.
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Affiliation(s)
- Ioana A Nicolau
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Tony Antoniou
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Jennifer D Brooks
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Rahim Moineddin
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Curtis Cooper
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Michelle Cotterchio
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Jennifer L Gillis
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Claire E Kendall
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Abigail E Kroch
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Joanne D Lindsay
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Colleen Price
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Kate Salters
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Marek Smieja
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont
| | - Ann N Burchell
- Division of Epidemiology Toronto (Nicolau, Brooks, Cotterchio, Gillis, Burchell, Dalla Lana School of Public Health, University of Toronto; ICES Central (Antoniou, Moineddin, Kendall, Burchell); Unity Health Toronto (Antoniou, Lindsay, Burchell), St Michael's Hospital; Department of Family and Community Medicine (Moineddin, Burchell), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Cooper), Ottawa, Ont.; Ontario Health (Cancer Care Ontario) (Cotterchio), Toronto, Ont.; Department of Medicine (Gillis), School of Population and Public Health, University of British Columbia, Vancouver, BC; Bruyère Research Institute (Kendall); ICES uOttawa (Kendall); Department of Family Medicine (Kendall), University of Ottawa; Institut du Savoir Montfort (Kendall); Clinical Epidemiology Program (Kendall), Ottawa Hospital Research Institute, Ottawa, Ont.; Ontario HIV Treatment Network (Kroch), Toronto, Ont.; CIHR Canadian HIV Trials Network - Chronic Pain and HIV Working Group (Price); British Columbia Centre for Excellence in HIV/AIDS (Salters), Vancouver, BC; Department of Pathology and Molecular Medicine (Smieja), McMaster University (Smieja), Hamilton, Ont.
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Boucher LM, Shoemaker ES, Liddy CE, Leonard L, MacPherson PA, Presseau J, Martin A, Pineau D, Lalonde C, Diliso N, Lafleche T, Fitzgerald M, Kendall CE. "The Drug Use Unfortunately isn't all Bad": Chronic Disease Self-Management Complexity and Strategy Among Marginalized People Who Use Drugs. Qual Health Res 2022; 32:871-886. [PMID: 35324352 PMCID: PMC9189593 DOI: 10.1177/10497323221083353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Self-management programs improve health outcomes and self-management is recommended for chronic conditions. Yet chronic disease self-management supports have rarely been applied to people who use drugs (PWUD). Thus, our objective was to explore self-management experiences among marginalized PWUD. We used community-based participatory methods and conducted qualitative interviews. Participants self-identified as having long-term and past year experience using non-prescribed drugs, one other chronic condition, and socioeconomic marginalization. We analyzed the data using reflexive thematic analysis. Although many participants considered drug use a chronic health issue, self-medicating with non-prescribed drugs was also a key self-management strategy to address other health issues. Participants also described numerous other strategies, including cognitive and behavioral tactics. These findings highlight the need for a safe supply of pharmaceutical-grade drugs to support self-management among marginalized PWUD. Self-management supports should also be tailored to address relevant topics (e.g., harm reduction, withdrawal), include creative activities, and not hinder PWUD's agency.
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Affiliation(s)
- Lisa M. Boucher
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Lisa M. Boucher, Elisabeth Bruyere Research Institute, 43 Bruyere Street, Annex E, Ottawa, ON K1N 5C7, Canada.
| | - Esther S. Shoemaker
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Clare E. Liddy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lynne Leonard
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Paul A. MacPherson
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alana Martin
- Somerset West Community Health Centre, Ottawa, ON, Canada
- Centretown Community Health Centre, Ottawa, ON, Canada
- The CDSM Among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Dave Pineau
- The CDSM Among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Christine Lalonde
- Centretown Community Health Centre, Ottawa, ON, Canada
- The CDSM Among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Nic Diliso
- The CDSM Among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
| | - Terry Lafleche
- The CDSM Among PWUD Study’s Community Advisory Committee, Bruyère Research Institute, Ottawa, ON, Canada
- Sandy Hill Community Health Centre, Ottawa, ONCanada
| | - Michael Fitzgerald
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Claire E. Kendall
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Kendall CE, Boucher LM, Donelle J, Martin A, Marshall Z, Boyd R, Oickle P, Diliso N, Pineau D, Renaud B, LeBlanc S, Tyndall M, Bayoumi AM. Cohort study of team-based care among marginalized people who use drugs in Ottawa. Can Fam Physician 2022; 68:117-127. [PMID: 35177504 PMCID: PMC9842166 DOI: 10.46747/cfp.6802117] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe team-based care use among a cohort of people who use drugs (PWUD) and to determine factors associated with receipt of team-based care. DESIGN A cohort study using survey data collected between March and December 2013. These data were then linked to provincial-level health administrative databases to assess patterns of primary care among PWUD in the 2 years before survey completion. SETTING Ottawa, Ont. PARTICIPANTS Marginalized PWUD 16 years of age or older. MAIN OUTCOME MEASURES Patients were assigned to primary care models based on survey responses and then were categorized as attached to team-based medical homes, attached to non-team-based medical homes, not attached to a medical home, and no primary care. Descriptive statistics and multinomial logistic regression were used to determine associations between PWUD and medical home models. RESULTS Of 663 total participants, only 162 (24.4%) received team-based care, which was associated with high school level of education (adjusted odds ratio [AOR] = 2.18; 95% CI 1.13 to 4.20), receipt of disability benefits (AOR = 2.47; 95% CI 1.22 to 5.02), and HIV infection (AOR = 2.88; 95% CI 1.28 to 6.52), and was inversely associated with recent overdose (AOR = 0.49; 95% CI 0.25 to 0.94). In comparison, 125 (18.8%) received non-team-based medical care, which was associated with university or college education (AOR = 2.31; 95% CI 1.04 to 5.15) and mental health comorbidity (AOR = 4.18; 95% CI 2.33 to 7.50), and was inversely associated with being detained in jail in the previous 12 months (AOR = 0.51; 95% CI 0.28 to 0.90). CONCLUSION Although team-based, integrated models of care will benefit disadvantaged groups the most, few PWUD receive such care. Policy makers should mitigate barriers to physician care and improve integration across health and social services.
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Affiliation(s)
- Claire E. Kendall
- Associate Professor in the Department of Family Medicine and is cross-appointed to the School of Epidemiology and Public Health at the University of Ottawa in Ontario; Senior Investigator at the Bruyère Research Institute in Ottawa; a practising family physician with the Bruyère Family Health Team; Adjunct Scientist at ICES in Toronto, Ont; Affiliate Investigator in the Clinical Epidemiology Program at the Ottawa Hospital Research Institute; Affiliate Scientist in the Li Ka Shing Knowledge Institute at St Michael’s Hospital in Toronto; and Associate Dean of Social Accountability in the Faculty of Medicine at the University of Ottawa.,Correspondence Dr Claire E. Kendall; e-mail
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25
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Mihan A, Muldoon L, Leider H, Tehfe H, Fitzgerald M, Fournier K, Kendall CE. Social accountability in undergraduate medical education: A narrative review. Educ Health (Abingdon) 2022; 35:3-8. [PMID: 36367022 DOI: 10.4103/efh.efh_305_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medical schools have been increasingly called upon to augment and prioritize their social accountability (SA). Approaches to increasing SA may include reorienting and focusing curricular activities on the priority health needs of the region that they serve. To inform the undergraduate medical education (UGME) curriculum renewal at our school, we examined how SA has been expressed in medical education across several countries and the impacts of SA activities on medical student experience and community-level outcomes. METHODS We conducted a narrative literature review using two electronic databases and searched for studies that reported on SA UGME activities implemented in Canada, Australia, New Zealand, the United States, and the United Kingdom. Studies were screened for inclusion based on predetermined eligibility criteria. RESULTS We included 40 studies for descriptive analysis and categorized UGME activities into five categories: (1) distributed medical education and community-specific placements/services (32; 80%), (2) community engagement and advocacy activities (23; 58%), (3) international elective preparation and experiences (8; 20%), (4) classroom-based learning of SA-related concepts (17; 43%), and (5) student engagement in SA UGME activities (6; 15%). We categorized impact into four main outcomes: student experience (21; 53%), student competencies (11; 28%), future career choice/practice setting (15; 38%), and community feedback (7; 18%). Student experience was most frequently examined, followed by future career choice/practice setting. DISCUSSION SA was primarily expressed in UGME activities through placement/service activities and most frequently assessed through student experiences. Student experiences of SA UGME activities have been reported to be largely positive, with benefits also reported for student competencies and influences on future career choice/practice setting. The expression of SA through community engagement in the development of curricular activities indicates a positive shift from social responsibility to SA, but a highly socially accountable curriculum would increasingly consider measures of community impact.
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Affiliation(s)
- Ariana Mihan
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
| | - Laura Muldoon
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Haley Leider
- Office of Social Accountability, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Hadi Tehfe
- Office of Social Accountability, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Michael Fitzgerald
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
| | | | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute; Department of Family Medicine, Faculty of Medicine; Office of Social Accountability, Faculty of Medicine, University of Ottawa, Ottawa, Canada
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Shoemaker ES, Saiyin T, Smith S, Loutfy M, Darling L, Walker M, Hawken S, Begum J, Bibeau C, Bertozzi B, Fraleigh A, Kwaramba G, Johnson K, Cousineau A, Kendall CE. Patterns of cesarean birth among women living with HIV in Ontario: A cross-sectional, population-level study. Birth 2021; 48:357-365. [PMID: 33733473 DOI: 10.1111/birt.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/10/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In Canada, as is found globally, women of reproductive age are a growing demographic of persons living with HIV. Combination antiretroviral therapy (cART) treatment enables women living with HIV (WLWH) to become pregnant without perinatal transmission, and they are increasingly planning to become pregnant. Since 2014, Canadian guidelines no longer recommend routine elective cesarean birth (CB) for women who are virally suppressed and receiving cART. It is unknown whether their obstetric care has changed since this update. Our objective was to describe trends in cesarean births among WLWH in Ontario, Canada, over a 12-year period. METHODS Our research is co-led and codesigned with WLWH. We conducted a retrospective population-level cohort study using linked health administrative databases at ICES (formally, the Institute for Clinical and Evaluative Sciences). Participants were all women who gave birth in Ontario, between 2006/07 and 2017/18. We assessed their intrapartum characteristics and used multivariable regression to determine an association between HIV status and CB, controlling for sociodemographic and clinical variables. RESULTS Since 2014, the overall proportion of CB among WLWH remained stable and was higher than among women without HIV (39.9% vs 29.0%, P < 0.001). In addition, the proportion of primary CB decreased between 2006 and 2010 and between 2014 and 2018 (28.5%-19.3%), whereas the proportion of repeat CB increased (13.1%-20.5%, P = 0.013). CONCLUSIONS Because of decreasing HIV-related indications for CB, more practitioners may be following the guidelines for first-time mothers. Currently, no guidelines exist for care of WLWH with a previous CB, and opportunities for vaginal birth may be missed in this population.
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Affiliation(s)
- Esther S Shoemaker
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Tana Saiyin
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stephanie Smith
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Mona Loutfy
- ICES, Ottawa, ON, Canada.,Infectious Disease Clinician Scientist, Departments of Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Liz Darling
- ICES, Ottawa, ON, Canada.,Department of Midwifery, McMaster University, Hamilton, ON, Canada
| | - Mark Walker
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Steven Hawken
- ICES, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Christine Bibeau
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Breklyn Bertozzi
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Annette Fraleigh
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Gladys Kwaramba
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Kerrigan Johnson
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Ashlee Cousineau
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
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Rowlands Snyder EC, Boucher LM, Bayoumi AM, Martin A, Marshall Z, Boyd R, LeBlanc S, Tyndall M, Kendall CE. A cross-sectional study of factors associated with unstable housing among marginalized people who use drugs in Ottawa, Canada. PLoS One 2021; 16:e0253923. [PMID: 34197552 PMCID: PMC8248707 DOI: 10.1371/journal.pone.0253923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Housing affects an individual’s physical and mental health, particularly among people who use substances. Understanding the association between individual characteristics and housing status can inform housing policy and help optimize the care of people who use drugs. The objective of this study was to explore the factors associated with unstable housing among people who use drugs in Ottawa. Methods This is a cross-sectional analysis of data from 782 participants in the Participatory Research in Ottawa: Understanding Drugs (PROUD) Study. PROUD is a prospective cohort study of people who use drugs in Ottawa. Between March and December 2013, participants were recruited through peer-based recruitment on the streets and in social services settings and completed a peer-administered questionnaire that explored socio-demographic information, drug use patterns, community integration, experiences with police and incarceration, and access to health care and harm reduction services. Eligibility criteria included age of 16 years or older, self-reported illicit drug use within the past 12 months and having lived in Ottawa for at least 3 months. Housing status was determined by self-report. “Stable housing” was defined as residence in a house or apartment and “unstable housing” was defined as all other residence types. Exploratory multivariable logistic regression analyses of the association between characteristics of people who use drugs and their housing status were conducted. Results Factors that were associated with unstable housing included: recent incarceration; not having a regular doctor; not having received support from a peer worker; low monthly income; income source other than public disability support payments; and younger age. Gender, language, ethnicity, education level, opioid use and injection drug use were not independently associated with housing status. Conclusions People who use drugs face significant barriers to stable housing. These results highlight key areas to address in order to improve housing stability among this community.
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Affiliation(s)
| | - Lisa M. Boucher
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ahmed M. Bayoumi
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alana Martin
- Somerset West Community Health Centre, Ottawa, Ontario, Canada
- PROUD Community Advisory Committee, Ottawa, Ontario, Canada
| | - Zack Marshall
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Rob Boyd
- Sandy Hill Community Health Centre, Ottawa, Ontario, Canada
| | - Sean LeBlanc
- PROUD Community Advisory Committee, Ottawa, Ontario, Canada
- Drug Users Advocacy League, Ottawa, Ontario, Canada
| | - Mark Tyndall
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Claire E. Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
- * E-mail:
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Zygmunt A, Kendall CE, James P, Lima I, Tuna M, Tanuseputro P. Avoidable Mortality Rates Decrease but Inequity Gaps Widen for Marginalized Neighborhoods: A Population-Based Analysis in Ontario, Canada from 1993 to 2014. J Community Health 2021; 45:579-597. [PMID: 31722048 DOI: 10.1007/s10900-019-00778-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Avoidable mortality (AM) is a health indicator used to examine trends in avoidable deaths amenable to public health and medical interventions. AM is more likely amongst marginalized populations. Our objective was to examine trends in AM rates by level of neighborhood marginalization. Decedents under age 75 years in Ontario from 1993 to 2014 (n = 691,453) were assigned to a quintile-level of each Ontario Marginalization (ON-Marg) Index dimension: material deprivation, residential instability, dependency, and ethnic concentration. We calculated ON-Marg Index dimension and quintile specific age- and sex-standardized AM incidence rates. We then calculated annual AM rate ratios between the most (Q5) and least (Q1) marginalized quintiles for each ON-Marg dimension. To describe the inequity gap in AM over time we calculated the absolute difference in the Q5/Q1 rate ratio between 2014 and 1993 for each dimension. AM rates in Ontario were almost halved (48.6%) from 1993 to 2014 (216 vs. 111 per 100,000 population). This decline was greater for treatable AM (75 vs. 36 per 100,000 population) than preventable AM (128 vs. 88 per 100,000 population). The inequity gap in AM Q5/Q1 rate ratios (RR) between 1993 and 2014 widened for all marginalization dimensions: dependency (RR 2.11-2.58), ethnic concentration (RR 0.59-0.48), material deprivation (RR 1.63-2.23), and residential instability (RR 2.01-2.43). To attain further declines in AM, policymakers and governments must address AM due to preventable deaths in neighborhoods highly marginalized by dependency, material deprivation, and residential instability.
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Affiliation(s)
- Austin Zygmunt
- School of Epidemiology and Public Health, University of Ottawa, Room 101 - 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada.
| | - Claire E Kendall
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Paul James
- ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Isac Lima
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada
| | - Meltem Tuna
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
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Kendzerska T, Zhu DT, Gershon AS, Edwards JD, Peixoto C, Robillard R, Kendall CE. The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review. Risk Manag Healthc Policy 2021; 14:575-584. [PMID: 33623448 PMCID: PMC7894869 DOI: 10.2147/rmhp.s293471] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions. METHODS A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021. FINDINGS During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed. INTERPRETATION Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.
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Affiliation(s)
- Tetyana Kendzerska
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute/The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - David T Zhu
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute/The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Science, Western University, London, Ontario, Canada
| | - Andrea S Gershon
- Department of Medicine, Sunnybrook Health Sciences Centre/University of Toronto, Toronto, Ontario, Canada
| | - Jodi D Edwards
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Cayden Peixoto
- The Institut Du Savoir Montfort, Ottawa, Ontario, Canada
| | - Rebecca Robillard
- The Royal’s Institute of Mental Health Research/University of Ottawa, Ottawa, Ontario, Canada
| | - Claire E Kendall
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute/The Ottawa Hospital, Ottawa, Ontario, Canada
- The Institut Du Savoir Montfort, Ottawa, Ontario, Canada
- C.T. Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Lignes directrices de pratique clinique pour les personnes sans-abri, logées précairement, ou ayant connu l’itinérance. CMAJ 2020; 192:E1225-E1241. [PMID: 33051325 PMCID: PMC7588247 DOI: 10.1503/cmaj.190777-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kevin Pottie
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont.
| | - Claire E Kendall
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Tim Aubry
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Olivia Magwood
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Anne Andermann
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ginetta Salvalaggio
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - David Ponka
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Gary Bloch
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Vanessa Brcic
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Eric Agbata
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Kednapa Thavorn
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Terry Hannigan
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Andrew Bond
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Susan Crouse
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ritika Goel
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Esther Shoemaker
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Jean Zhuo Jing Wang
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Sebastian Mott
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Harneel Kaur
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Christine Mathew
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Syeda Shanza Hashmi
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ammar Saad
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Thomas Piggott
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Neil Arya
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Nicole Kozloff
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Michaela Beder
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Dale Guenter
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Wendy Muckle
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Stephen Hwang
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Vicky Stergiopoulos
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Peter Tugwell
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
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Kendall CE, Boucher LM, Donelle J, Martin A, Marshall Z, Boyd R, Oickle P, Diliso N, Pineau D, Renaud B, LeBlanc S, Tyndall M, Bayoumi AM. Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada. BMC Health Serv Res 2020; 20:837. [PMID: 32894114 PMCID: PMC7487534 DOI: 10.1186/s12913-020-05670-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD. METHODS The Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March-December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care. RESULTS Characteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0-10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)). CONCLUSIONS Despite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.
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Affiliation(s)
- Claire E. Kendall
- Bruyère Research Institute, 43 Bruyère Street, Annex E, Ottawa, Ontario K1N 5C8 Canada
| | - Lisa M. Boucher
- Bruyère Research Institute, 43 Bruyère Street, Annex E, Ottawa, Ontario K1N 5C8 Canada
| | - Jessy Donelle
- ICES, Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Box 684, Administrative Services Building, 1st Floor, Ottawa, Ontario K1Y 4E9 Canada
| | - Alana Martin
- Somerset West Community Health Centre, 55 Eccles Street, Ottawa, Ontario K1R 6S3 Canada
- PROUD Community Advisory Committee, Ottawa, Ontario Canada
| | - Zack Marshall
- School of Social Work, McGill University, 3506 University Street, Room 421, Montreal, Quebec H3A 2A7 Canada
| | - Rob Boyd
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7 Canada
| | - Pam Oickle
- Ottawa Public Health, 179 Clarence Street, Ottawa, Ontario, K1N 1B3 Canada
| | - Nicola Diliso
- PROUD Community Advisory Committee, Ottawa, Ontario Canada
| | - Dave Pineau
- PROUD Community Advisory Committee, Ottawa, Ontario Canada
| | - Brad Renaud
- PROUD Community Advisory Committee, Ottawa, Ontario Canada
| | - Sean LeBlanc
- PROUD Community Advisory Committee, Ottawa, Ontario Canada
- Drug Users Advocacy League, Ottawa, Ontario Canada
| | - Mark Tyndall
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada
| | - Ahmed M. Bayoumi
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael’s Hospital; Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada
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Andermann A, Bloch G, Goel R, Brcic V, Salvalaggio G, Twan S, Kendall CE, Ponka D, Pottie K. Caring for patients with lived experience of homelessness. Can Fam Physician 2020; 66:563-570. [PMID: 32817028 PMCID: PMC7430777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. SOURCES OF INFORMATION The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient's Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. MAIN MESSAGE Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. CONCLUSION Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.
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Affiliation(s)
- Anne Andermann
- Associate Professor in the Department of Family Medicine, Director of the Community Outreach Clinic at St Mary's Hospital Family Medicine Centre, and Chair of the Social Accountability, Population Health and Health Advocacy Theme in Undergraduate Medical Education in the Faculty of Medicine at McGill University in Montreal, Que; a member of the Social Accountability Working Group of the College of Family Physicians of Canada in Mississauga, Ont; and a member of the National Advisory Council on Poverty of the Government of Canada.
| | - Gary Bloch
- Family physician in the Department of Family and Community Medicine at St Michael's Hospital in Toronto, Ont, and a family physician and cofounder of Inner City Health Associates
| | - Ritika Goel
- Chair of the Social Accountability Working Group of the College of Family Physicians of Canada, Population Health Lead of Inner City Health Associates at St Michael's Hospital, and Faculty Lead in Social Accountability in the Department of Family and Community Medicine at the University of Toronto
| | - Vanessa Brcic
- Clinical Assistant Professor in the Department of Family Practice at the University of British Columbia in Vancouver
| | - Ginetta Salvalaggio
- Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton and Associate Scientific Director of the Inner City Health and Wellness Program in Edmonton
| | - Shanell Twan
- Outreach worker and core team supervisor with the Streetworks harm reduction program in Edmonton, and a person with lived experience
| | - Claire E Kendall
- Associate Professor in the Department of Family Medicine at the University of Ottawa in Ontario, Clinician Scientist at the Bruyère Research Institute, Affiliate Investigator in the Clinical Epidemiology Program at the Ottawa Hospital Research Institute, Clinicienne Chercheure at the Institut du Savoir Montfort and Affiliate Scientist in the Li Ka Shing Knowledge Institute of St Michael's Hospital
| | - David Ponka
- Associate Professor in the C.T. Lamont Primary Health Care Research Centre in the Bruyère Research Institute at the University of Ottawa, and Director of the Besrour Centre for Global Family Medicine at the College of Family Physicians of Canada
| | - Kevin Pottie
- Associate Professor in the C.T. Lamont Primary Health Care Research Centre at the Bruyère Research Institute, and a member of the Campbell and Cochrane Equity Methods Group, the World Health Organization Guideline Review Committee, and the Canadian Task Force on Preventive Health Care
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Andermann A, Bloch G, Goel R, Brcic V, Salvalaggio G, Twan S, Kendall CE, Ponka D, Pottie K. [Not Available]. Can Fam Physician 2020; 66:e204-e212. [PMID: 32817047 PMCID: PMC7430794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Objectif Guider les médecins de famille de divers types de pratique familiale quant à la façon de dispenser des soins et du soutien aux patients logés précairement ou qui vivent l’itinérance. Sources d’information L’approche intègre les recommandations tirées des lignes directrices cliniques fondées sur les données probantes, l’opinion des personnes avec une expérience vécue de l’itinérance, les principes théoriques du cadre de travail du Centre de médecine de famille et des leçons pratiques provenant de médecins de famille qui travaillent dans des contextes cliniques variés. Message principal Les médecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinérants ou logés précairement; franchir les premières étapes pour faciliter l’accès au logement, à l’aide financière, à la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel à des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les médecins de famille ont un solide pouvoir de plaidoyer et peuvent s’associer aux organisations communautaires locales et aux personnes ayant vécu l’itinérance pour revendiquer des réformes politiques qui tiennent compte des iniquités sociales. Conclusion Les médecins de famille ont la capacité de répondre directement aux besoins sociaux et aux besoins en matière de santé physique et de santé mentale des patients itinérants ou logés précairement. En outre, ils peuvent promouvoir les programmes d’approche et d’intégration qui aident les personnes avec une expérience vécue de l’itinérance à accéder aux centres de médecine de famille et peuvent militer pour l’adoption de mesures générales visant à contrer les causes structurelles sous-jacentes de l’itinérance.
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Affiliation(s)
- Anne Andermann
- Professeure agrégée au Département de médecine de famille, directrice de la clinique d'approche communautaire au Centre de médecine familiale du Centre hospitalier de St. Mary et présidente du thème de responsabilité sociale, santé des populations et défense de la santé durant les études médicales prédoctorales à la Faculté de médecine de l'Université McGill, à Montréal (Québec); membre du Groupe de travail sur la responsabilité sociale du Collège des médecins de famille du Canada à Mississauga, en Ontario; et membre du Conseil consultatif national sur la pauvreté du Gouvernement du Canada.
| | - Gary Bloch
- Médecin de famille au Département de médecine familiale et communautaire de l'Hôpital St Michael's à Toronto (Ontario), et médecin de famille et cofondateur des Inner City Health Associates
| | - Ritika Goel
- Présidente du Groupe de travail sur la responsabilité sociale du Collège des médecins de famille du Canada, chef de santé des populations à Inner City Health Associates de l'Hôpital St Michael's et chef du corps enseignant de responsabilité sociale au Département de médecine de famille et communautaire de l'Université de Toronto
| | - Vanessa Brcic
- Professeure adjointe de clinique au département de médecine familiale de l'Université de la Colombie-Britannique, à Vancouver
| | - Ginetta Salvalaggio
- Professeure agrégée au département de médecine familiale à l'Université de l'Alberta à Edmonton et directrice scientifique adjointe du programme Inner City Health and Wellness à Edmonton
| | - Shanell Twan
- Travailleuse d'approche et superviseure de l'équipe centrale du programme de réduction des méfaits Streetworks à Edmonton, et elle est une personne avec expérience vécue
| | - Claire E Kendall
- Professeure agrégée au département de médecine familiale de l'Université d'Ottawa en Ontario, scientifique clinicienne à l'Institut de recherche Bruyère, investigatrice affiliée au programme d'épidémiologie clinique de l'Institut de recherche de l'Hôpital d'Ottawa, clinicienne chercheure à l'Institut du savoir Montfort et scientifique affiliée au Li Ka Shing Knowledge Institute de l'Hôpital St Michael's
| | - David Ponka
- Professeur agrégé au C.T. Lamont Primary Health Care Research Centre à l'Institut de recherche Bruyère de l'Université d'Ottawa et directeur du Centre Besrour des systèmes mondiaux de médecine familiale du Collège des médecins de famille du Canada
| | - Kevin Pottie
- Professeur agrégé au C.T. Lamont Primary Health Care Research Centre à l'Institut de recherche Bruyère et membre du Campbell and Cochrane Equity Methods Group, du comité d'examen des lignes directrices de l'Organisation mondiale de la santé et du Groupe d'étude canadien sur les soins de santé préventifs
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Mandel E, E Kendall C, Mason K, Guyton M, Lettner B, Broad J, Altenberg J, Donelle J, Powis J. Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto. CanLivJ 2020. [DOI: 10.3138/canlivj-2019-0021] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: The majority of new hepatitis C (HCV) cases occur among people who inject drugs. In recent years, multidisciplinary models of HCV treatment have emerged that demonstrate successful treatment outcomes for this population, as well as broad positive individual- and system-level impacts. Our objective was to evaluate changes in health care use among a cohort of people living with HCV before and after engagement with one such program. Methods: Program data were uniquely linked to provincial health administrative databases. Rates of emergency department (ED) visits and hospital admissions of clients from 2011 through 2015 ( N = 103) were evaluated using linkages with administrative data for the 2 years before and after program initiation. Data were evaluated using negative binomial regression models with a covariance structure to account for within-individual correlations. Results: Of participants, 72.8% were men (mean age 47 years), and 38% experienced high rates of physical and mental health comorbidity (Aggregated Diagnosis Group score ≥10). Female clients had significantly fewer ED visits 2 years after program initiation (5.04 versus 3.12; risk ratio [RR] 0.61 [95% CI 0.44% to 0.86%]). ED visits for infectious diseases and soft tissue injury were significantly lower for the cohort overall (RRs 0.58 0.51 [95% CIs 0.35% to 0.95% and 0.29% to 0.90%], respectively). Conclusion: Co-locating HCV treatment within comprehensive primary care and harm reduction services appears to have benefits beyond HCV, including a reduction in ED visits among women and a decrease in ED visits for soft tissue infections for all participants.
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Affiliation(s)
- Erin Mandel
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario
| | - Claire E Kendall
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario
| | - Kate Mason
- South Riverdale Community Health Centre, Toronto, Ontario
| | | | | | - Jennifer Broad
- South Riverdale Community Health Centre, Toronto, Ontario
| | | | | | - Jeff Powis
- South Riverdale Community Health Centre, Toronto, Ontario
- Michael Garron Hospital, Toronto, Ontario
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Mandel E, E Kendall C, Mason K, Guyton M, Lettner B, Broad J, Altenberg J, Donelle J, Powis J. Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto. CanLivJ 2020; 3:203-211. [DOI: 10.3138/canlivj.2019-0021] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/14/2019] [Indexed: 11/20/2022]
Abstract
Background: The majority of new hepatitis C (HCV) cases occur among people who inject drugs. In recent years, multidisciplinary models of HCV treatment have emerged that demonstrate successful treatment outcomes for this population, as well as broad positive individual- and system-level impacts. Our objective was to evaluate changes in health care use among a cohort of people living with HCV before and after engagement with one such program. Methods: Program data were uniquely linked to provincial health administrative databases. Rates of emergency department (ED) visits and hospital admissions of clients from 2011 through 2015 ( N = 103) were evaluated using linkages with administrative data for the 2 years before and after program initiation. Data were evaluated using negative binomial regression models with a covariance structure to account for within-individual correlations. Results: Of participants, 72.8% were men (mean age 47 years), and 38% experienced high rates of physical and mental health comorbidity (Aggregated Diagnosis Group score ≥10). Female clients had significantly fewer ED visits 2 years after program initiation (5.04 versus 3.12; risk ratio [RR] 0.61 [95% CI 0.44% to 0.86%]). ED visits for infectious diseases and soft tissue injury were significantly lower for the cohort overall (RRs 0.58 0.51 [95% CIs 0.35% to 0.95% and 0.29% to 0.90%], respectively). Conclusion: Co-locating HCV treatment within comprehensive primary care and harm reduction services appears to have benefits beyond HCV, including a reduction in ED visits among women and a decrease in ED visits for soft tissue infections for all participants.
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Affiliation(s)
- Erin Mandel
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario
| | - Claire E Kendall
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario
| | - Kate Mason
- South Riverdale Community Health Centre, Toronto, Ontario
| | | | | | - Jennifer Broad
- South Riverdale Community Health Centre, Toronto, Ontario
| | | | | | - Jeff Powis
- South Riverdale Community Health Centre, Toronto, Ontario
- Michael Garron Hospital, Toronto, Ontario
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Kendall CE, Fitzgerald M, Donelle J, Kwong JC, Galanakis C, Boyd R, Cooper CL. A cross-sectional study of prolonged disengagement from clinic among people with HCV receiving care in a low-threshold, multidisciplinary clinic. CanLivJ 2020; 3:212-223. [DOI: 10.3138/canlivj.2019-0020] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/22/2019] [Indexed: 11/20/2022]
Abstract
Background: Disengagement from care can affect treatment outcomes of patients with hepatitis C virus (HCV). We assessed the extent and determinants of disengagement among HCV patients receiving care at the Ottawa Hospital Viral Hepatitis Program (TOHVHP). Methods: We linked clinical data of adult patients, categorized as ever or never disengaged from clinic (no TOHVHP encounters over 18 months), receiving care between April 1, 2002, and October 1, 2015, to provincial health administrative databases and calculated primary care use in the year after disengagement. We used adjusted Cox proportional hazards models to analyze variables associated with disengagement. Results: Those disengaged from care ( n = 657) were younger at presentation (46.6 [SD 11.1] versus 51.9 [SD 11.0] years), p < 0.001) and had lower comorbidity. After multivariable adjustment, we observed lower hazards of disengagement among those with higher compared with lower fibrosis scores (F3, hazard ratio [HR] 0.21 [95% CI 0.08–0.57]; F4, HR 0.32 [95% CI 0.19–0.55]) and those treated compared with never treated (received direct-acting antivirals [DAAs], HR 0.71 [95% CI 0.58–0.88]; received interferon but not DAA, HR 0.66 [95% CI 0.55–0.80]). We found no association with mental health or substance use disorders. In the year after disengagement, 74.3% ( n = 488), 37.1% ( n = 244), and 17.7% ( n = 116) had at least one family physician visit, emergency department visit, and hospitalization, respectively. Conclusions: Better integration of HCV specialty and primary care could improve disengagement rates among people with HCV.
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Affiliation(s)
- Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, 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
| | - Chrissi Galanakis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rob Boyd
- Sandy Hill Community Health Centre, Ottawa, Ontario, Canada
| | - Curtis L Cooper
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Shoemaker ES, Kendall CE, Mathew C, Crispo S, Welch V, Andermann A, Mott S, Lalonde C, Bloch G, Mayhew A, Aubry T, Tugwell P, Stergiopoulos V, Pottie K. Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: A Delphi consensus study. PLoS One 2020; 15:e0231758. [PMID: 32298388 PMCID: PMC7162520 DOI: 10.1371/journal.pone.0231758] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 04/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. Methods We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys. Findings Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. Interpretation The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.
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Affiliation(s)
- Esther S. Shoemaker
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institute of Clinical and Evaluative Sciences, Toronto, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Claire E. Kendall
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institute of Clinical and Evaluative Sciences, Toronto, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Institute du Savoir Montfort, Ottawa, ON, Canada
| | | | | | - Vivian Welch
- Bruyère Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Anne Andermann
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- St Mary’s Research Centre, St Mary’s Hospital, Montreal, QC, Canada
| | - Sebastian Mott
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | | | - Gary Bloch
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Inner City Health Associates, Toronto, ON, Canada
| | | | - Tim Aubry
- School of Psychology and Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tugwell
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Vicky Stergiopoulos
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addictions and Mental Health, Toronto, ON, Canada
| | - Kevin Pottie
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- * E-mail:
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. CMAJ 2020; 192:E240-E254. [PMID: 32152052 PMCID: PMC7062440 DOI: 10.1503/cmaj.190777] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont.
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Tim Aubry
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Anne Andermann
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ginetta Salvalaggio
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - David Ponka
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Gary Bloch
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Vanessa Brcic
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Eric Agbata
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Kednapa Thavorn
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Terry Hannigan
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Andrew Bond
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Susan Crouse
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ritika Goel
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Esther Shoemaker
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Jean Zhuo Jing Wang
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Sebastian Mott
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Harneel Kaur
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Christine Mathew
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Syeda Shanza Hashmi
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ammar Saad
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Thomas Piggott
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Neil Arya
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Nicole Kozloff
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Michaela Beder
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Dale Guenter
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Wendy Muckle
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Stephen Hwang
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Vicky Stergiopoulos
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Peter Tugwell
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
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Zygmunt A, Tanuseputro P, James P, Lima I, Tuna M, Kendall CE. Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study. Can J Public Health 2019; 111:169-181. [PMID: 31828730 DOI: 10.17269/s41997-019-00270-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the impact of neighbourhood marginalization on avoidable mortality (AM) from preventable and treatable causes of death. METHODS All premature deaths between 1993 and 2014 (N = 691,453) in Ontario, Canada, were assigned to quintiles of neighbourhood marginalization using the four dimensions of the Ontario Marginalization Index: dependency, ethnic concentration, material deprivation, and residential instability. We conducted two multivariate logistic regressions to examine the association between neighbourhood marginalization, first with AM compared with non-AM as the outcome, and second with AM from preventable causes compared with treatable causes as the outcome. All models were adjusted for decedent age, sex, urban/rural location, and level of comorbidity. RESULTS A total of 463,015 deaths were classified as AM and 228,438 deaths were classified as non-AM. Persons living in the most materially deprived (OR, 1.24; 95% CI, 1.22 to 1.27) and residentially unstable neighbourhoods (OR, 1.13; 95% CI, 1.11 to 1.15) had greater odds of AM, particularly from preventable causes. Those living in the most dependent (OR, 0.91; 95% CI, 0.89 to 0.93) and ethnically concentrated neighbourhoods (OR, 0.93; 95% CI, 0.91 to 0.93) had lower odds of AM, although when AM occurred, it was more likely to arise from treatable causes. CONCLUSION Different marginalization dimensions have unique associations with AM. By identifying how different aspects of neighbourhood marginalization influence AM, these results may have important implications for future public health efforts to reduce inequities in avoidable deaths.
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Affiliation(s)
- Austin Zygmunt
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Canada
| | - Paul James
- ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Isac Lima
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada
| | - Meltem Tuna
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada
| | - Claire E Kendall
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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Cooper CL, Galanakis C, Donelle J, Kwong JC, Boyd R, Boucher L, Kendall CE. Correction to: HCV-infected individuals have higher prevalence of comorbidity and multimorbidity: a retrospective cohort study. BMC Infect Dis 2019; 19:889. [PMID: 31651290 PMCID: PMC6813993 DOI: 10.1186/s12879-019-4579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
After publication of the original article [1], we were notified that an author's name has been incorrectly spelled. Jeff Kwong's full name is Jeffery C. Kwong.
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Affiliation(s)
- Curtis L Cooper
- Department of Medicine, University of Ottawa, Ottawa, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital-General Campus, G12-501 Smyth Rd, Ottawa, Ontario, K1H8L6, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
| | - Chrissi Galanakis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital-General Campus, G12-501 Smyth Rd, Ottawa, Ontario, K1H8L6, Canada
| | | | - Jeffery C Kwong
- ICES, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rob Boyd
- Sandy Hill Community Health Centre, Ottawa, Canada
| | | | - Claire E Kendall
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital-General Campus, G12-501 Smyth Rd, Ottawa, Ontario, K1H8L6, Canada.,ICES, Toronto, Canada.,Bruyère Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
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Kendall CE, Porter JE, Shoemaker ES, Seoyeon Kang R, Fitzgerald M, Keely E, Afkham A, Crowe L, MacPherson P, Rosenes R, Lundrigan P, Bibeau C, Liddy C. Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service. MDM Policy Pract 2019; 4:2381468319868216. [PMID: 31453365 PMCID: PMC6699006 DOI: 10.1177/2381468319868216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 06/17/2019] [Indexed: 11/28/2022] Open
Abstract
Background. Electronic consultation (eConsultation) is a potential
strategy to improve access to specialist expertise and facilitate collaborative
care models. The Champlain BASE eConsult service allows for asynchronous
communication between primary care providers (PCP) and specialists on a secure,
web-based system. HIV experts accessible include HIV physician specialists, HIV
pharmacists, and social workers with expertise in HIV. Objective.
This study aims to describe the use, value, and utility of this eConsultation
service in the care of people living with HIV and to characterize the common
question types and clinical topics asked by PCPs. Methods. We
analyzed the data from eConsults sent to the HIV specialty group in Ontario’s
Champlain Local Health Integration Network between February 2015 and December
2017. Usage data and close-out survey responses were analyzed using descriptive
statistics, eConsults were classified using a predefined list of validated
taxonomy, and a thematic analysis was performed on the consultation logs to
identify common clinical themes. Results. Among the 46 eConsults,
the most common question type related to drug treatment (58.7%,
n = 27) and management (19.6%, n = 9). The
main clinical themes involved the care of significant complexities in people
living with HIV, such as comorbidities and drug interactions, and suggestions of
coordinated patient care. As well, eConsult was used for advice regarding
pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection.
PCPs highly valued the eConsult service (average rating 4.8/5).
Conclusion. Overall, this study demonstrates that eConsult
provides an efficient and valuable service to PCPs caring for patients living
with or at risk for HIV by improving access to HIV specialists and facilitating
the delivery of team-based comprehensive care.
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Affiliation(s)
- Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Janessa E Porter
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Esther S Shoemaker
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Rachel Seoyeon Kang
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Michael Fitzgerald
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Lois Crowe
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Paul MacPherson
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ron Rosenes
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Philip Lundrigan
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Christine Bibeau
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
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Shoemaker ES, Becker ML, Liddy CE, McClarty LM, Asghari S, Hurd J, Rourke SB, Shaw SY, Bibeau C, Rosenes R, Lundrigan P, Crowe L, Ireland L, Loeppky C, Kendall CE. Creating Clinical Cohorts: Challenges Encountered in Two Canadian Provinces. Healthc Policy 2019; 15:10-18. [PMID: 31629452 PMCID: PMC7008696 DOI: 10.12927/hcpol.2019.25942] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In 2013, the Living with HIV (LHIV) Innovation team established clinical cohorts of people living with HIV in Manitoba and Newfoundland and Labrador, and they linked the data to provincial health administrative databases. Access to these data enabled researchers to conduct studies across provincial borders; contribute to a national dialogue on HIV health system performance; and give recommendations for evidence-based healthcare, health policy and public health. However, research funding is episodic; maintaining cohorts requires stable funding. We support the establishment of a cross-jurisdictional approach to facilitate streamlined data collection and linkage without interruption and to allow for meaningful analysis in order to inform national policies.
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Affiliation(s)
- Esther S Shoemaker
- Bruyère Research Institute, University of Ottawa, Ottawa Hospital Research Institute, Institute of Clinical and Evaluative Sciences, Ottawa, ON
| | - Marissa L Becker
- Centre for Global Public Health, University of Manitoba, Winnipeg, MB
| | - Clare E Liddy
- Bruyère Research Institute, Department of Family Medicine, University of Ottawa, Ottawa, ON
| | - Leigh M McClarty
- Centre for Global Public Health, University of Manitoba, Winnipeg, MB
| | - Shabnam Asghari
- Department of Family Medicine, Centre for Rural Health Studies, Memorial University of Newfoundland, St. John's, NL
| | - Jillian Hurd
- Department of Family Medicine, Centre for Rural Health Studies, Memorial University of Newfoundland, St. John's, NL
| | - Sean B Rourke
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Department of Psychiatry, University of Toronto Toronto, ON
| | - Souradet Y Shaw
- Centre for Global Public Health, University of Manitoba, Winnipeg, MB
| | - Christine Bibeau
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON
| | - Ron Rosenes
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON
| | - Philip Lundrigan
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON
| | - Lois Crowe
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON
| | | | - Carla Loeppky
- Manitoba Health, Seniors and Active Living, Government of Manitoba, Winnipeg, MB
| | - Claire E Kendall
- Bruyère Research Institute, University of Ottawa, Institute of Clinical and Evaluative Sciences, Li Ka Shing Knowledge Institute, Ottawa, ON
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Boucher LM, O'Brien KK, Baxter LN, Fitzgerald ML, Liddy CE, Kendall CE. Healthy aging with HIV: The role of self-management support. Patient Educ Couns 2019; 102:1565-1569. [PMID: 30827568 DOI: 10.1016/j.pec.2019.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/19/2019] [Accepted: 02/19/2019] [Indexed: 06/09/2023]
Abstract
People living with HIV on antiretroviral treatment have significantly improved longevity, but as a result may also face increasing multimorbidity due to aging and long-term medication use. Thus, care needs for this population have evolved to require a chronic disease management approach in which self-management plays a central role. Here we highlight the importance of expanding self-management support options for people living with HIV, and discuss strategies for implementing and evaluating self-management interventions, outlining potential opportunities, challenges and solutions. We contend that standardized programs such as those offered through the Self-Management Resource Centre provide a rich opportunity to build the evidence base regarding the potential effectiveness of self-management support among people living with HIV. Thus we recommend enhancing self-management support through meaningful community-level collaboration with people with lived experience, careful assessment of process and outcome factors including who does not participate and why, attention to stigma and the specific needs of HIV priority groups, and consideration of how to extend engagement with services to address social and material needs beyond self-management program participation. We hope this reflection will serve as an aide for researchers and program managers to improve the array of evidence-based self-management support options available to people living with HIV.
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Affiliation(s)
- Lisa M Boucher
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Kelly K O'Brien
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, 160-500 University Avenue, Toronto, ON, M5G 1V7, Canada; Rehabilitation Sciences Institute, School of Graduate Studies, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
| | | | - Michael L Fitzgerald
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada
| | - Clare E Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada; Department of Family Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada; Department of Family Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada; Institute of Clinical and Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
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Liddy C, Moroz I, Keely E, Taljaard M, Deri Armstrong C, Afkham A, Kendall CE. Understanding the impact of a multispecialty electronic consultation service on family physician referral rates to specialists: a randomized controlled trial using health administrative data. Trials 2019; 20:348. [PMID: 31182123 PMCID: PMC6558850 DOI: 10.1186/s13063-019-3393-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 05/04/2019] [Indexed: 12/03/2022] Open
Abstract
Background Electronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult’s impact on family physicians’ referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care. Methods In this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data. Results One hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03). Conclusions Our randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials. Trial registration Clinicaltrials.gov, ID: NCT02053467. Registered prospectively on 3 February 2014.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, ON, Canada
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Masindi KI, Jembere N, Kendall CE, Burchell AN, Bayoumi AM, Loutfy M, Raboud J, Rourke SB, Luyombya H, Antoniou T. Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV. J Immigr Minor Health 2019; 20:536-545. [PMID: 29209931 DOI: 10.1007/s10903-017-0681-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.
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Affiliation(s)
- Khatundi-Irene Masindi
- Department of Family and Community Medicine, St. Michael's Hospital, 410 Sherbourne Street, Toronto, ON, M4X 1K2, Canada
| | | | - Claire E Kendall
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,CT Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ann N Burchell
- Department of Family and Community Medicine, St. Michael's Hospital, 410 Sherbourne Street, Toronto, ON, M4X 1K2, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Ahmed M Bayoumi
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Mona Loutfy
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Janet Raboud
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Sean B Rourke
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Ontario HIV Treatment Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Tony Antoniou
- Department of Family and Community Medicine, St. Michael's Hospital, 410 Sherbourne Street, Toronto, ON, M4X 1K2, Canada. .,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Boucher LM, Bayoumi AM, Mark AE, Cooper C, Martin A, Marshall Z, Boyd R, Oickle P, Diliso N, Pineau D, Renaud B, LeBlanc S, Tyndall M, Lee OM, Kendall CE. Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study. Subst Use Misuse 2019; 54:18-30. [PMID: 29932800 DOI: 10.1080/10826084.2018.1485699] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services. METHODS We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment. RESULTS Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.
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Affiliation(s)
- Lisa M Boucher
- a Bruyere Research Institute , Ottawa , Ontario , Canada.,b Department of Epidemiology and Public Health , University of Ottawa , Ottawa , Ontario , Canada
| | - Ahmed M Bayoumi
- c Division of General Internal Medicine , St. Michael's Hospital , Ontario , Canada.,d Department of Medicine and Institute of Health Policy, Management, and Evaluation , University of Toronto , Toronto , Ontario , Canada
| | - Amy E Mark
- e Institute for Clinical Evaluative Sciences , Toronto , Canada
| | - Curtis Cooper
- f Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - Alana Martin
- f Clinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - Zack Marshall
- g School of Social Work , McGill University , Montreal , Quebec , Canada
| | - Rob Boyd
- h Sandy Hill Community Health Centre , Ottawa , Ontario , Canada
| | - Pam Oickle
- i Ottawa Public Health , Ottawa , Ontario , Canada
| | - Nicola Diliso
- j PROUD Community Advisory Committee , Ottawa , Ontario , Canada
| | - Dave Pineau
- j PROUD Community Advisory Committee , Ottawa , Ontario , Canada
| | - Brad Renaud
- j PROUD Community Advisory Committee , Ottawa , Ontario , Canada
| | - Sean LeBlanc
- k Drug Users Advocacy League , Ottawa , Ontario , Canada
| | - Mark Tyndall
- l BC Centre for Disease Control , Vancouver , British Columbia , Canada
| | - Olivia M Lee
- b Department of Epidemiology and Public Health , University of Ottawa , Ottawa , Ontario , Canada
| | - Claire E Kendall
- a Bruyere Research Institute , Ottawa , Ontario , Canada.,b Department of Epidemiology and Public Health , University of Ottawa , Ottawa , Ontario , Canada.,m Li Ka Shing Knowledge Institute of St. Michael's Hospital , Ontario , Canada
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Burchell AN, Raboud J, Donelle J, Loutfy MR, Rourke SB, Rogers T, Rosenes R, Liddy C, Kendall CE. Cause-specific mortality among HIV-infected people in Ontario, 1995-2014: a population-based retrospective cohort study. CMAJ Open 2019; 7:E1-E7. [PMID: 30622108 PMCID: PMC6350837 DOI: 10.9778/cmajo.20180159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Risk factors for cause-specific mortality have not been widely studied among people with HIV infection. Our objectives were to estimate rates of and risk factors for all-cause and cause-specific mortality from 1995 to 2014 among HIV-infected people in Ontario. METHODS We conducted a population-based retrospective cohort study using provincial health databases of people with HIV infection who were aged 16 years or more, were residents of Ontario between 1995 and 2014, and had HIV infection according to a previously validated algorithm. We used International Classification of Diseases codes to classify the underlying cause of death and estimated age-adjusted mortality rates per 100 person-years for 1995 to 2014. We used descriptive statistics to characterize the cohort at baseline and calculated adjusted mortality rate ratios (RRs) using generalized estimating equations. RESULTS Among 23 043 people, the all-cause mortality rate declined from 6.69 to 1.53 per 100 person-years over the study period, and the rate of death from HIV/AIDS declined from 4.75 to 0.46 per 100 person-years. Concomitantly, the proportions of deaths due to cancer, cardiovascular disease and other noncommunicable diseases rose; however, rates remained constant or declined. Compared to males, females had higher mortality due to cardiovascular disease (adjusted RR 1.36, 95% confidence interval [CI] 1.04-1.77), noncommunicable causes (adjusted RR 1.75, 95% CI 1.39-2.20) and, by 2010-2014, any cause (adjusted RR 1.19, 95% CI 1.02-1.38). Residing in a low-income neighbourhood was associated with increased risk for most causes, including HIV/AIDS (adjusted RR in 2010-2014 1.86, 95% CI 1.49-2.31). Rural residence was associated with increased mortality due to malignant disease (adjusted RR 1.60, 95% CI 1.10-2.34) and noncommunicable disease (adjusted RR 1.86, 95% CI 1.25-2.77). Being an immigrant was associated with lower risk of death from all causes. INTERPRETATION Over the study period, death was increasingly due to common chronic conditions rather than to HIV infection itself. Care should incorporate the prevention and management of these conditions, especially among females and those residing in rural and low-income areas.
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Affiliation(s)
- Ann N Burchell
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Janet Raboud
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Jessy Donelle
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Mona R Loutfy
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Sean B Rourke
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Tim Rogers
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Ron Rosenes
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Clare Liddy
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Claire E Kendall
- Centre for Urban Health Solutions (Burchell, Rourke), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Department of Family and Community Medicine (Burchell), University of Toronto; ICES (Burchell, Loutfy); Toronto General Hospital Research Institute (Raboud), Toronto, Ont.; ICES uOttawa (Donelle, Kendall), Ottawa Hospital Research Institute, Civic Campus, Ottawa Ont.; Maple Leaf Medical Clinic (Loutfy); Women's College Research Institute (Loutfy), Women's College Hospital; Department of Medicine (Loutfy), University of Toronto; Canadian AIDS Treatment Information Exchange (Rogers), Toronto, Ont.; C.T. Lamont Primary Health Care Research Centre (Rosenes, Kendall), Bruyère Research Institute; Department of Family Medicine (Liddy), University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont.
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Kendall CE, Raboud J, Donelle J, Loutfy M, Rourke SB, Kroch A, Liddy C, Rosenes R, Burchell AN. Lost but not forgotten: A population-based study of mortality and care trajectories among people living with HIV who are lost to follow-up in Ontario, Canada. HIV Med 2018; 20:88-98. [PMID: 30474908 PMCID: PMC9292000 DOI: 10.1111/hiv.12682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/27/2022]
Abstract
Objectives Selection as a consequence of volunteer participation in, and loss to follow‐up from, cohort studies may bias estimates of mortality and other health outcomes. To quantify this potential, we estimated mortality and health service use among people living with HIV (PLWH) who were lost to cohort follow‐up (LTCFU) from a volunteer clinical HIV‐infected cohort, and compared these to mortality and health service use in active cohort participants and non‐cohort‐participants living with HIV in Ontario, Canada. Methods We analysed population‐based provincial health databases from 1995 to 2014, identifying PLWH ≥ 18 years old; these included data from participants in the Ontario HIV Treatment Network Cohort Study (OCS), a volunteer, multi‐site clinical HIV‐infected cohort. We calculated all‐cause mortality, hospitalization and emergency department (ED) visit rates per 100 person‐years (PY) and estimated hazard ratios (HRs) of mortality, adjusting for age, sex, income, rurality, and immigration status. Results Among 23 043 PLWH, 5568 were OCS participants. Compared with nonparticipants, participants were younger and less likely to be female, to be an immigrant and to reside in a major urban centre, and had lower comorbidity. Mortality among active participants, participants LTCFU and nonparticipants was 2.52, 3.30 and 2.20 per 100 PY, respectively. After adjustment for covariates, mortality risk was elevated among participants LTCFU compared with active participants (HR 2.26; 95% confidence interval 1.91, 2.68). Age‐adjusted hospitalization rates and ED visit rates were highest among participants LTCFU. Conclusions Mortality risk and use of health care resources were lower among active cohort participants. Our findings may inform health outcome estimates based on volunteer cohorts, as well as quantitative bias adjustment to correct for such biases.
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Affiliation(s)
- C E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,ICES, Toronto, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - J Raboud
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - J Donelle
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - M Loutfy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Maple Leaf Medical Clinic, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - S B Rourke
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - A Kroch
- Ontario HIV Treatment Network, Toronto, ON, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - C Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - R Rosenes
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | | | - A N Burchell
- ICES, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Wilton J, Light L, Gardner S, Rachlis B, Conway T, Cooper C, Cupido P, Kendall CE, Loutfy M, McGee F, Murray J, Lush J, Rachlis A, Wobeser W, Bacon J, Kroch AE, Gilbert M, Rourke SB, Burchell AN. Late diagnosis, delayed presentation and late presentation among persons enrolled in a clinical HIV cohort in Ontario, Canada (1999-2013). HIV Med 2018; 20:110-120. [PMID: 30430742 DOI: 10.1111/hiv.12686] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Timely HIV diagnosis and presentation to medical care are important for treatment and prevention. Our objective was to measure late diagnosis, delayed presentation and late presentation among individuals in the Ontario HIV Treatment Network Cohort Study (OCS) who were newly diagnosed in Ontario. METHODS The OCS is a multi-site clinical cohort study of people living with HIV in Ontario, Canada. We measured prevalence of late diagnosis [CD4 count < 350 cells/μL or an AIDS-defining condition (ADC) within 3 months of HIV diagnosis], delayed presentation (≥ 3 months from HIV diagnosis to presentation to care), and late presentation (CD4 count < 350 cells/μL or ADC within 3 months of presentation). We identified characteristics associated with these outcomes and explored their overlap. RESULTS A total of 1819 OCS participants were newly diagnosed in Ontario from 1999 to 2013. Late diagnosis (53.0%) and presentation (54.0%) were common, and a quarter (23.1%) of participants were delayed presenters. In multivariable models, the participants of delayed presentation decreased over calendar time, but that of late diagnosis/presentation did not. Late diagnosis contributed to the majority (> 87%) of late presentation, and the prevalence of delayed presentation was similar among those diagnosed late versus early (13.4 versus 13.4%, respectively; P = 0.99). Characteristics associated with higher odds of late diagnosis/presentation in multivariable analyses included older age at diagnosis/presentation; African, Caribbean and Black race/ethnicity; Indigenous race/ethnicity; female sex; and being a male who did not report sex with men. There were lower odds of late diagnosis/presentation among participants who had ever injected drugs. In contrast, delayed presentation risk factors included younger age at diagnosis and having ever injected drugs. CONCLUSIONS Late presentation is common in Ontario, as it is in other high-income countries. Our findings suggest that efforts to reduce late presentation should focus on facilitating earlier diagnosis for the populations identified in this analysis.
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Affiliation(s)
- J Wilton
- Ontario HIV Treatment Network, Toronto, Canada
| | - L Light
- Ontario HIV Treatment Network, Toronto, Canada
| | - S Gardner
- Baycrest Health Sciences, Toronto, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - B Rachlis
- Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - T Conway
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Canadian Positive People Network, Ottawa, Canada
| | - C Cooper
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - P Cupido
- Ontario HIV Treatment Network, Toronto, Canada
| | - C E Kendall
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - M Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - F McGee
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - J Murray
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - J Lush
- AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - A Rachlis
- Department of Medicine, University of Toronto, Toronto, Canada.,Sunnybrook Health Science Centre, Toronto, Canada
| | - W Wobeser
- Department of Molecular and Biomedical Sciences, Queen's University, Kingston, Canada.,Department of Public Health, Queen's University, Kingston, Canada
| | - J Bacon
- Ontario HIV Treatment Network, Toronto, Canada
| | - A E Kroch
- Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - M Gilbert
- Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - S B Rourke
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - A N Burchell
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine, St Michael's Hospital, Toronto, Canada.,Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Ben Charif A, Hassani K, Wong ST, Zomahoun HTV, Fortin M, Freitas A, Katz A, Kendall CE, Liddy C, Nicholson K, Petrovic B, Ploeg J, Légaré F. Assessment of scalability of evidence-based innovations in community-based primary health care: a cross-sectional study. CMAJ Open 2018; 6:E520-E527. [PMID: 30389751 PMCID: PMC6221806 DOI: 10.9778/cmajo.20180143] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 01/24/2023] Open
Abstract
BACKGROUND In 2013, the Canadian Institutes of Health Research funded 12 community-based primary health care research teams to develop evidence-based innovations. We aimed to explore the scalability of these innovations. METHODS In this cross-sectional study, we invited the 12 teams to rate their evidence-based innovations for scalability. Based on a systematic review, we developed a self-administered questionnaire with 16 scalability assessment criteria grouped into 5 dimensions (theory, impact, coverage, setting and cost). Teams completed a questionnaire for each of their innovations. We analyzed the data using simple frequency counts and hierarchical cluster analysis. We calculated the mean number and standard deviation (SD) of innovations that met criteria within each dimension that included more than 1 criterion. The analysis unit was the innovation. RESULTS The 11 responding teams evaluated 33 evidence-based innovations (median 3, range 1-8 per team). The innovations focused on access to care and chronic disease prevention and management, and varied from health interventions to methodological innovations. Most of the innovations were health interventions (n = 21), followed by analytical methods (n = 4), conceptual frameworks (n = 4), measures (n = 3) and strategies to build research capacity (n = 1). Most (29) met criteria in the theory dimension, followed by impact (mean 22.3 [SD 5.6] innovations per dimension), setting (mean 21.7 [SD 8.5]), cost (mean 17.5 [SD 2.1]) and coverage (mean 14.0 [SD 4.1]). On average, the innovations met 10 of the 16 criteria. Adoption was the least assessed criterion (n = 9). Most (20) of the innovations were highly ranked for scalability. INTERPRETATION Scalability varied among innovations, which suggests that readiness for scale up was suboptimal for some innovations. Coverage remained largely unaddressed; further investigation of this critical dimension is necessary.
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Affiliation(s)
- Ali Ben Charif
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Kasra Hassani
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Sabrina T Wong
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Hervé Tchala Vignon Zomahoun
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Martin Fortin
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Adriana Freitas
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Alan Katz
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Claire E Kendall
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Clare Liddy
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Kathryn Nicholson
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Bojana Petrovic
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - Jenny Ploeg
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne (Ben Charif, Zomahoun, Freitas, Légaré); Health and Social Services Systems, Knowledge Translation and Implementation component (Ben Charif, Zomahoun, Légaré), Quebec Strategy for Patient-Oriented Research (SPOR) Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit; Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation (Ben Charif, Freitas, Légaré); Department of Family Medicine and Emergency Medicine (Ben Charif, Légaré), Université Laval, Québec, Que.; School of Nursing (Hassani, Wong) and Centre for Health Services and Policy Research (Hassani, Wong), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Diabetes Action Canada (Freitas, Légaré), Université Laval, Québec, Que.; Departments of Community Health Sciences (Katz) and Family Medicine (Katz), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Élisabeth Bruyère Research Institute (Kendall, Liddy), C.T. Lamont Primary Health Care Research Group; Department of Family Medicine (Kendall, Liddy) and Ottawa Hospital Research Institute (Kendall), University of Ottawa, Ottawa, Ont.; Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; Department of Epidemiology and Biostatistics (Nicholson), Western University, London, Ont.; Department of Family and Community Medicine (Petrovic) and Dalla Lana School of Public Health (Petrovic), University of Toronto, Toronto, Ont.; School of Nursing (Ploeg), Faculty of Health Sciences, and Diabetes Action Canada (Ploeg), McMaster University, Hamilton, Ont.
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