The human health effects of unconventional oil and gas development (UOGD): A scoping review of epidemiologic studies

OBJECTIVE

Unconventional oil and gas development (UOGD, sometimes termed "fracking" or "hydraulic fracturing") is an industrial process to extract methane gas and/or oil deposits. Many chemicals used in UOGD have known adverse human health effects. Canada is a major producer of UOGD-derived gas with wells frequently located in and around rural and Indigenous communities. Our objective was to conduct a scoping review to identify the extent of research evidence assessing UOGD exposure-related health impacts, with an additional focus on Canadian studies.

METHODS

We included English- or French-language peer-reviewed epidemiologic studies (January 2000-December 2022) which measured exposure to UOGD chemicals directly or by proxy, and where health outcomes were plausibly caused by UOGD-related chemical exposure. Results synthesis was descriptive with results ordered by outcome and hierarchy of methodological approach.

SYNTHESIS

We identified 52 studies from nine jurisdictions. Only two were set in Canada. A majority (n = 27) used retrospective cohort and case-control designs. Almost half (n = 24) focused on birth outcomes, with a majority (n = 22) reporting one or more significant adverse associations of UOGD exposure with: low birthweight; small for gestational age; preterm birth; and one or more birth defects. Other studies identified adverse impacts including asthma (n = 7), respiratory (n = 13), cardiovascular (n = 6), childhood acute lymphocytic leukemia (n = 2), and all-cause mortality (n = 4).

CONCLUSION

There is a growing body of research, across different jurisdictions, reporting associations of UOGD with adverse health outcomes. Despite the rapid growth of UOGD, which is often located in remote, rural, and Indigenous communities, Canadian research on its effects on human health is remarkably sparse. There is a pressing need for additional evidence.

The association of facility ownership with COVID-19 outbreaks in long-term care homes in British Columbia, Canada: a retrospective cohort study

BACKGROUND

Long-term care (LTC) in Canada is delivered by a mix of government-, for-profit- and nonprofit-owned facilities that receive public funding to provide care, and were sites of major outbreaks during the early stages of the COVID-19 pandemic. We sought to assess whether facility ownership was associated with COVID-19 outbreaks among LTC facilities in British Columbia, Canada.

METHODS

We conducted a retrospective observational study in which we linked LTC facility data, collected annually by the Office of the Seniors Advocate BC, with public health data on outbreaks. A facility outbreak was recorded when 1 or more residents tested positive for SARS-CoV-2 between Mar. 1, 2020, and Jan. 31, 2021. We used the Cox proportional hazards method to calculate the adjusted hazard ratio (HR) of the association between risk of COVID-19 outbreak and facility ownership, controlling for community incidence of COVID-19 and other facility characteristics.

RESULTS

Overall, 94 outbreaks involved residents in 80 of 293 facilities. Compared with health authority-owned facilities, for-profit and nonprofit facilities had higher risks of COVID-19 outbreaks (adjusted HR 1.99, 95% confidence interval [CI] 1.12-3.52 and adjusted HR 1.84, 95% CI 1.00-3.36, respectively). The model adjusted for community incidence of infection (adjusted HR 1.12, 95% CI 1.07-1.17), total nursing hours per resident-day (adjusted HR 0.84, 95% CI 0.33-2.14), facility age (adjusted HR 1.01, 95% CI 1.00-1.02), number of facility beds (adjusted HR 1.20, 95% CI 1.12-1.30) and facilities with beds in shared rooms (adjusted HR 1.16, 95% CI 0.73-1.85).

INTERPRETATION

Findings suggest that ownership of LTC facilities by health authorities in BC offered some protection against COVID-19 outbreaks. Further study is needed to unpack the underlying pathways behind this observed association.

Characterizing people with frequent emergency department visits and substance use: a retrospective cohort study of linked administrative data in Ontario, Alberta, and B.C., Canada

Background

Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces.

Methods

This was a retrospective cohort study (April 1^st, 2013 to March 31^st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use.

We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1^st, 2014 to March 31^st, 2015.

Results

In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37–43 years; 60.9–63.0% male), whose ED visits and hospitalizations were higher than comparison groups.

In all provinces, cluster analyses identified subgroups with “extreme” and “moderate” frequent visits (median 13–19 versus 4–6 visits/year). “Extreme” versus “moderate” subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups.

Conclusions

Subgroups of people with “extreme” (13–19 visits/year) and “moderate” (4–6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the “extreme” subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00673-x.

Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study

BACKGROUND

The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups.

METHODS

This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health-related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale.

RESULTS

The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: "short duration" (frequent, regularly spaced visits), "older patients" (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), "young mental health" (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health-related and alcohol-related visits) and "injury" (increased prevalence of injury-related visits).

INTERPRETATION

From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.

People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study

BACKGROUND

The factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use.

METHODS

This was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health-related hospitalization data.

RESULTS

We identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use-related presentations, mental health hospitalizations and instances of leaving hospital against medical advice.

INTERPRETATION

Higher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.

Evaluation of an initiative to improve advance care planning for a home-based primary care service

Background

Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP.

Methods

The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation.

Results

We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively.

Conclusions

Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.

Identifying subgroups and risk among frequent emergency department users in British Columbia

Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits. We employed cluster analysis to identify frequent user subgroups. We assessed 365-day mortality using Kaplan-Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 ("Elderly") had median age 77 years (interquartile range [IQR]: 66-85), 5 visits/year (IQR: 4-6), median 8 prescription medications (IQR: 5-11), and 24.7% mortality. Subgroup 2 ("Mental Health and Alcohol Use") had median age 48 years (IQR: 34-61), 13 visits/year (IQR: 10-16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19-51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 ("Young Mental Health") had median age 39 years (IQR: 28-51), 5 visits/year (IQR: 4-6), and 2.2% mortality. Subgroup 4 ("Short-term") had median age 50 years (IQR: 34-65), 4 visits/year (IQR: 4-5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long-term care ("Mental Health and Alcohol Use;" "Young Mental Health"), and rural residence ("Elderly" in long-term care; "Young Mental Health") were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups' unmet needs and tailor interventions toward them.

Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis

BACKGROUND

Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada.

METHODS

We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year).

RESULTS

Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users.

INTERPRETATION

Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.

Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study

OBJECTIVE

Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016.

MEASURES

Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors.

RESULTS

The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29-1.38) and nonprofit (adjHR 1.37; 95% CI 1.32-1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36-1.48) and nonprofit (adjHR 1.38, 95% CI 1.33-1.44).

CONCLUSIONS AND IMPLICATIONS

This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.

Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre

Background

Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice.

Methods

This was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis.

Results

In 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four per cent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively.

Conclusions

Clinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.

An International Mapping of Medical Care in Nursing Homes

Nursing home (NH) residents are increasingly in need of timely and frequent medical care, presupposing not only available but perhaps also continual medical care provision in NHs. The provision of this medical care is organized differently both within and across countries, which may in turn profoundly affect the overall quality of care provided to NH residents. Data were collected from official legislations and regulations, academic publications, and statistical databases. Based on this set of data, we describe and compare the policies and practices guiding how medical care is provided across Canada (2 provinces), Germany, Norway, and the United States. Our findings disclose that there is a considerable difference to find among jurisdictions regarding specificity and scope of regulations regarding medical care in NHs. Based on our data, we construct 2 general models of medical care: (1) more regulations-fee-for-service payment-open staffing models and (2) less regulation-salaried positions-closed staffing models. Some evidence indicates that model 1 can lead to less available medical care provision and to medical care provision being less integrated into the overall care services. As such, we argue that the service models discussed can significantly influence continuity of medical care in NH.

Advance Care Planning in the Nursing Home Setting: A Practice Improvement Evaluation

This study evaluated a practice improvement initiative conducted over a 6 month period in 15 Canadian nursing homes. Goals of the initiative included: (1) use the Plan-Do-Study-Act (PDSA) model to improve advance care planning (ACP) within the sample of nursing homes; (2) investigate whether improved ACP practice resulted in a change in residents' hospital use and ACP preferences for home-based care; (3) engage participating facilities in regular data collection to inform the initiative and provide a basis for reflection about ACP practice and; (4) foster a team-based participatory care culture. The initiative entailed two cycles of learning sessions followed by implementation of ACP practice improvement projects in the facilities using a PDSA approach by participating clinicians (e.g., physicians, social workers, nurses). Clinicians reported significantly increased confidence in many dimensions of ACP activities. Rates of hospital use and resident preference for home-based care did not change significantly. The initiative established routine data collection of outcomes to inform practice change, and successfully engaged physicians and non-physician clinicians to work together to improve ACP practices. Results suggest recurrent PDSA cycles that engage a 'critical mass' of clinicians may be warranted to reinforce the standardization of ACP in practice.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

Associations between polypharmacy and treatment intensity for hypertension and diabetes: a cross-sectional study of nursing home patients in British Columbia, Canada

OBJECTIVES

Describe nursing home polypharmacy prevalence in the context of prescribing for diabetes and hypertension and determine possible associations between lower surrogate markers for treated hypertension and diabetes (overtreatment) and polypharmacy.

DESIGN

Cross-sectional study.

SETTING

6 nursing homes in British Columbia, Canada.

PARTICIPANTS

214 patients residing in one of the selected facilities during data collection period.

PRIMARY AND SECONDARY OUTCOME MEASURES

Polypharmacy was defined as ≥9 regular medications. Overtreatment of diabetes was defined as being prescribed at least one hypoglycaemic medication and a glycosylated haemoglobin (HbA1c) ≤7.5%. Overtreatment of hypertension required being prescribed at least one hypertension medication and having a systolic blood pressure ≤128 mm Hg. Polypharmacy prescribing, independent of overtreatment, was calculated by subtracting condition-specific medications from total medications prescribed.

RESULTS

Data gathering was completed for 214 patients, 104 (48%) of whom were prescribed ≥9 medications. All patients were very frail. Patients with polypharmacy were more likely to have a diagnosis of hypertension (p=0.04) or congestive heart failure (p=0.003) and less likely to have a diagnosis of dementia (p=0.03). Patients with overtreated hypertension were more likely to also experience polypharmacy (Relative Risk (RR))1.77 (1.07 to 2.96), p=0.027). Patients with overtreated diabetes were prescribed more non-diabetic medications than those with a higher HbA1c (11.0±3.7vs 7.2±3.1, p=0.01).

CONCLUSION

Overtreated diabetes and hypertension appear to be prevalent in nursing home patients, and the presence of polypharmacy is associated with more aggressive treatment of these risk factors. The present study was limited by its small sample size and cross-sectional design. Further study of interventions designed to reduce overtreatment of hypertension and diabetes is needed to fully understand the potential links between polypharmacy and potential of harms of condition-specific overtreatment.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Choosing your partner for the PROM: a review of evidence on patient-reported outcome measures for use in primary and community care

Patient-reported outcome measures (PROMs) are assessments of health status from the patient's perspective. The systematic and routine collection and use of PROMs in healthcare settings adds value in several ways, including quality improvement and service evaluation. We address the issue of instrument selection for use in primary and/or community settings. Specifically, from the large number of available PROMs, which instrument delivers the highest level of performance and validity? For selected generic PROMs, we reviewed literature on psychometric properties and other instrument features (e.g., health domains captured). Briefly we summarize key strengths of the three PROMs that received the most favourable psycho-metric and overall evaluation. The Short-Form 36 has a number of strengths, chiefly, its strong psychometric properties such as responsiveness. The PROMIS/Global Health Scale scored highly on most criteria and warrants serious consideration, especially as it is free to use. The EQ-5D scored satisfactorily on many criteria and, beneficially, it has a low response burden.

Practice and payment preferences of newly practising family physicians in British Columbia

OBJECTIVE

To examine the remuneration model preferences of newly practising family physicians.

DESIGN

Mixed-methods study comprising a cross-sectional, Web-based survey, as well as qualitative content analysis of answers to open-ended questions.

SETTING

British Columbia.

PARTICIPANTS

University of British Columbia family practice residents who graduated between 2000 and 2009.

MAIN OUTCOME MEASURES

Preferred remuneration models of newly practising physicians.

RESULTS

The survey response rate was 31% (133 of 430). Of respondents, 71% (93 of 132) preferred non-fee-for-service practice models and 86% (110 of 132) identified the payment model as very or somewhat important in their choice of future practice. Three principal themes were identified from content analysis of respondents' open-ended comments: frustrations with fee-for-service billing, which encompassed issues related to aggravations with "the business side of things" and was seen as impeding "the freedom to focus on medicine"; quality of patient care, which embraced the importance of a payment model that supported "comprehensive patient care" and "quality rather than quantity"; and freedom to choose, which supported the plurality of practice preferences among providers who strived to provide quality care for patients, "whatever model you happen to be working in."

CONCLUSION

Newly practising physicians in British Columbia preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.

Complaints in for-profit, non-profit and public nursing homes in two Canadian provinces

BACKGROUND

Nursing homes provide long-term housing, support and nursing care to frail elders who are no longer able to function independently. Although studies conducted in the United States have demonstrated an association between for-profit ownership and inferior quality, relatively few Canadian studies have made performance comparisons with reference to type of ownership. Complaints are one proxy measure of performance in the nursing home setting. Our study goal was to determine whether there is an association between facility ownership and the frequency of nursing home complaints.

METHODS

We analyzed publicly available data on complaints, regulatory measures, facility ownership and size for 604 facilities in Ontario over 1 year (2007/08) and 62 facilities in British Columbia (Fraser Health region) over 4 years (2004-2008). All analyses were carried out at the facility level. Negative binomial regression analysis was used to assess the association between type of facility ownership and frequency of complaints.

RESULTS

The mean (standard deviation) number of verified/substantiated complaints per 100 beds per year in Ontario and Fraser Health was 0.45 (1.10) and 0.78 (1.63) respectively. Most complaints related to resident care. Complaints were more frequent in facilities with more citations, i.e., violations of the legislation or regulations governing a home, (Ontario) and inspection violations (Fraser Health). Compared with Ontario's for-profit chain facilities, adjusted incident rate ratios and 95% confidence intervals of verified complaints were 0.56 (0.27-1.16), 0.58 (0.34-1.00), 0.43 (0.21- 0.88), and 0.50 (0.30- 0.84) for for-profit single-site, non-profit, charitable, and public facilities respectively. In Fraser Health, the adjusted incident rate ratio of substantiated complaints in non-profit facilities compared with for-profit facilities was 0.18 (0.07-0.45).

INTERPRETATION

Compared with for-profit chain facilities, non-profit, charitable and public facilities had significantly lower rates of complaints in Ontario. Likewise, in British Columbia's Fraser Health region, non-profit owned facilities had significantly lower rates of complaints compared with for-profit owned facilities.

Hospitalization rates of nursing home residents and community-dwelling seniors in British Columbia

The overall use of acute care services by nursing home (NH) residents in Canada has not been well documented. Our objectives were to identify the major causes of hospitalization among NH facility residents and to compare rates to those of community-dwelling seniors. A retrospective cohort was defined using population-level health administrative data, including all individuals aged 65 years and older living in a British Columbia NH facility between April 1996 and March 1999. Hospitalization rates of NH residents were compared to estimated rates for community-dwelling seniors, using age- and sex-adjusted standardized incidence ratios (SIRs): SIR = 2.81 (95%CI: 2.71, 2.91) for femoral fractures, 1.96 (1.88, 2.04) for pneumonia, 0.73 (0.70, 0.76) for other heart disease, and 1.01 (0.99, 1.02) for all causes. NH residents have disproportionately higher rates of hospitalization for femoral fractures and pneumonia, with NH residents accounting for approximately one quarter of all femoral fracture hospitalizations of BC seniors.

Finding a model that supports quality

While Canadian provinces demonstrate considerable diversity of performance within the non-profit sector and further research is needed to better understand which non-profit models support the best quality, Canadian research has been generally consistent with US research in confirming a relationship between for-profit ownership and inferior quality. The quality concerns arising from public funding to the private for-profit residential long-term care sector are unlikely to be addressed by adopting tighter regulations. With the expansion of private for-profit delivery, the organizational goals of the regulator and the facilities being regulated become less aligned. The former is likely to move to a more deterrence-based model of regulation, which is costly, less effective and draws resources away from direct patient care.

Trends in long-term care staffing by facility ownership in British Columbia, 1996 to 2006

BACKGROUND

Long-term care facilities (nursing homes) in British Columbia consist of a mix of for-profit, not-for-profit non-government, and not-for-profit health-region-owned establishments. This study assesses the extent to which staffing levels have changed by facility ownership category.

DATA AND METHODS

With data from Statistics Canada's Residential Care Facilities Survey, various types of care hours per resident-day were examined from 1996 through 2006 for the province of British Columbia. Random effects linear regression modeling was used to investigate the effect of year and ownership on total nursing hours per resident-day, adjusting for resident demographics, case mix, and facility size.

RESULTS

From 1996 to 2006, crude mean total nursing hours per resident-day rose from 1.95 to 2.13 hours in for-profit facilities (p = 0.06); from 1.99 to 2.48 hours in not-for-profit non-government facilities (p < 0.001); and from 2.25 to 3.30 hours in not-for-profit health-region-owned facilities (p < 0.001). The adjusted rate of increase in total nursing hours per resident-day was significantly greater in not-for-profit health-region-owned facilities.

INTERPRETATION

While total nursing hours per resident-day have increased in all facility groups, the rate of increase was greater in not-for-profit facilities operated by health authorities.

Examination for sexual assault: evaluating the literature for indicators of women-centered care

This study aimed to assess the extent to which recent peer-reviewed published literature on the acute management of sexual assault was women-centered. We developed indicators and a framework that operationalized women-centered care provision in the context of sexual assault. We then reviewed and evaluated the literature in relation to these indicators. A systematic search identified a total of 20 relevant articles for inclusion in the analysis. These were published in medical journals (65%, 13/20), nursing journals (20%, 4/20), and journals targeted toward other health care practitioners (15%, 3/20), and originated from the United States (65%, 13/20), the United Kingdom (15%, 3/20), Australia (10%, 2/20), Spain (5%, 1/20), and Canada (5%, 1/20) between January 2000 and August 2005. We found little acknowledgment of the inherent tensions faced by sexual assault examiners in providing women-centered care. Moreover, absent from most articles were discussions of the complexities of consent in sexual assault examinations, social justice issues, the need for gender-sensitive training for health care providers, and a critical appraisal of colposcopic and DNA technologies. Indicators of respect, safety and restoring control, and connections to community were present in the majority of articles.

Responding to health impacts of climate change in the Australian desert

Climate change is likely to have a significant effect on the health of those living in the 70% of Australia that is desert. The direct impacts on health, such as increased temperature, are important. But so too are the secondary impacts that will occur as a result of the impact of climate change on an uncertain and highly variable natural environment and on the interlinking social and economic systems. The consequence of these secondary impacts will appear as changes in the incidence of disease and infections, and on the psychosocial determinants of health. Responding to the impacts of climate change on health in desert Australia will involve the active participation of a variety of interest groups ranging from local to state and federal governments and a range of public and private agencies, including those not traditionally defined as within the health sector. The modes of engagement required for this process need to be innovative, and will differ among regions on different trajectories. To this end, a first classification of these trajectories is proposed.

Socioeconomic status and hospital utilization among younger adult pneumonia admissions at a Canadian hospital

BACKGROUND

Although the general association between socioeconomic status (SES) and hospitalization has been well established, few studies have considered the relationship between SES and hospital length of stay (LOS), and/or hospital re-admission. The primary objective of this study therefore, was to examine the relationship of SES to LOS and early re-admission among adult patients hospitalized with community-acquired pneumonia in a setting with universal health insurance.

METHODS

Four hundred and thirty-four (434) individuals were included in this retrospective, longitudinal cohort analysis of adult patients less than 65 years old admitted to a large teaching hospital in Vancouver, British Columbia. Hospital chart review data were linked to population-based health plan administrative data. Chart review was used to gather data on demographics, illness severity, co-morbidity, functional status and other measures of case mix. Two different types of administrative data were used to determine hospital LOS and the occurrence of all-cause re-admission to any hospital within 30 days of discharge. SES was measured by individual-level financial hardship (receipt of income assistance or provincial disability pension) and neighbourhood-level income quintiles.

RESULTS

Those with individual-level financial hardship had an estimated 15% (95% CI -0.4%, +32%, p = 0.057) longer adjusted LOS and greater risk of early re-admission (adjusted OR 2.65, 95% CI 1.38, 5.09). Neighbourhood-level income quintiles, showed no association with LOS or early re-admission.

CONCLUSION

Among hospitalized pneumonia patients less than 65 years, financial hardship derived from individual-level data, was associated with an over two-fold greater risk of early re-admission and a marginally significant longer hospital LOS. However, the same association was not apparent when an ecological measure of SES derived from neighbourhood income quintiles was examined. The ecological SES variable, while useful in many circumstances, may lack the sensitivity to detect the full range of SES effects in clinical studies.

Care Outcomes in Long-Term Care Facilities in British Columbia, Canada

OBJECTIVES

This study investigated whether for-profit (FP) versus not-for-profit (NP) ownership of long-term care facilities resulted in a difference in hospital admission and mortality rates among facility residents in British Columbia, Canada.

RESEARCH DESIGN

This retrospective cohort study used administrative data on all residents of British Columbia long-term care facilities between April 1, 1996, and August 1, 1999 (n = 43,065). Hospitalizations were examined for 6 diagnoses (falls, pneumonia, anemia, dehydration, urinary tract infection, and decubitus ulcers and/or gangrene), which are considered to be reflective of facility quality of care. In addition to FP versus NP status, facilities were divided into ownership subgroups to investigate outcomes by differences in governance and operational structures.

RESULTS

We found that, overall, FP facilities demonstrated higher adjusted hospitalization rates for pneumonia, anemia, and dehydration and no difference for falls, urinary tract infections, or DCU/gangrene. FP facilities demonstrated higher adjusted hospitalization rates compared with NP facilities attached to a hospital, amalgamated to a regional health authority, or that were multisite. This effect was not present when comparing FP facilities to NP single-site facilities. There was no difference in mortality rates in FP versus NP facilities.

CONCLUSIONS

The higher adjusted hospitalization rates in FP versus NP facilities is consistent with previous research from U.S. authors. However, the superior performance by the NP sector is driven by NP-owned facilities connected to a hospital or health authority, or that had more than one site of operation.

Determinants of hospital length of stay among patients with pneumonia admitted to a large Canadian hospital from 1991 to 2001

BACKGROUND

Pneumonia is a common reason for hospital admission, and the cost of treatment is primarily determined by length of stay (LOS).

OBJECTIVES

To explore the changes to and determinants of hospital LOS for patients admitted for the treatment of community-acquired pneumonia over a decade of acute hospital downsizing.

METHODS

Data were extracted from the database of Vancouver General Hospital, Vancouver, British Columbia, on patients admitted with community-acquired pneumonia (International Classification of Diseases, Ninth Revision, Clinical Modification codes 481.xx, 482.xx, 483.xx, 485.xx and 486.xx) from January 1, 1991 to March 31, 2001. The effects of sociodemographic factors, the specialty of the admitting physician (family practice versus specialist), admission from and/or discharge to a long-term care facility (nursing home) and year of admission, adjusted for comorbidity, illness severity measures and other potential confounders were examined. Longitudinal changes in these factors over the 10-year period were also investigated.

RESULTS

The study population (n=2495) had a median age of 73 years, 53% were male and the median LOS was six days. Adjusted LOS was longer for women (10% increase, 95% CI 3 to 16), increasing age group (7% increase, 95% CI 4 to 10), admission under a family physician versus specialist (42% increase, 95% CI 32 to 52) and admission from home with subsequent discharge to a long-term care facility (75% increase, 95% CI 47 to 108). Adjusted hospital LOS decreased by an estimated 2% (95% CI 1 to 3) per annum. The mean age at admission and the proportion admitted from long-term care facilities both increased significantly over the decade (P<0.05).

CONCLUSIONS

Results suggest that the management of hospitalized patients with pneumonia changed substantially between 1991 and 2001. The interface of long-term care facilities with acute care would be an important future area to explore potential efficiencies in caring for patients with pneumonia.

Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter?

BACKGROUND

Currently there is a lot of debate about the advantages and disadvantages of for-profit health care delivery. We examined staffing ratios for direct-care and support staff in publicly funded not-for-profit and for-profit nursing homes in British Columbia.

METHODS

We obtained staffing data for 167 long-term care facilities and linked these to the type of facility and ownership of the facility. All staff were members of the same bargaining association and received identical wages in both not-for-profit and for-profit facilities. Similar public funding is provided to both types of facilities, although the amounts vary by the level of functional dependence of the residents. We compared the mean number of hours per resident-day provided by direct-care staff (registered nurses, licensed practical nurses and resident care aides) and support staff (housekeeping, dietary and laundry staff) in not-for-profit versus for-profit facilities, after adjusting for facility size (number of beds) and level of care.

RESULTS

The nursing homes included in our study comprised 76% of all such facilities in the province. Of the 167 nursing homes examined, 109 (65%) were not-for-profit and 58 (35%) were for-profit; 24% of the for-profit homes were part of a chain, and the remaining homes were owned by a single operator. The mean number of hours per resident-day was higher in the not-for-profit facilities than in the for-profit facilities for both direct-care and support staff and for all facility levels of care. Compared with for-profit ownership, not-for-profit status was associated with an estimated 0.34 more hours per resident-day (95% confidence interval [CI] 0.18-0.49, p < 0.001) provided by direct-care staff and 0.23 more hours per resident-day (95% CI 0.15-0.30, p < 0.001) provided by support staff.

INTERPRETATION

Not-for-profit facility ownership is associated with higher staffing levels. This finding suggests that public money used to provide care to frail eldery people purchases significantly fewer direct-care and support staff hours per resident-day in for-profit long-term care facilities than in not-for-profit facilities.

Rising incidence of hospital-reported drug-facilitated sexual assault in a large urban community in Canada. Retrospective population-based study

BACKGROUND

Drug-facilitated sexual assault (DFSA) occurs when an individual has been sexually assaulted due to the surreptitious administration of drug(s) thereby rendering her/him unable to give consent. Our study aim was to calculate the age- and sex-specific annual incidence of hospital-reported DFSA and to determine whether a one-year increase in DFSA observed in 1999 in a pilot study on the same population was a significant and sustained trend.

METHODS

We identified cases of DFSA by reviewing the sexual assault examination records of all the individuals who presented to a hospital-based sexual assault care referral service in Vancouver, British Columbia during the study time period (January 1, 1993 to May 31, 2002). The annual sex- and age-specific incidence and temporal trends of drug-facilitated sexual assault were examined using population data from the British Columbia Ministry of Health.

RESULTS

The mean annual incidence of female DFSA increased from 3.4 per 100,000 (years 1993--1998) to 10.7 per 100,000 (years 1999--2002). Age-adjusted relative risks for female DFSAs were significantly higher in 1999 (2.77, 95% CI 1.85-4.15), 2000 (3.01, 95% CI 1.97-4.57), 2001 (3.14, 95% CI 2.07-4.78) and 2002 (4.88, 95% CI 2.84-8.37) compared to 1993-1998. Women aged 15-19 years had the highest DFSA incidence, with a year-adjusted relative risk of 3.89 (95% CI 2.75-5.50) compared to all other age groups.

CONCLUSION

This study demonstrates that the incidence of hospital-reported DFSA has shown a marked and sustained increase since 1999. Young women in their teens are particularly vulnerable to this form of sexual assault and further efforts are needed to develop and evaluate prevention programs for this group.

Sexual assault in the lives of urban sex workers: a descriptive and comparative analysis

This exploratory study contributes to the sparse literature on sexually assaulted sex workers. We examined 462 sexual assault cases seen at an emergency department-based sexual assault service and reported to the police between 1993 and 1997. More than one fifth of victims were sex workers. We compared them to other victims on victim characteristics, assault characteristics, and medical-legal findings. Relative to other victims, sex workers were younger, had lower incomes, and were more likely to be heroin and/or cocaine users. They suffered a greater number of injuries and forensic samples collected from their bodies were more likely to test positive for sperm and/or semen. These victims were also less likely to have been using alcohol and/or marijuana prior to the assault and to be emotionally expressed during the medical- legal examination. The substantial proportion of sex workers in the study population suggests that attention to their particular needs should be an important part of hospital-based sexual assault services. Clinical implications and directions for future research are discussed.

Rising incidence of hospital-reported drug-facilitated sexual assault in a large urban community in Canada. Retrospective population-based study

BACKGROUND

Drug-facilitated sexual assault (DFSA) occurs when an individual has been sexually assaulted due to the surreptitious administration of drug(s) thereby rendering her/him unable to give consent. Our study aim was to calculate the age- and sex-specific annual incidence of hospital-reported DFSA and to determine whether a one-year increase in DFSA observed in 1999 in a pilot study on the same population was a significant and sustained trend.

METHODS

We identified cases of DFSA by reviewing the sexual assault examination records of all the individuals who presented to a hospital-based sexual assault care referral service in Vancouver, British Columbia during the study time period (January 1, 1993 to May 31, 2002). The annual sex- and age-specific incidence and temporal trends of drug-facilitated sexual assault were examined using population data from the British Columbia Ministry of Health.

RESULTS

The mean annual incidence of female DFSA increased from 3.4 per 100,000 (years 1993--1998) to 10.7 per 100,000 (years 1999--2002). Age-adjusted relative risks for female DFSAs were significantly higher in 1999 (2.77, 95% CI 1.85-4.15), 2000 (3.01, 95% CI 1.97-4.57), 2001 (3.14, 95% CI 2.07-4.78) and 2002 (4.88, 95% CI 2.84-8.37) compared to 1993-1998. Women aged 15-19 years had the highest DFSA incidence, with a year-adjusted relative risk of 3.89 (95% CI 2.75-5.50) compared to all other age groups.

CONCLUSION

This study demonstrates that the incidence of hospital-reported DFSA has shown a marked and sustained increase since 1999. Young women in their teens are particularly vulnerable to this form of sexual assault and further efforts are needed to develop and evaluate prevention programs for this group.

An exploratory analysis of suspected drug-facilitated sexual assault seen in a hospital emergency department

This retrospective review of sexual assault cases seen in an emergency department from 1993 to 1999 examined rates and characteristics of suspected drug-facilitated sexual assault (DFSA). Overall, 12% of cases were identified as suspected DFSAs. The rate of suspected DFSA in 1999 was more than double that in the preceding six years. As well, compared to other sexual assaults, suspected DFSA cases had a longer time delay in presenting to the hospital, were less likely to involve the police, and had a lower occurrence of both genital and extra-genital injury. The clinical implications of these findings, particularly in terms of toxicology evidence collection, are discussed.

Sexual assault forensic medical examination: is evidence related to successful prosecution?

STUDY OBJECTIVE

We describe the medical-legal findings in a population of adult sexual assault cases assessed in an emergency department setting and reported to the police, document the law enforcement and legal disposition of cases seen over the study period, and determine whether medical-legal findings are associated with filing of charges and conviction after adjusting for demographic factors and assault characteristics.

METHODS

This was a retrospective chart review of all police-reported cases seen from January 1993 to December 1997 at the British Columbia Women's Sexual Assault Service, a 24-hour hospital-based emergency service. Information on patient demographics, assault characteristics, and medical-legal findings was merged with data extracted from police and court files on the cases' legal outcomes and sperm-semen test results of collected forensic evidence. Cases were assigned a clinical injury extent score reflecting the degree of documented genital and extragenital injury. The association of medical-legal variables, patient demographics, and assault characteristics with filing of charges (among the subset of cases in which a suspect was identified by police) and conviction (among the subset of cases in which charge were filed) was examined by using logistic regression.

RESULTS

Charges were filed in 151 (32.7%) and a conviction secured in 51 (11.0%) of the 462 cases examined in this study. Genital injury was observed in 193 (41.8%), and sperm-semen-positive forensic results were obtained in 100 (38.2%) of the 262 samples tested. A gradient association was found for injury extent score and charge filing in the following categories: mild injury (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.09 to 7.45); moderate injury (OR 4.00; 95% CI 1.63 to 9.84); and severe injury (OR 12.29; 95% CI 3.04 to 49.65). Documentation on the police file of receipt of forensic samples collected by the Sexual Assault Service examiner was also significantly associated with charges being filed (OR 3.45; 95% CI 1.82 to 6.56). Injury extent score defined as severe was the only variable significantly associated with conviction (OR 6.51; 95% CI 1.31 to 32.32).

CONCLUSION

The finding that documented injury extent had a significant positive association with both filing of charges and conviction is an important step in confirming the value of injury documentation in the forensic examination of sexual assault victims.

Pharmacophore fingerprinting. 2. Application to primary library design

A methodology for pharmacophore fingerprinting (PharmPrint), previously described in the context of QSAR, has been used to address the issues involved in primary library design. A subset of the MDDR (MDDR9104) has been used to define a reference set of bioactive molecules. A statistic has been devised to measure the discriminating power of molecular descriptors using the target class assignments for this set, for which the PharmPrint fingerprint outperformed other descriptors. A principal components analysis (PCA) of the fingerprints for the MDDR9104 produces a low dimensional representation within which molecular properties and other libraries can be visualized and explored. PCA calculations on subsets of classes show that this space is robust to the addition of new classes, suggesting that pharmacophoric space is finite and rapidly converging. We demonstrate the application of the PharmPrint methodology to the analysis and design of virtual combinatorial libraries using common scaffolds and building blocks.

Examination for sexual assault: is the documentation of physical injury associated with the laying of charges? A retrospective cohort study

BACKGROUND

Few studies have examined whether there is an association between individual medical findings and legal outcome in cases of sexual assault. This study was undertaken to determine the relation between the extent of documented physical injury and a positive legal outcome in cases of sexual assault and to determine other factors associated with the laying of charges in such cases.

METHODS

In this retrospective cohort study, the authors reviewed the charts and medicolegal reports for all cases of sexual assault that were handled by the BC Women's Sexual Assault Service in 1992 for which a police report had been filed. Information on patients' characteristics, the nature of the assault and the extent of injury was extracted from these records. A system for scoring clinical injury was developed by 4 of the physicians at the Sexual Assault Service, and a clinical injury score was assigned for each case by one physician. The relation between the outcome (in terms of whether charges were laid) and the circumstances of the case was examined by logistic regression.

RESULTS

A total of 95 cases with complete medical records and information about legal outcome were identified during the 1992 calendar year. After adjustment for income level and the patient's knowledge of the assailant (either as an acquaintance or as his or her partner), the odds ratio (OR) for charge-laying in a sexual assault case with documented moderate to severe injury was 3.33 (95% confidence interval [CI] 1.06-10.42). Socioeconomic status above the group median (defined as annual income greater than $21,893) (OR 3.26, 95% CI 1.09-9.71) and knowledge of the assailant (OR 4.58, 95% CI 1.52-13.79) were also associated with charge-laying. Presence of genital injury per se, age of the patient and detection of sperm by microscopy at the time of examination were not associated with the laying of charges.

INTERPRETATION

The results of this study show that the extent of documented injury is associated with the laying of charges in cases of sexual assault. However, many questions remain about the effectiveness of the medical component of gathering such evidence.