Non-fatal self-harm and suicide following postpartum psychiatric emergency department visits: A population-based retrospective cohort study

In a population-based cohort of postpartum individuals in Ontario, Canada, this study aimed to determine the risk of non-fatal self-harm and suicide within one year of an initial postpartum psychiatric emergency department (ED) visit (2008-2020), and the key associated factors. Of 16,475 postpartum individuals with psychiatric ED visits, 714 (4.3 %) had non-fatal self-harm within one year, and 23 (0.15 %) died by suicide. Risk was substantially higher for those with self-harm at the initial presentation. Further efforts to connect individuals with postpartum psychiatric ED visits with needed inpatient care and outpatient follow-up are required to reduce non-fatal self-harm and suicide risk.

Risk of Repeat Psychiatric Emergency Department Visits in the Postpartum Period: A Population-Based Retrospective Cohort Study

STUDY OBJECTIVE

Approximately 1 in 100 postpartum individuals visit an emergency department (ED) for a psychiatric reason. Repeat visits can signify problems with the quality of care received during or after the initial visit; this study aimed to understand risk for repeat postpartum psychiatric ED visits.

METHODS

This population-based cohort study used Ontario, Canada health administrative data available through ICES (formerly the Institute for Clinical Evaluative Sciences) to identify all individuals discharged from postpartum psychiatric ED visits (2008 to 2021) and measured the proportion with one or more repeat psychiatric ED visit within 30 days. Using modified Poisson regression, we calculated the association between one or more repeat visits and sociodemographic, medical, obstetric, infant, continuity of care, past service use, and index ED visit characteristics both overall and stratified by psychiatric diagnosis.

RESULTS

Of 14,100 individuals, 11.7% had one or more repeat psychiatric ED visits within 30 days. Repeat visit risk was highest for those with schizophrenia-spectrum disorders (28.2%, adjusted risk ratio 2.41; 95% confidence interval 1.88 to 3.08, versus 9.5% anxiety referent). Low (versus no) psychiatric care continuity, prior psychiatric ED visits and admissions, and initial visits within 90 days postpartum were also associated with increased risk, whereas intentional self-injury was associated with reduced risk. In diagnosis-stratified analyses, the factors most consistently associated with repeat ED visits were past psychiatric ED visits and admissions, and initial visits within 90 days postpartum.

CONCLUSIONS

Over 1 in 10 postpartum psychiatric ED visits are followed by a repeat visit within 30 days. Targeted approaches are needed across clinical populations to reduce repeat ED visits in this population with young infants.

Sex-based trajectories of health system use in lonely and not lonely older people: A population-based cohort study

BACKGROUND

There is growing interest in understanding the care needs of lonely people but studies are limited and examine healthcare settings separately. We estimated and compared healthcare trajectories in lonely and not lonely older female and male respondents to a national health survey.

METHODS

We conducted a retrospective cohort study of community-dwelling, Ontario respondents (65+ years) to the 2008/2009 Canadian Community Health Survey-Healthy Aging. Respondents were classified at baseline as not lonely, moderately lonely, or severely lonely using the Three-Item Loneliness Scale and then linked with health administrative data to assess healthcare transitions over a 12 -year observation period. Annual risks of moving from the community to inpatient, long-stay home care, long-term care settings-and death-were estimated across loneliness levels using sex-stratified multistate models.

RESULTS

Of 2684 respondents (58.8% female sex; mean age 77 years [standard deviation: 8]), 635 (23.7%) experienced moderate loneliness and 420 (15.6%) severe loneliness. Fewer lonely respondents remained in the community with no transitions (not lonely, 20.3%; moderately lonely, 17.5%; and severely lonely, 12.6%). Annual transition risks from the community to home care and long-term care were higher in female respondents and increased with loneliness severity for both sexes (e.g., 2-year home care risk: 6.1% [95% CI 5.5-6.6], 8.4% [95% CI 7.4-9.5] and 9.4% [95% CI 8.2-10.9] in female respondents, and 3.5% [95% CI 3.1-3.9], 5.0% [95% CI 4.0-6.0], and 5.4% [95% CI 4.0-6.8] in male respondents; 5-year long-term care risk: 9.2% [95% CI 8.0-10.8], 11.1% [95% CI 9.3-13.6] and 12.2% [95% CI 9.9-15.3] [female], and 5.3% [95% CI 4.2-6.7], 9.1% [95% CI 6.8-12.5], and 10.9% [95% CI 7.9-16.3] [male]).

CONCLUSIONS

Lonely older female and male respondents were more likely to need home care and long-term care, with severely lonely female respondents having the highest probability of moving to these settings.

Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study

BACKGROUND

Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits.

METHODS

We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk.

RESULTS

Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines.

CONCLUSIONS

History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.

Sex-based differences in the association between loneliness and polypharmacy among older adults in Ontario, Canada

BACKGROUND

Emerging evidence shows loneliness is associated with polypharmacy and high-risk medications in older adults. Despite notable sex-based differences in the prevalence in each of loneliness and polypharmacy, the role of sex in the relationship between loneliness and polypharmacy is unclear. We explored the relationship between loneliness and polypharmacy in older female and male respondents and described sex-related variations in prescribed medication subclasses.

METHODS

We performed a cross-sectional analysis of representative data from the Canadian Community Health Survey-Healthy Aging cycle (2008/2009) linked to health administrative databases in Ontario respondents aged 66 years and older. Loneliness was measured using the Three-Item Loneliness Scale, with respondents classified as not lonely, moderately lonely, or severely lonely. Polypharmacy was defined as five or more concurrently-prescribed medications. Sex-stratified multivariable logistic regression models with survey weights were used to assess the relationship between loneliness and polypharmacy. Among those with polypharmacy, we examined the distribution of prescribed medication subclasses and potentially inappropriate medications.

RESULTS

Of the 2348 individuals included in this study, 54.6% were female respondents. The prevalence of polypharmacy was highest in those with severe loneliness both in female (no loneliness, 32.4%; moderate loneliness, 36.5%; severe loneliness, 44.1%) and male respondents (32.5%, 32.2%, and 42.5%). Severe loneliness was significantly associated with greater adjusted odds of polypharmacy in female respondents (OR = 1.59; 95% CI: 1.01-2.50) but this association was attenuated after adjustment in male respondents (OR = 1.00; 95% CI: 0.56-1.80). Among those with polypharmacy, antidepressants were more commonly prescribed in female respondents with severe loneliness (38.7% [95% CI: 27.3-50.0]) compared to those who were moderately lonely (17.7% [95% CI: 9.3-26.2]).

CONCLUSIONS

Severe loneliness was independently associated with polypharmacy in older female but not male respondents. Clinicians should consider loneliness as an important risk factor in medication reviews and deprescribing efforts to minimize medication-related harms, particularly in older women.

Linkage of whole genome sequencing and administrative health data in autism: A proof of concept study

Whether genetic testing in autism can help understand longitudinal health outcomes and health service needs is unclear. The objective of this study was to determine whether carrying an autism-associated rare genetic variant is associated with differences in health system utilization by autistic children and youth. This retrospective cohort study examined 415 autistic children/youth who underwent genome sequencing and data collection through a translational neuroscience program (Province of Ontario Neurodevelopmental Disorders Network). Participant data were linked to provincial health administrative databases to identify historical health service utilization, health care costs, and complex chronic medical conditions during a 3-year period. Health administrative data were compared between participants with and without a rare genetic variant in at least 1 of 74 genes associated with autism. Participants with a rare variant impacting an autism-associated gene (n = 83, 20%) were less likely to have received psychiatric care (at least one psychiatrist visit: 19.3% vs. 34.3%, p = 0.01; outpatient mental health visit: 66% vs. 77%, p = 0.04). Health care costs were similar between groups (median: $5589 vs. $4938, p = 0.4) and genetic status was not associated with odds of being a high-cost participant (top 20%) in this cohort. There were no differences in the proportion with complex chronic medical conditions between those with and without an autism-associated genetic variant. Our study highlights the feasibility and potential value of genomic and health system data linkage to understand health service needs, disparities, and health trajectories in individuals with neurodevelopmental conditions.

An interrupted time series study using administrative health data to examine the impact of the COVID-19 pandemic on alternate care level acute hospitalizations in Ontario, Canada

BACKGROUND

Many health systems struggle with delayed discharges (known as alternate level of care [ALC] in Canada). Our objectives were to describe and compare patient and hospitalization characteristics by ALC status, and to examine the impact of the initial period of the COVID-19 pandemic on ALC rates in Ontario, Canada.

METHODS

We conducted an interrupted time series using linked administrative data for acute care hospital discharges in Ontario between Feb. 28, 2018, and Nov. 30, 2020. We measured the monthly ALC rate among discharges before and after the onset of the COVID-19 pandemic (Mar. 1, 2020). We used interrupted time series regressions to examine the association between the onset of the pandemic and average ALC monthly rates.

RESULTS

We identified no meaningful differences in patient and admission characteristics, irrespective of time; however, differences were identified by ALC status. The overall average monthly rate of ALC discharges before the COVID-19 pandemic was 4.9% and after the onset of the pandemic was 5.0%. These discharges dropped to 4.3% (n = 3558) in March 2020 but then rebounded to their peak of 5.8% (n = 3915). There was no significant change in the average level of ALC rates per month after the onset of the pandemic (increase of 0.36% average per month, 95% confidence interval [CI] -0.11% to 0.83%) or monthly rate of change (slope) after the onset of the pandemic (-0.08%, 95% CI -0.15 to 0).

INTERPRETATION

We identified a continued high rate of hospital discharges with an ALC component despite the considerable efforts in hospital to reduce hospital occupancy during the COVID-19 pandemic. Future research should examine why ALC rates remain high despite hospital efforts.

Factors associated with loneliness in immigrant and Canadian-born older adults in Ontario, Canada: a population-based study

BACKGROUND

While loneliness is common in older adults, some immigrant groups are at higher risk. To inform tailored interventions, we identified factors associated with loneliness among immigrant and Canadian-born older adults living in Ontario, Canada.

METHODS

We conducted a cross-sectional analysis of 2008/09 data from the Canadian Community Health Survey (Healthy Aging Cycle) and linked health administrative data for respondents 65 years and older residing in Ontario, Canada. Loneliness was measured using the Three-Item Loneliness Scale, with individuals categorized as 'lonely' if they had an overall score of 4 or greater. For immigrant and Canadian-born older adults, we developed separate multivariable logistic regression models to assess individual, relationship and community-level factors associated with loneliness.

RESULTS

In a sample of 968 immigrant and 1703 Canadian-born older adults, we found a high prevalence of loneliness (30.8% and 34.0%, respectively). Shared correlates of loneliness included low positive social interaction and wanting to participate more in social, recreational or group activities. In older immigrants, unique correlates included: widowhood, poor health (i.e., physical, mental and social well-being), less time in Canada, and lower neighborhood-level ethnic diversity and income. Among Canadian-born older adults, unique correlates were: female sex, poor mental health, weak sense of community belonging and living alone. Older immigrant females, compared to older immigrant males, had greater prevalence (39.1% vs. 21.9%) of loneliness.

CONCLUSIONS

Although both groups had shared correlates of loneliness, community-level factors were more strongly associated with loneliness in immigrants. These findings enhance our understanding of loneliness and can inform policy and practice tailored to immigrants.

New and Persistent Sedative Prescriptions Among Older Adults Following a Critical Illness: A Population-Based Cohort Study

BACKGROUND

ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization.

RESEARCH QUESTION

For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt?

STUDY DESIGN AND METHODS

This population-based cohort study included ICU survivors aged ≥ 66 years who had not filled sedative prescriptions within ≤ 6 months before hospitalization (sedative-naive) in Ontario, Canada (2003-2019). Using multilevel logistic regression, demographic, clinical, and hospital characteristics and their association with new sedative prescription within ≤ 7 days of discharge are described. Variation between hospitals was quantified by using the adjusted median OR. Factors associated with persistent prescriptions (≤ 6 months) were examined with a multivariable proportional hazards model.

RESULTS

A total of 250,428 patients were included (mean age, 76 years; 61% male). A total of 15,277 (6.1%) filled a new sedative prescription, with variation noted across hospitals (2% [95% CI, 1-3] to 44% [95% CI, 3-57]); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (adjusted OR [aOR], 4.00; 95% CI, 3.72-4.31), receipt of inpatient geriatric (aOR, 1.95; 95% CI, 1.80-2.10) or psychiatry (aOR, 2.76; 95% CI, 2.62-2.91) consultation, invasive ventilation (aOR, 1.59; 95% CI, 1.53-1.66), and ICU length of stay ≥ 7 days (aOR, 1.50; 95% CI, 1.42-1.58). The residual heterogeneity between hospitals (adjusted median OR, 1.43; 95% CI, 1.35-1.49) had a stronger association with new sedative prescriptions than the Charlson Comorbidity Index score or sepsis. Factors associated with persistent sedative use were similar with the addition of female subjects (subdistribution hazard ratio, 1.07; 95% CI, 1.02-1.13) and pre-existing polypharmacy (subdistribution hazard ratio, 0.88; 95% CI, 0.80-0.93).

INTERPRETATION

One in 15 sedative-naive, older adult ICU survivors filled a new sedative within ≤ 7 days of discharge; more than one-half of these survivors filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.

Risk of hospital admission after discharge from postpartum psychiatric emergency department visits: A focus on the social determinants of health

OBJECTIVE

Of those with postpartum psychiatric emergency department (ED) visits, a minority of receive hospital admission at their initial visit. Among those discharged, we aimed to determine subsequent risk of psychiatric admission, and understand how social determinants of health (SDOH) - individually and collectively - impact this risk.

METHOD

From all postpartum individuals discharged from psychiatric ED visits in Ontario, Canada (2008-2020)(n = 13,130), we generated adjusted relative risks (aRR) for psychiatric inpatient admission within 365 days post-ED visit by four SDOH (age, neighbourhood income, community size, immigration) and other clinical factors. Using latent class analysis (LCA) to identify subgroups based on clustering of SDOH, we then compared adjusted risk across subgroups.

RESULTS

Psychiatric admission occurred for 9.5% (n = 1242) within 365 days. Across SDOH, risk was lower among adolescents (vs. ≥35 years aRR 0.80, 95%CI 0.65-0.97) and immigrants (<5 years in Canada vs. Canadian-born/long-term residents 0.70, 0.51-0.96; ≥5 years in Canada 0.79, 0.65-0.95). Among four identified subgroups, compared to the "older/urban/high-income" subgroup (11.1% admission), the "urban/immigrant/low-income" (7.6%; 0.68, 0.55-0.82) and "young/rural/low-income" subgroups (9.7%; 0.78, 0.63-0.96), but not the "semi-urban/middle-income" subgroup (9.5%; 0.86, 0.73-1.01), were at lower admission risk.

CONCLUSIONS

Future research is needed to explore reasons for SDOH-based differences in admission risk, and inform equitable postpartum services.

Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents

BACKGROUND

A concern with long-term opioid use is the increased risk arising when opioids are used concurrently with drugs that can potentiate their associated adverse effects. The drugs most often encountered are benzodiazepines (BZDs) and gabapentinoids. Our study objectives were to examine trends in the concurrent use of opioids and BZDs, or gabapentinoids, in a Canadian nursing home population over an 11-year period, and current resident-level correlates of this concurrent use.

METHODS

We conducted a population-based, repeated cross-sectional study among Ontario nursing home residents (>65 years) dispensed opioids between April 2009 and February 2020. For the last study year, we examined cross-sectional associations between resident characteristics and concurrent use of opioids with BZDs or gabapentinoids. Linked data on nursing home residents from clinical and health administrative databases was used. The yearly proportions of residents who were dispensed an opioid concurrently with a BZD or gabapentinoid were plotted with percent change derived from log-binomial regression models. Separate modified Poisson regression models estimated resident-level correlates of concurrent use of opioids with BZDs or gabapentinoids.

RESULTS

Over the study period, among residents dispensed an opioid there was a 53.2% relative decrease (30.7% to 14.4%) in concurrent BZD and a 505.4% relative increase (4.4% to 26.6%) in concurrent gabapentinoid use. In adjusted models, increasing age and worsening cognition were inversely associated with the concurrent use of both classes, but most other significantly related covariates were unique to each drug class (e.g., sex and anxiety disorders for BZD, pain severity and presence of pain-related conditions for gabapentinoids).

CONCLUSIONS

Co-administration of BZDs or gabapentinoids in Ontario nursing home residents dispensed opioids remains common, but the pattern of co-use has changed over time. Observed covariates of concurrent use in 2019/20 suggest distinct but overlapping resident populations requiring consideration of the relative risks versus benefits of this co-use and monitoring for potential harm.

Retrospective cross-sectional study examining the association between loneliness and unmet healthcare needs among middle-aged and older adults using the Canadian Longitudinal Study of Aging (CLSA)

OBJECTIVES

Our primary objective was to estimate the association between loneliness and unmet healthcare needs and if the association changes when adjusted for demographic and health factors. Our secondary objective was to examine the associations by gender (men, women, gender diverse).

DESIGN, SETTING, PARTICIPANTS

Retrospective cross-sectional data from 44 423 community-dwelling Canadian Longitudinal Study on Aging participants aged 45 years and older were used.

PRIMARY OUTCOME MEASURE

Unmet healthcare needs are measured by asking respondents to indicate (yes, no) if there was a time when they needed healthcare in the last 12 months but did not receive it.

RESULTS

In our sample of 44 423 respondents, 8.5% (n=3755) reported having an unmet healthcare need in the previous 12 months. Lonely respondents had a higher percentage of unmet healthcare needs (14.4%, n=1474) compared with those who were not lonely (6.7%, n=2281). Gender diverse had the highest percentage reporting being lonely and having an unmet healthcare need (27.3%, n=3), followed by women (15.4%, n=887) and men (13.1%, n=583). In our logistic regression, lonely respondents had higher odds of having an unmet healthcare need in the previous 12 months than did not lonely (adjusted odd ratios (aOR) 1.80, 95% CI 1.64 to 1.97), adjusted for other covariates. In the gender-stratified analysis, loneliness was associated with a slightly greater likelihood of unmet healthcare needs in men (aOR 1.90, 95% CI 1.64 to 2.19) than in women (aOR 1.73, 95% CI 1.53 to 1.95). In the gender diverse, loneliness was also associated with increased likelihood of having an unmet healthcare need (aOR 1.38, 95% CI 0.23 to 8.29).

CONCLUSIONS

Loneliness was related to unmet healthcare needs in the previous 12 months, which may suggest that those without robust social connections experience challenges accessing health services. Gender-related differences in loneliness and unmet needs must be further examined in larger samples.

Can Patients with Dementia Be Identified in Primary Care Electronic Medical Records Using Natural Language Processing?

Dementia and mild cognitive impairment can be underrecognized in primary care practice and research. Free-text fields in electronic medical records (EMRs) are a rich source of information which might support increased detection and enable a better understanding of populations at risk of dementia. We used natural language processing (NLP) to identify dementia-related features in EMRs and compared the performance of supervised machine learning models to classify patients with dementia. We assembled a cohort of primary care patients aged 66 + years in Ontario, Canada, from EMR notes collected until December 2016: 526 with dementia and 44,148 without dementia. We identified dementia-related features by applying published lists, clinician input, and NLP with word embeddings to free-text progress and consult notes and organized features into thematic groups. Using machine learning models, we compared the performance of features to detect dementia, overall and during time periods relative to dementia case ascertainment in health administrative databases. Over 900 dementia-related features were identified and grouped into eight themes (including symptoms, social, function, cognition). Using notes from all time periods, LASSO had the best performance (F1 score: 77.2%, sensitivity: 71.5%, specificity: 99.8%). Model performance was poor when notes written before case ascertainment were included (F1 score: 14.4%, sensitivity: 8.3%, specificity 99.9%) but improved as later notes were added. While similar models may eventually improve recognition of cognitive issues and dementia in primary care EMRs, our findings suggest that further research is needed to identify which additional EMR components might be useful to promote early detection of dementia.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41666-023-00125-6.

Patterns of diabetes testing for older adults without diabetes in Ontario's nursing homes: A population-based study

BACKGROUND

Asymptomatic diabetes testing may be of limited value for older nursing home residents, but most diabetes guidelines lack upper-age cutoffs for screening cessation. We evaluated patterns of glycated hemoglobin (HbA1c) and serum blood glucose (SBG) testing among older residents without diabetes in Ontario, Canada.

METHODS

This population-based retrospective cohort study used provincial health administrative data from ICES to identify older nursing home residents in Ontario without diabetes between January 1, 2015 and December 31, 2018. We examined HbA1c and glucose testing rates overall, by age, sex, and near end-of-life. The number of tests needed to identify one case of diabetes (using HbA1c thresholds of 6.5% and 8.0%) were also calculated.

RESULTS

Among 102,923 older nursing home residents (70.3% women; average age 85.6 ± SD 7.7 years), 46.1% of residents received ≥1 HbA1c test over an average follow-up period of 2.15 (± SD 1.49) years, and 18.2% of these tested residents received ≥4 HbA1c tests. The crude HbA1c testing rate was 52.6 tests/100 person-years (95% CI 52.3-52.9). Testing rates among residents aged ≥80 years was 50.7 HbA1c tests/100 person-years (95% CI 50.4-51.0), and 47.8 tests/100 person-years (95% CI 46.5-49.0) among residents near end-of-life. The number of tests to identify a case of diabetes (HbA1c ≥ 6.5%) was 44, while the number of tests to identify a case of actionable diabetes (HbA1c ≥ 8%) was 310. Less than 1% of residents with an HbA1c test met criteria for actionable diabetes.

CONCLUSIONS

Nursing home residents without diabetes receive frequent diabetes testing, with high testing rates even in residents over 80 years old and residents near end-of-life. The high number of tests needed to identify a case of actionable diabetes highlights the urgent need to re-evaluate diabetes testing practices in nursing homes.

Comparative Risk of Harm Associated with Zopiclone or Trazodone Use in Nursing Home Residents: a Retrospective Cohort Study in Alberta, Canada

Background

There is growing evidence of harm associated with trazodone and nonbenzodiazepine sedative hypnotics (e.g., zopiclone); however, their comparative risk of harm is unknown.

Methods

We conducted a retrospective cohort study with linked health administrative data, which enrolled older (≥66 years old) nursing home residents living in Alberta, Canada, between December 1, 2009, and December 31, 2018; the last follow-up date was June 30, 2019. We compared the rate of injurious falls and major osteoporotic fractures (primary outcome) and all-cause mortality (secondary outcome) within 180 days of first prescription of zopiclone or trazodone with cause-specific hazard models and inverse probability of treatment weights to control for confounding; primary analysis was intention-to-treat and secondary analysis was per-protocol (i.e., residents censored if dispensed the other exposure drug).

Results

Our cohort included 1,403 residents newly dispensed trazodone and 1,599 residents newly dispensed zopiclone. At cohort entry, the mean resident age was 85.7 (standard deviation [SD] 7.4), 61.6% were female, and 81.2% had dementia. New zopiclone use was associated with similar rates of injurious falls and major osteoporotic fractures (intention-to-treat-weighted hazard ratio 1.15, 95% confidence interval [CI] 0.90-1.48; per-protocol-weighted hazard ratio 0.85, 95% CI 0.60-1.21) and all-cause mortality (intention-to-treat-weighted hazard ratio 0.96, 95% CI 0.79-1.16; per-protocol-weighted hazard ratio 0.90, 95% CI 0.66-1.23) compared to trazodone.

Conclusions

Zopiclone was associated with a similar rate of injurious falls, major osteoporotic fractures, and all-cause mortality compared to trazodone-suggesting one medication should not be used in lieu of the other. Appropriate prescribing initiatives should also target zopiclone and trazodone.

Variation and Correlation of Potential Unintended Consequences of Antipsychotic Reduction in Ontario Nursing Homes Over Time

BACKGROUND

Potentially inappropriate antipsychotic use has declined in nursing homes over the past decade; however, increases in the documentation of relevant clinical indications (eg, delusions) and the use of other psychotropic medications have raised concerns about diagnosis upcoding and medication substitution. Few studies have examined how these trends over time vary across and within nursing homes, information that may help to support antipsychotic reduction efforts.

OBJECTIVE

To jointly model facility-level time trends in potentially inappropriate antipsychotic use, antidepressant use, and the indications used to define appropriate antipsychotic use.

RESEARCH DESIGN

We conducted a repeated cross-sectional study of all nursing homes in Ontario, Canada between April 1, 2010 and December 31, 2019 using linked health administrative data (N=649). Each nursing home's quarterly prevalence of potentially inappropriate antipsychotic use, antidepressant use, and relevant indications were measured as outcome variables. With time as the independent variable, multivariate random effects models jointly estimated time trends for each outcome across nursing homes and the correlations between time trends within nursing homes.

RESULTS

We observed notable variations in the time trends for each outcome across nursing homes, especially for the relevant indications. Within facilities, we found no correlation between time trends for potentially inappropriate antipsychotic and antidepressant use ( r =-0.0160), but a strong negative correlation between time trends for potentially inappropriate antipsychotic use and relevant indications ( r =-0.5036).

CONCLUSIONS

Nursing homes with greater reductions in potentially inappropriate antipsychotics tended to show greater increases in the indications used to define appropriate antipsychotic use-possibly leading to unmonitored use of antipsychotics.

Changes in the Initiation of Antipsychotics and Trazodone Over Time: A Cohort Study of New Admissions to Nursing Homes in Ontario, Canada

OBJECTIVES

To investigate whether trazodone is being initiated in lieu of antipsychotics following antipsychotic reduction efforts, this study described changes in medication initiation over time.

METHODS

We conducted a retrospective cohort study of new admissions to nursing homes in Ontario, Canada between April 2010 and December 2019 using health administrative data (N = 61,068). The initiation of antipsychotic and trazodone use was compared by year of admission using discrete time survival analysis and stratified by history of dementia.

RESULTS

Relative to residents admitted in 2014, antipsychotic initiation significantly decreased in later years (e.g., 2017 admission year hazard odds ratio [HOR₂₀₁₇]=0.72 [95% confidence interval (95%CI)=0.62-0.82]) while trazodone initiation modestly increased (e.g., HOR₂₀₁₇=1.09 [95%CI=0.98-1.21]). The relative increase in trazodone initiation was larger among residents with dementia (e.g., HOR_2017Dem =1.22 [95%CI=1.07-1.39]).

CONCLUSIONS

Differences in which medications were started following nursing home admission were observed and suggest trazodone may be initiated in lieu of antipsychotics.

The use of key social determinants of health variables in psychiatric research using routinely collected health data: a systematic analysis

PURPOSE

Social determinants of health (SDoH) impact psychiatric conditions. Routinely collected health data are frequently used to evaluate important psychiatric clinical and health services outcomes. This study explored how key SDoH are used in psychiatric research employing routinely collected health data.

METHODS

A search was conducted in PubMed for English-language articles published in 2019 that used routinely collected health data to study psychiatric conditions. Studies (n = 19,513) were randomly ordered for title/abstract review; the first 150 meeting criteria progressed to full-text review. Three key SDoH categories were assessed: (1) gender and sex, (2) race and ethnicity, and (3) socioeconomic status. Within each category, data were extracted on how variables were included, defined, and used in study design and analysis.

RESULTS

All studies (n = 103) reported on at least one of the key SDoH variables; 102 (99.0%) studies included a gender and/or sex variable, 30 (29.1%) included a race and/or ethnicity variable, and 55 (53.4%) included a socioeconomic status variable. No studies explicitly differentiated between gender and sex, and SDoH were often defined only as binary variables. SDoH were used to define the target population in 14 (13.6%) studies. Within analysis, SDoH were most often included as confounders (n = 65, 63.1%), exposures or predictors (n = 23, 22.3%), and effect modifiers (n = 14, 13.6%). Only 21 studies (20.4%) disaggregated results by SDoH and 7 (6.8%) considered intersections between SDoH.

CONCLUSIONS

Results suggest improvements are needed in how key SDoH are used in routinely collected health data-based psychiatric research, to ensure relevance to diverse populations and improve equity-oriented research.

Examining the immediate and ongoing impact of the COVID-19 pandemic on population-based estimates of dementia: a population-based time series analysis in Ontario, Canada

OBJECTIVES

Population-based chronic disease surveillance systems were likely disrupted by the COVID-19 pandemic. The objective of this study was to examine the immediate and ongoing impact of the COVID-19 pandemic on the claims-based incidence of dementia.

METHODS

We conducted a population-based time series analysis from January 2015 to December 2021 in Ontario, Canada. We calculated the monthly claims-based incidence of dementia using a validated case ascertainment algorithm drawing from routinely collected health administrative data. We used autoregressive linear models to compare the claims-based incidence of dementia during the COVID-19 period (2020-2021) to the expected incidence had the pandemic not occurred, controlling for seasonality and secular trends. We examined incidence by source of ascertainment and across strata of sex, age, community size and number of health conditions.

RESULTS

The monthly claims-based incidence of dementia dropped from a 2019 average of 11.9 per 10 000 to 8.5 per 10 000 in April 2020 (32.6% lower than expected). The incidence returned to expected levels by late 2020. Across the COVID-19 period there were a cumulative 2990 (95% CI 2109 to 3704) fewer cases of dementia observed than expected, equivalent to 1.05 months of new cases. Despite the overall recovery, ascertainment rates continued to be lower than expected among individuals aged 65-74 years and in large urban areas. Ascertainment rates were higher than expected in hospital and among individuals with 11 or more health conditions.

CONCLUSIONS

The claims-based incidence of dementia recovered to expected levels by late 2020, suggesting minimal long-term changes to population-based dementia surveillance. Continued monitoring of claims-based incidence is necessary to determine whether the lower than expected incidence among individuals aged 65-74 and in large urban areas, and higher than expected incidence among individuals with 11 or more health conditions, is transitory.

Trends in health service use among persons with Parkinson's disease by rurality: A population-based repeated cross-sectional study

BACKGROUND

The global burden of Parkinson's disease (PD) has more than doubled over the past three decades, and this trend is expected to continue. Despite generally poorer access to health care services in rural areas, little previous work has examined health system use in persons with PD by rurality. We examined trends in the prevalence of PD and health service use among persons with PD by rurality in Ontario, Canada.

METHODS

We conducted a repeated, cross-sectional analysis of persons with prevalent PD aged 40+ years on April 1st of each year from 2000 to 2018 using health administrative databases and calculated the age-sex standardized prevalence of PD. Prevalence of PD was also stratified by rurality and sex. Negative binomial models were used to calculate rate ratios with 95% confidence intervals comparing rates of health service use in rural compared to urban residents in 2018.

RESULTS

The age-sex standardized prevalence of PD in Ontario increased by 0.34% per year (p<0.0001) and was 459 per 100,000 in 2018 (n = 33,479), with a lower prevalence in rural compared to urban residents (401 vs. 467 per 100,000). Rates of hospitalizations and family physician visits declined over time in both men and women with PD in rural and urban areas, while rates of emergency department, neurologist, and other specialist visits increased. Adjusted rates of hospitalizations were similar between rural and urban residents (RR = 1.04, 95% CI [0.96, 1.12]), while rates of emergency department visits were higher among rural residents (RR = 1.35, 95% CI [1.27, 1.42]). Rural residents had lower rates of family physician (adjusted RR = 0.82, (95% CI [0.79, 0.84]) and neurologist visits (RR = 0.74, 95% CI [0.72, 0.77]).

INTERPRETATION

Lower rates of outpatient health service use among persons residing in rural regions, contrasting with higher rates of emergency department visits suggest inequities in access. Efforts to improve access to primary and specialist care for persons with PD in rural regions are needed.

Language discordance as a marker of disparities in cerebrovascular risk and stroke outcomes: A multi-center Canadian study

Background

Differences in ischemic stroke outcomes occur in those with limited English proficiency. These health disparities might arise when a patient's spoken language is discordant from the primary language utilized by the health system. Language concordance is an understudied concept. We examined whether language concordance is associated with differences in vascular risk or post-stroke functional outcomes, depression, obstructive sleep apnea and cognitive impairment.

Methods

This was a multi-center observational cross-sectional cohort study. Patients with ischemic stroke/transient ischemic attack (TIA) were consecutively recruited across eight regional stroke centers in Ontario, Canada (2012 - 2018). Participants were language concordant (LC) if they spoke English as their native language, ESL if they used English as a second language, or language discordant (LD) if non-English speaking and requiring translation.

Results

8156 screened patients. 6,556 met inclusion criteria: 5067 LC, 1207 ESL and 282 LD. Compared to LC patients: (i) ESL had increased odds of diabetes (OR = 1.28, p = 0.002), dyslipidemia (OR = 1.20, p = 0.007), and hypertension (OR = 1.37, p<0.001) (ii) LD speaking patients had an increased odds of having dyslipidemia (OR = 1.35, p = 0.034), hypertension (OR = 1.37, p<0.001), and worse functional outcome (OR = 1.66, p<0.0001). ESL (OR = 1.88, p<0.0001) and LD (OR = 1.71, p<0.0001) patients were more likely to have lower cognitive scores. No associations were noted with obstructive sleep apnea (OSA) or depression.

Conclusions

Measuring language concordance in stroke/TIA reveals differences in neurovascular risk and functional outcome among patients with limited proficiency in the primary language of their health system. Lower cognitive scores must be interpreted with caution as they may be influenced by translation and/or greater vascular risk. Language concordance is a simple, readily available marker to identify those at risk of worse functional outcome. Stroke systems and practitioners must now study why these differences exist and devise adaptive care models, treatments and education strategies to mitigate barriers influenced by language discordance.

New opioid use and risk of opioid-related adverse events among adults with intellectual and developmental disabilities in Ontario, Canada

BACKGROUND

Individuals with intellectual and developmental disability (IDD) can have a high prevalence of pain, which can be managed with prescription opioids. However, the prevalence of substance use disorder is also high in this population, raising concern about opioid-related adverse events.

AIMS

To assess the risk of opioid-related adverse events following opioid initiation among adults with versus without IDD.

METHOD

We conducted a population-based, propensity score matched cohort study on all adults starting prescription opioid therapy in Ontario, Canada, between January 2013 and December 2018. The outcomes of interest were opioid toxicity, new opioid use disorder (OUD) diagnosis and dose escalation (≥90 mg morphine or equivalent) in the year after opioid initiation. We used Cox proportional hazards models to assess the association between IDD diagnosis and each outcome.

RESULTS

The hazards of opioid toxicity and OUD were significantly higher in those with IDD compared with those without IDD in unmatched analyses (opioid toxicity hazard ratio 3.19, 95% CI 2.81-5.18; OUD hazard ratio 2.36, 95% CI 2.10-2.65), whereas the hazard of dose escalation was significantly lower (hazard ratio 0.76, 95% CI 0.66-0.88). Findings were no longer significant in propensity score matched models for opioid toxicity and dose escalation, whereas the hazard of OUD diagnosis was attenuated substantially in those with IDD (hazard ratio 0.79, 95% CI 0.68-0.91).

CONCLUSIONS

IDD diagnosis is not a driver of opioid-related harm. The increased risk we observed is likely driven by various risk factors often present in this population.

Interprofessional Primary Care and Acute Care Hospital Use by People With Dementia: A Population-Based Study

PURPOSE

Interprofessional primary care has the potential to optimize hospital use for acute care among people with dementia. We compared 1-year emergency department (ED) visits and hospitalizations among people with dementia enrolled in a practice having an interprofessional primary care team with those enrolled in a physician-only group practice.

METHODS

A population-based, repeated cohort study design was used to extract yearly cohorts of 95,323 community-dwelling people in Ontario, Canada, newly identified in administrative data with dementia between April 1, 2005 and March 31, 2015. Patient enrollment in an interprofessional practice or a physician-only practice was determined at the time of dementia diagnosis. We used propensity score-based inverse probability weighting to compare study groups on overall and nonurgent ED visits as well as on overall and potentially avoidable hospitalizations in the 1 year following dementia diagnosis.

RESULTS

People with dementia enrolled in a practice having an interprofessional primary care team were more likely to have ED visits (relative risk = 1.03; 95% CI, 1.01-1.05) and nonurgent ED visits (relative risk = 1.22; 95% CI, 1.18-1.28) compared with those enrolled in a physician-only primary care practice. There was no evidence of an association between interprofessional primary care and hospitalization outcomes.

CONCLUSIONS

Interprofessional primary care was associated with increased ED use but not hospitalizations among people newly identified as having dementia. Although interprofessional primary care may be well suited to manage the growing and complex dementia population, a better understanding of the optimal characteristics of team-based care and the reasons leading to acute care hospital use by people with dementia is needed.

Defining the Assisted Living Sector in Canada: An Environmental Scan

OBJECTIVES

In this study, we (1) identify the terms used to describe the assisted living sector and the legislation governing operation in all Canadian provinces and territories; (2) identify the cost estimates associated with residency in these homes; and (3) quantify the growth of the sector.

DESIGN

Environmental scan.

SETTING AND PARTICIPANTS

Internet searches of Canadian provincial and territorial government websites and professional associations were conducted in 2021 to retrieve publicly accessible sources related to the assisted living sector.

METHODS

We synthesized data that identified the terms used to describe the sector in all provinces and territories, the legislation governing operation, financing, median fees per month for care, and growth of the sector from 2012 to 2020. Counts and proportions were calculated for some extracted variables. All data were narratively synthesized.

RESULTS

The terms used to describe the assisted living sector varied across Canada. The terms "assisted living," "retirement homes," and "supportive living" were prevalent. Ontario was the only province to regulate the sector through an independent, not-for-profit organization. Ontario, British Columbia, and Alberta had some of the highest median fees for room, board, and care per month (range: $1873 to $6726). The licensed assisted living sector in Ontario doubled in size (768 in 2020 vs 383 in 2012), and there was a threefold increase in the number of corporate-owned chain assisted living facilities (465 in 2020 vs 142 in 2012).

CONCLUSIONS AND IMPLICATIONS

The rapid growth of the assisted living sector that is primarily financed through out-of-pocket payments may indicate a rise in a two-tier system of housing and health care for older adults. Policymakers need better mechanisms, such as standardized reporting systems and assessments, to understand the needs of older adults who reside in assisted living facilities and inform the need for sector regulation and oversight.

Quality indicator framework for primary care of patients with dementia

OBJECTIVE

To develop a framework of population-based primary care quality indicators adapted to patients with dementia and to identify a subset of stakeholder-driven priority indicators.

DESIGN

Framework development was carried out through the selection of an initial framework based on a rapid review and identification of relevant indicators and enrichment based on existing dementia indicators and guidelines. Prioritization of indicators was carried out through a stakeholder survey.

SETTING

Ontario, Quebec, New Brunswick, and Saskatchewan.

PARTICIPANTS

Stakeholders in community dementia care (N=109) including clinicians, patients, caregivers, decision makers, and managers.

MAIN OUTCOME MEASURES

Primary care quality indicators.

RESULTS

The framework comprised 34 indicators across 8 domains of quality (access, integration, effective care, efficient care, equity, safety, population health, and patient-centred care). Access to a regular primary care provider, continuity of care, early-stage diagnosis, and access to home care were consistently rated as priorities. Equitable care was a specific priority among patients and caregivers; clinicians reported avoidable hospitalizations as among their priorities.

CONCLUSION

A framework of indicators was established for persons with dementia that adds an important dimension to existing primary care and dementia quality indicators by providing primary care and population-based perspectives. This framework could set a foundation for the ongoing monitoring of primary care practices and policies for persons with dementia at a population level.

Association between depression, gender and Alzheimer's neuropathology in older adults without dementia

OBJECTIVES

Previous studies regarding the relationship between depression and Alzheimer's neuropathology in older adults without dementia have reported conflicting findings. This study examined whether depression is associated with Alzheimer's neuropathology and whether sex moderates these relationships.

METHODS

This is a cross-sectional study of older adults without dementia (normal cognition or mild cognitive impairment, age 50+; CDR ≤ 0.5) who had autopsy within 1 year of their last clinic visit in the National Alzheimer's Coordinating Center database (2005-2020). Logistic regression models were fitted to determine if a recent or remote history of depression was associated with amyloid spread beyond the neocortex measured by modified Thal phase score, density of amyloid plaques measured by CERAD score or tau neuropathology measured by modified Braak score. A moderator analysis was performed to determine if any of these associations were moderated by sex.

RESULTS

This study included 407 participants (96 Thal, 405 Braak, and 406 CERAD). Those who had recently active depression (within previous 2 years) but not remote depression only were more likely to have higher Thal phase score compared to those without a history of depression (OR = 3.74; 95% CI, 1.15-12.17; p = 0.028). Sex did not moderate this association. No significant associations between recent depression and Braak or CERAD scores were observed.

CONCLUSION

Our findings indicate that the association between late life depression and Alzheimer's neuropathology is associated with spread of amyloid pathology beyond the neocortex to include allocortical and subcortical regions critical for regulation of mood and motivated behavior.

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

Background

Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management.

Objectives

The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity.

Methods

We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018–2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents’ health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents’ characteristics and opioid use, overall and across strata capturing pain frequency and intensity.

Results

Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57–0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66–0.72) or dementia (aRR = 0.76, 95% CI 0.74–0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32–1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74–1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28–1.38), or antidepressants (aRR = 1.31, 95% CI 1.27–1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata.

Conclusions

Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00972-9.

Opioid Initiation and the Hazard of Falls or Fractures Among Older Adults with Varying Levels of Central Nervous System Depressant Burden

BACKGROUND

Co-prescription of opioids with other central nervous system (CNS) depressants is common but the combination may increase the risk for adverse events such as falls and fractures, particularly among older adults. We explored the risk of fall- or fracture-related hospital visits after opioid initiation among older adults with varying degrees of concomitant CNS depressant burden.

METHODS

We used population-based administrative health data from Ontario, Canada, to examine the relationship between hospital visits for falls or fractures at different levels of CNS burden among individuals aged 66 and older who started prescription opioids between March 1, 2008, and March 31, 2019. For comparison, we identified individuals starting prescription non-steroidal anti-inflammatory drugs (NSAIDs). The outcome was a hospital visit for falls or fractures within 14 days after starting analgesic therapy. We stratified the cohort according to additional CNS burden: none, low (one concurrent CNS depressant drug class) and high (≥ 2 concurrent CNS depressant classes) on the index date. We balanced opioid and NSAID recipients using inverse probability of treatment weighting and reported weighted hazard ratios from Cox proportional hazards models. We then used pairwise comparisons to determine differences between hazard ratios at different levels of CNS burden.

RESULTS

The cohort included 1,066,692 older adults, with 562,692 new opioid recipients and 504,000 new NSAID recipients. Among opioid recipients, 83 % had no additional CNS burden, 13 % had low burden and 4 % had high burden. The short-term rate of falls or fractures for new opioid recipients increased by CNS burden from 97 per 1000 person-years (no burden) to 233 per 1000 person-years (high CNS burden). Opioid recipients had a similarly elevated hazard of falls or fractures within each CNS burden level compared to NSAID recipients (adjusted hazard ratio [aHR] 1.62, 95 % CI 1.50-1.76 for no burden; aHR 1.69, 95 % CI 1.45-1.97 for low burden; aHR 1.40, 95 % CI 1.08-1.82 for high burden).

CONCLUSION

Among older adults, initiation of opioids is associated with an increased hazard of falls; however, this hazard is not modified by different levels of CNS depressant burden. This suggests that it remains important for physicians, patients, and caregivers to be vigilant when starting new opioid therapy regardless of other CNS medications taken concurrently.

Visits to the emergency department by community-dwelling people with dementia during the first 2 waves of the COVID-19 pandemic in Ontario: a repeated cross-sectional analysis

BACKGROUND

Community-dwelling people with dementia have been affected by COVID-19 pandemic health risks and control measures that resulted in worsened access to health care and service cancellation. One critical access point in health systems is the emergency department. We aimed to determine the change in weekly rates of visits to the emergency department of community-dwelling people with dementia in Ontario during the first 2 waves of the COVID-19 pandemic compared with historical patterns.

METHODS

We conducted a population-based repeated cross-sectional study and used health administrative databases to compare rates of visits to the emergency department among community-dwelling people with dementia who were aged 40 years and older in Ontario during the first 2 waves of the COVID-19 pandemic (March 2020-February 2021) with the rates of a historical period (March 2019-February 2020). Weekly rates of visits to the emergency department were evaluated overall, by urgency and by chapter from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. We used Poisson models to compare pandemic and historical rates at the week of the lowest rate during the pandemic period and the latest week.

RESULTS

We observed large immediate declines in rates of visits to the emergency department during the COVID-19 pandemic (rate ratio [RR] 0.50, 95% confidence interval [CI] 0.47-0.53), which remained below historical levels by the end of the second wave (RR 0.88, 95% CI 0.83-0.92). Rates of both nonurgent (RR 0.33, 95% CI 0.28-0.39) and urgent (RR 0.51, 95% CI 0.48-0.55) visits to the emergency department also declined and remained low (RR 0.68, 95% CI 0.59-0.79, RR 0.91, 95% CI 0.86-0.96), respectively. Visits for injuries, and circulatory, respiratory and musculoskeletal diseases declined and remained below historical levels.

INTERPRETATION

Prolonged reductions in visits to the emergency department among people with dementia during the first 2 pandemic waves raise concerns about patients who delay seeking acute care services. Understanding the long-term effects of these reductions requires further research.

Prevalence of prescription and non-prescription polypharmacy by frailty and sex among middle-aged and older Canadians

BACKGROUND

Estimates of polypharmacy have primarily been derived from prescription claims, and less is known about the use of non-prescription medications (alone or in combination with prescription medications) across the frailty spectrum or by sex. Our objectives were to estimate the prevalence of polypharmacy (total, prescription, non-prescription, and concurrent prescription and non-prescription) overall, and by frailty, sex and broad age group.

DATA

Canadian Health Measures Survey, Cycle 5, 2016 to 2017.

METHODS

Among Canadians aged 40 to 79 years, all prescription and non-prescription medications used in the month prior to the survey were documented. Polypharmacy was defined as using five or more medications total (prescription and non-prescription), prescription only and non-prescription only. Concurrent prescription and non-prescription use was defined as two or more and three or more of each. Frailty was defined using a 31-item frailty index (FI) and categorized as non-frail (FI ≤ 0.1) and pre-frail or frail (FI > 0.1). Survey-weighted descriptive statistics were calculated overall and age standardized.

RESULTS

We analyzed 2,039 respondents, representing 16,638,026 Canadians (mean age of 56.9 years; 51% women). Overall, 52.4% (95% confidence interval [CI] = 47.3 to 57.4) were defined as pre-frail or frail. Age-standardized estimates of total polypharmacy, prescription polypharmacy and concurrent prescription and non-prescription medication use were significantly higher among pre-frail or frail versus non-frail adults (e.g., total polypharmacy: 64.1% versus 31.8%, respectively). Polypharmacy with non-prescription medications was common overall (20.5% [95% CI = 16.1 to 25.8]) and greater among women, but did not differ significantly by frailty.

INTERPRETATION

Polypharmacy and concurrent prescription and non-prescription medication use were common among Canadian adults, especially those who were pre-frail or frail. Our findings highlight the importance of considering non-prescribed medications when measuring the exposure to medications and the potential risk for adverse outcomes.

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study

BACKGROUND

Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults.

METHODS

We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits.

RESULTS

We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14).

INTERPRETATION

Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

Follow-up after post-partum psychiatric emergency department visits: an equity-focused population-based study in Canada

BACKGROUND

Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care.

METHODS

In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up.

FINDINGS

We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13-47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables.

INTERPRETATION

Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population.

FUNDING

Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

Reasons for repeated emergency department visits among community-dwelling older adults with dementia in Ontario, Canada

BACKGROUND

Community-dwelling older adults living with dementia visit the emergency department (ED) more frequently than other older adults, but research on the reasons for repeated visits is lacking. We examined the rate of repeated ED visits and reasons for visits in a cohort of individuals with dementia.

METHODS

We conducted a population-based retrospective cohort study of community-dwelling older adults (≥66 years) living with dementia in Ontario, Canada, who visited the ED and were discharged home between April 1, 2010, and March 31, 2019. We calculated the proportion of the population with one, two, and three or more repeat ED visits within 1 year of the baseline visit and the categorized the reason for the visits.

RESULTS

Our cohort contained 175,863 individuals with dementia who visited the ED at least once. Overall, 66.1% returned at least once to the ED within 1 year, 39.4% returned twice, and 23.5% returned 3 or more times. Visit reasons were heterogenous and were most frequently related to general signs and symptoms (25.3%) while being infrequently due to cognitive or behavioral reasons (5.9%). Individuals typically visited for different reasons across successive visits.

CONCLUSIONS

Community-dwelling older adults with dementia who visited an ED were very likely to return to the ED within a year, with a substantial proportion visiting multiple times. The high frequency of repeated visits for different reasons highlights the complexity of caring for this population and indicates greater need for comprehensive community and primary care as well as timely communication between the ED and the community.

Behavioral Nudges to Improve Audit and Feedback Report Opening among Antibiotic Prescribers: A Randomized Controlled Trial

Background

Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested three behavioral nudging techniques delivered by email to improve report opening.

Methods

We conducted a pragmatic randomized controlled trial among Ontario long-term care (LTC) prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions.

Results

The trial included 421 physicians caring for more than 28,000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio (OR) 1.51 (95%CI 1.10-2.07, p=0.011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR (aOR) 1.74 (95%CI 1.24-2.45, p=0.0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR 1.62, 95%CI 1.06-2.47, p=0.026; aOR 2.16, 95%CI 1.33-3.50, p=0.0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR 1.28, 95%CI 1.14-1.43, p&lt;0.001).

Conclusions

Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.

Incidence of neurological and psychiatric comorbidity over time: a population-based cohort study in Ontario, Canada

INTRODUCTION

Comprehensive, population-based investigations of the extent and temporality of associations between common neurological and psychiatric disorders are scarce.

METHODS

This retrospective cohort study used linked health administrative data for Ontarians aged 40-85 years on 1 April 2002, to estimate the adjusted rate of incident dementia, Parkinson's disease (PD), stroke or mood/anxiety disorder (over 14 years) according to the presence and time since diagnosis of a prior disorder. Sex differences in the cumulative incidence of a later disorder were also examined.

RESULTS

The cohort included 5,283,546 Ontarians (mean age 56.2 ± 12.1 years, 52% female). The rate of dementia was significantly higher for those with prior PD (adjusted hazard ratio [adjHR] 4.05, 95% confidence interval [CI] 3.99-4.11); stroke (adjHR 2.49, CI 2.47-2.52) and psychiatric disorder (adjHR 1.79, CI 1.78-1.80). The rate of PD was significantly higher for those with prior dementia (adjHR 2.23, CI 2.17-2.30) and psychiatric disorder (adjHR 1.77, CI 1.74-1.81). The rate of stroke was significantly higher among those with prior dementia (adjHR 1.56, CI 1.53-1.58). Prior dementia (adjHR 2.36, CI 2.33-2.39), PD (adjHR 1.80, CI 1.75-1.85) and stroke (adjHR 1.47, CI 1.45-1.49) were associated with a higher rate of an incident psychiatric disorder. Generally, associations were strongest in the 6 months following a prior diagnosis and demonstrated a J-shape relationship over time. Significant sex differences were evident in the absolute risks for several disorders.

CONCLUSIONS

The observed nature of bidirectional associations between these neurological and psychiatric disorders indicates opportunities for earlier diagnosis and interventions to improve patient care.

Greater opioid use among nursing home residents in Ontario, Canada during the first two waves of the COVID-19 pandemic

Objectives

To examine the association between the COVID-19 pandemic and opioid use among nursing home residents followed up to March 2021, and possible variation by dementia and frailty status.

Design

Population-based cohort study with an interrupted time series analysis.

Setting and Participants

Linked health administrative databases for residents of all nursing homes (n = 630) in Ontario, Canada were examined. Residents were divided into consecutive weekly cohorts (first observation week was March 5 to 11, 2017 and last was March 21 to March 27, 2021).

Methods

The weekly proportion of residents dispensed an opioid was examined overall and by strata defined by the presence of dementia and frailty. Autoregressive Integrated Moving Average models with step and ramp intervention functions tested for immediate level and slope changes in weekly opioid use after the onset of the pandemic (March 1, 2020) and were fit on prepandemic data for projected trends.

Results

The average weekly cohort ranged from 76,834 residents (prepandemic) to 69,359 (pandemic period), with a consistent distribution by sex (69% female) and age (54% age 85 + years). There was a statistically significant increased slope change in the weekly proportion of residents dispensed opioids (parameter estimate (β) = 0.035; standard error (SE) = 0.005, P < .001). Although significant for all 4 strata, the increased slope change was more pronounced among nonfrail residents (β = 0.038; SE = 0.008, P < .001) and those without dementia (β = 0.044; SE = 0.008, P < .001). The absolute difference in observed vs predicted opioid use in the last week of the pandemic period ranged from 1.25% (frail residents) to 2.28% (residents without dementia).

Conclusions and Implications

Among Ontario nursing home residents, there was a statistically significant increase in opioid dispensations following the onset of the pandemic that persisted up to 1 year later. Investigations of the reasons for increased use, potential for long-term use and associated health consequences for residents are warranted.

Examining the association between loneliness and emergency department visits using Canadian Longitudinal Study of Aging (CLSA) data: a retrospective cross-sectional study

Background

Loneliness is a public health concern and its influence on morbidity and mortality are well documented. The association between loneliness and emergency department visits is less clear. Further, while sex and gender-related factors are known to be associated with loneliness and health services use, little research looks at the relationship by gender. Our study aimed to estimate the association between loneliness and emergency department use in the previous 12 months. We aimed to determine if this association differed based on gender identity and gender-related characteristics.

Methods

We used a retrospective cohort study design to analyze population-based survey data from the Canadian Longitudinal Study on Aging (CLSA). We analysed data from the baseline and follow-up 1 survey respondents (2015-2018) from both the tracking (telephone interviews) and comprehensive (in-home data collection) cohorts (n=44816). Loneliness was assessed using a dichotomous measure (lonely/not lonely) from a validated scale. Emergency department visits were dichotomous (yes/no) by self-reported emergency department use in the 12 months prior to the survey date. Multivariable logistic regression analyses using analytic weights examined the association between loneliness and emergency department visit, controlling for other demographic, social, and health related factors.

Results

We identified 44,413 respondents to the baseline and follow-up 1 survey. The prevalence of loneliness in our sample was 23.1% (n=10263). Of those who had been to the emergency department in the previous year, 27.2% (n=2793) were lonely. Lonely respondents had higher odds of an emergency department visit (aOR: 1.13, 95% CI: 1.05-1.21), adjusted for various demographic and health factors. Loneliness was associated with emergency department visits more so in women (aOR: 1.15, 95% CI: 1.05-1.25) than in men (aOR: 1.10, 95% CI: 0.99-1.22).

Conclusions

In our study, loneliness was associated with emergency department visits in the previous 12 months. When our analysis was disaggregated by gender, we found differences in the odds of emergency department visit for men, women, and gender-diverse respondents. The odds of ED visit were higher in women than men. These findings highlight the general importance of identifying loneliness in both primary care and hospital. Care providers in ED need resources to refer patients who present in this setting with health issues complicated by social conditions such as loneliness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02763-8.

Trends in Health Service Use for Canadian Adults With Dementia and Parkinson Disease During the First Wave of the COVID-19 Pandemic

Question

Was the COVID-19 pandemic associated with changes in health service use and mortality among community-dwelling persons with dementia and Parkinson disease compared with older adults?

Findings

In this population-based repeated cross-sectional analysis, large declines in hospital use and nursing home admission were experienced across all cohorts. After the first wave, most services returned to historical levels, with physician visits elevated and mostly virtual, nursing home admissions reduced, and excess all-cause mortality.

Meaning

The pandemic was associated with meaningful health service disruptions for persons with dementia and Parkinson disease, highlighting that continued support for virtual care is needed to ensure optimal health outcomes.

Importance

Persons with dementia and Parkinson disease (PD) are vulnerable to disruptions in health care and services.

Objective

To examine changes in health service use among community-dwelling persons with dementia, persons with PD, and older adults without neurodegenerative disease during the first wave of the COVID-19 pandemic.

Design, Setting, and Participants

Repeated cross-sectional analysis using population-based administrative data among community-dwelling persons with dementia, persons with PD, and adults 65 years and older at the start of each week from March 1 through the week of September 20, 2020 (pandemic period), and March 3 through the week of September 22, 2019 (historical period), in Ontario, Canada.

Exposures

COVID-19 pandemic as of March 1, 2020.

Main Outcomes and Measures

Main outcomes were weekly rates of emergency department visits, hospitalizations, nursing home admissions, home care, virtual and in-person physician visits, and all-cause mortality. Poisson regression models were used to calculate weekly rate ratios (RRs) with 95% CIs comparing pandemic weeks with historical levels.

Results

Among those living in the community as of March 1, 2020, persons with dementia (n = 131 466; mean [SD] age, 80.1 [10.1] years) were older than persons with PD (n = 30 606; 73.7 [10.2] years) and older adults (n = 2 363 742; 74.0 [7.1] years). While all services experienced declines, the largest drops occurred in nursing home admissions (RR for dementia: 0.10; 95% CI, 0.07-0.15; RR for PD: 0.03; 95% CI, 0.00-0.21; RR for older adults: 0.11; 95% CI, 0.06-0.18) and emergency department visits (RR for dementia: 0.45; 95% CI, 0.41-0.48; RR for PD: 0.40; 95% CI, 0.34-0.48; RR for older adults: 0.45; 95% CI, 0.44-0.47). After the first wave, most services returned to historical levels except physician visits, which remained elevated (RR for dementia: 1.07; 95% CI, 1.05-1.09; RR for PD: 1.10, 95% CI, 1.06-1.13) and shifted toward virtual visits. Older adults continued to experience lower hospitalizations. All-cause mortality was elevated across cohorts.

Conclusions and Relevance

In this population-based repeated cross-sectional study in Ontario, Canada, those with dementia, those with PD, and older adults sought hospital care far less than usual, were not admitted to nursing homes, and experienced excess mortality during the first wave of the pandemic. Most services returned to historical levels, but virtual physician visits remained a feature of care. While issues of equity and quality of care are still emerging among persons with neurodegenerative diseases, policies to support virtual care are necessary.

Pivoting data and analytic capacity to support Ontario's COVID-19 response

Introduction

Health care systems have faced unprecedented challenges due to the COVID-19 pandemic. Access to timely population-based data has been vital to informing public health policy and practice.

Methods

We describe how ICES, an independent not-for-profit research and analytic institute in Ontario, Canada, pivoted existing research infrastructure and engaged health system stakeholders to provide near real-time population-based data and analytics to support Ontario's COVID-19 pandemic response.

Results

Since April 2020, ICES provided the Ontario COVID-19 Provincial Command Table and public health partners with regular and ad hoc reports on SARS-CoV-2 testing and COVID-19 vaccine coverage. These reports: 1) helped identify congregate care/shared living settings that needed testing and prevention efforts early in the pandemic; 2) provided early indications of inequities in testing and infection in marginalized neighbourhoods, including areas with higher proportions of immigrants and visible minorities; 3) identified areas with high test positivity, which helped Public Health Units target and evaluate prevention efforts; and 4) contributed to altering the province's COVID-19 vaccine roll-out strategy to target high-risk neighbourhoods and helping Public Health Units and community organizations plan local vaccination programs. In addition, ICES is a key component of the Ontario Health Data Platform, which provides scientists with data access to conduct COVID-19 research and analyses.

Discussion and Conclusion

ICES was well-positioned to provide rapid analyses for decision-makers to respond to the evolving public health emergency, and continues to contribute to Ontario's pandemic response by providing timely, relevant reports to health system stakeholders and facilitating data access for externally-funded COVID-19 research.

Resident loneliness, social isolation and unplanned emergency department visits from supportive living facilities: a population-based study in Alberta, Canada

BACKGROUND

Supportive living (SL) facilities are intended to provide a residential care setting in a less restrictive and more cost-effective way than nursing homes (NH). SL residents with poor social relationships may be at risk for increased health service use. We describe the demographic and health service use patterns of lonely and socially isolated SL residents and to quantify associations between loneliness and social isolation on unplanned emergency department (ED) visits.

METHODS

We conducted a retrospective cohort study using population-based linked health administrative data from Alberta, Canada. All SL residents aged 18 to 105 years who had at least one Resident Assessment Instrument-Home Care (RAI-HC) assessment between April 1, 2013 and March 31, 2018 were observed. Loneliness and social isolation were measured as a resident indicating that he/she feels lonely and if the resident had neither a primary nor secondary caregiver, respectively. Health service use in the 1 year following assessment included unplanned ED visits, hospital admissions, admission to higher levels of SL, admission to NH and death. Multivariable Cox proportional hazard models examined the association between loneliness and social isolation on the time to first unplanned ED visit.

RESULTS

We identified 18,191 individuals living in Alberta SL facilities. The prevalence of loneliness was 18% (n = 3238), social isolation was 4% (n = 713). Lonely residents had the greatest overall health service use. Risk of unplanned ED visit increased with loneliness (aHR = 1.10, 95% CI: 1.04-1.15) but did not increase with social isolation (aHR = 0.95, 95% CI: 0.84-1.06).

CONCLUSIONS

Lonely residents had a different demographic profile (older, female, cognitively impaired) from socially isolated residents and were more likely to experience an unplanned ED visit. Our findings suggest the need to develop interventions to assist SL care providers with how to identify and address social factors to reduce risk of unplanned ED visits.

The impact of the first wave of the COVID‐19 pandemic on health service use by persons with dementia in Ontario, Canada: A population‐based time series analysis

Background

Little has been quantified, at a population‐level, about the magnitude of heath service disruption to persons living with dementia in community settings during the COVID‐19 pandemic. Sustained access to health care services is particularly important for persons with dementia and other neurodegenerative diseases as they are vulnerable to decline.

Method

Health administrative data from Ontario, Canada were used to examine patterns of health service use among all persons with Alzheimer disease and related dementias (dementia) who were alive and living in the community. This cohort was compared to persons with Parkinson’s disease (PD) as well as all older adults (age 65+ years) without neurodegenerative diseases. Rates of all‐cause hospital admissions, emergency department visits, primary care and specialist physician visits and home care visits were analyzed for all individuals alive and eligible for provincial health insurance at the start of each weekly period from March 1, 2020 to September 20, 2020 (pandemic period) and from March 3, 2019 to September 22, 2019 (pre‐pandemic period). Rates of health service use during specific weeks in the pandemic period (i.e., lowest week, last available week) were compared to corresponding weeks in the pre‐pandemic period within each cohort using percent changes.

Results

On March 1, 2020, 128,696 persons with dementia, 30,099 with PD and 2,460,358 older adults were eligible for provincial health services. Across cohorts and services, dramatic declines in use of health services were observed at the lowest week: hospitalization (‐38.7% dementia, ‐72.3% PD, ‐44.2% older adults); emergency department (‐54.9% dementia, ‐57.7% PD, ‐53.6% older adults); home care (‐14.8% dementia, ‐19.4% PD, ‐7.4% older adults). Health services varied in how quickly they rebounded to pre‐pandemic levels within cohorts; notably, by the end of the study period, emergency department visits had increased to a level higher than corresponding 2019 weekly rates (24.2% dementia, 15.2% PD, 7.4% older adults).

Conclusions

The first wave of the COVID‐19 pandemic meaningfully and immediately disrupted use of health care services for persons living with dementia and PD and may have resulted in long‐term consequences that should be monitored.

The Impact of COVID-19 on Outpatient Antibiotic Prescriptions in Ontario, Canada; An Interrupted Time Series Analysis

Background

The coronavirus disease 2019 (COVID-19) pandemic has potentially impacted outpatient antibiotic prescribing. Investigating this impact may identify stewardship opportunities in the ongoing COVID-19 period and beyond.

Methods

We conducted an interrupted time series analysis on outpatient antibiotic prescriptions and antibiotic prescriptions/patient visits in Ontario, Canada, between January 2017 and December 2020 to evaluate the impact of the COVID-19 pandemic on population-level antibiotic prescribing by prescriber specialty, patient demographics, and conditions.

Results

In the evaluated COVID-19 period (March–December 2020), there was a 31.2% (95% CI, 27.0% to 35.1%) relative reduction in total antibiotic prescriptions. Total outpatient antibiotic prescriptions decreased during the COVID-19 period by 37.1% (95% CI, 32.5% to 41.3%) among family physicians, 30.7% (95% CI, 25.8% to 35.2%) among subspecialist physicians, 12.1% (95% CI, 4.4% to 19.2%) among dentists, and 25.7% (95% CI, 21.4% to 29.8%) among other prescribers. Antibiotics indicated for respiratory infections decreased by 43.7% (95% CI, 38.4% to 48.6%). Total patient visits and visits for respiratory infections decreased by 10.7% (95% CI, 5.4% to 15.6%) and 49.9% (95% CI, 43.1% to 55.9%). Total antibiotic prescriptions/1000 visits decreased by 27.5% (95% CI, 21.5% to 33.0%), while antibiotics indicated for respiratory infections/1000 visits with respiratory infections only decreased by 6.8% (95% CI, 2.7% to 10.8%).

Conclusions

The reduction in outpatient antibiotic prescribing during the COVID-19 pandemic was driven by less antibiotic prescribing for respiratory indications and largely explained by decreased visits for respiratory infections.

New Opioid Use and Risk of Emergency Department Visits Related to Motor Vehicle Collisions in Ontario, Canada

IMPORTANCE

Opioids can impair motor skills and may affect the ability to drive; however, the association of opioid use with driving ability is not well established.

OBJECTIVE

To examine the risk of motor vehicle collisions (MVCs) among drivers starting opioid therapy compared with that among drivers starting nonsteroidal anti-inflammatory drug (NSAID) therapy.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study included all residents of Ontario aged 17 years or older who started new prescription analgesic therapy between March 1, 2008, and March 17, 2019.

EXPOSURES

Initiation of opioid therapy or NSAID therapy, ascertained through prescription dispensing records in administrative data.

MAIN OUTCOMES AND MEASURES

The primary outcome was an emergency department visit for injuries sustained as a driver in an MVC during the 14 days after starting analgesic therapy. Inverse probability treatment weighting was used to balance baseline covariates, and weighted Cox proportional hazards regression models were used to assess the association between new analgesic therapy and hazard of an emergency department visit after an MVC.

RESULTS

Of the 1 454 824 individuals included in the study, 765 464 (52.6%) were new opioid recipients and 689 360 (47.4%) were new NSAID recipients. Most participants were aged 65 years or older (75.2%), and 55.2% were women. Of 194 individuals who had emergency department visits for injuries from an MVC within 14 days of initiating therapy, 98 (50.5%) were opioid recipients (3.41 per 1000 person-years; 95% CI, 2.80-4.15 per 1000 person-years) and 96 (49.5%) were NSAID recipients (3.64 per 1000 person-years; 95% CI, 2.98-4.45 per 1000 person-years). There was no significant difference in the risk of an emergency department visit for MVC injuries between opioid and NSAID recipients (weighted hazard ratio, 0.94; 95% CI, 0.70-1.25).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the hazard of an emergency department visit for injuries relating to an MVC as a driver is similar between individuals starting prescription opioids and those starting prescription NSAIDs. These results may be useful for patients, clinicians, and caregivers when considering new analgesic therapy.

Co-Locating Older Retirement Home Residents: Uncovering an Under-Researched Population via Postal Code

BACKGROUND

Retirement home residents represent a growing proportion of older Ontarians who cannot be identified within existing administrative databases.

OBJECTIVE

This article aims to develop an approach for determining, from an individual's postal code, their likelihood of residing in a retirement home.

METHODS

We identified 748 licensed retirement homes in Ontario as of June 1, 2018, from a public registry. We developed a two-step evaluation and verification process to determine the probability (certain, likely or unlikely) of identifying a retirement home, as opposed to other dwellings, within a postal code.

RESULTS

We identified 274 (36.7%) retirement homes within a postal code certain to indicate that a person was residing in a retirement home, 200 (26.7%) for which it was likely and 274 (36.7%) for which it was unlikely. Postal codes that were certain and likely identified retirement homes with a capacity for 59,920 residents (79.9% of total provincial retirement home capacity).

CONCLUSION

It is feasible to identify a substantive cohort of retirement home residents using postal code data in settings where street address is unavailable for linkage to administrative databases.

Association of Neighborhood-Level Material Deprivation With Health Care Costs and Outcome After Stroke

BACKGROUND AND OBJECTIVES

To determine the association between material deprivation and direct health care costs and clinical outcomes following stroke in the context of a publicly funded universal health care system.

METHODS

In this population-based cohort study of patients with ischemic and hemorrhagic stroke admitted to the hospital between 2008 and 2017 in Ontario, Canada, we used linked administrative data to identify the cohort, predictor variables, and outcomes. The exposure was a 5-level neighborhood material deprivation index. The primary outcome was direct health care costs incurred by the public payer in the first year. Secondary outcomes were death and admission to long-term care.

RESULTS

Among 90,289 patients with stroke, the mean (SD) per-person costs increased with increasing material deprivation, from $50,602 ($55,582) in the least deprived quintile to $56,292 ($59,721) in the most deprived quintile (unadjusted relative cost ratio and 95% confidence interval 1.11 [1.08, 1.13] and adjusted relative cost ratio 1.07 [1.05, 1.10] for least compared to most deprived quintile). People in the most deprived quintile had higher mortality within 1 year compared to the least deprived quintile (adjusted hazard ratio [HR] 1.07 [1.03, 1.12]) as well as within 3 years (adjusted HR 1.09 [1.05, 1.13]). Admission to long-term care increased incrementally with material deprivation and those in the most deprived quintile had an adjusted HR of 1.33 (1.24, 1.43) compared to those in the least deprived quintile.

DISCUSSION

Material deprivation is a risk factor for increased costs and poor outcomes after stroke. Interventions targeting health inequities due to social determinants of health are needed.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that the neighborhood-level material deprivation predicts direct health care costs.

Long-term survival in high-risk older adults following emergency general surgery admission

BACKGROUND

Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions.

METHODS

We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups.

RESULTS

A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation.

CONCLUSION

Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients.

LEVEL OF EVIDENCE

Epidemiological, level III.

Impact of the COVID-19 Pandemic on Home Care Services Among Community-Dwelling Adults With Dementia

Objective

To examine how the COVID-19 pandemic impacted use of home care services for individuals with dementia across service types and sociodemographic strata.

Design

Population-based time series analysis.

Setting and Participants

Community-dwelling adults with dementia in Ontario, Canada, from January 2019 to September 2020.

Methods

We used health administrative databases (Ontario Registered Persons Database and Home Care Database) to measure home care services used by participants. Poisson regression models were fit to compare weekly rates of home care services during the pandemic to historical trends with rate ratios (RRs) and 95% confidence intervals (CIs) stratified by service type (nursing, personal care, therapy), sex, rurality, and neighborhood income quintile.

Results

During the first wave of the pandemic, personal care fell by 16% compared to historical levels (RR 0.84, 95% CI 0.84, 0.85) and therapies fell by 50% (RR 0.50, 95% CI 0.48, 0.52), whereas nursing did not significantly decline (RR 1.02, 95% CI 1.00, 1.04). All rates had recovered by September 2020, with nursing and therapies higher than historical levels. Changes in services were largely consistent across sociodemographic strata, although the rural population experienced a larger decline in personal care and smaller rebound in nursing.

Conclusions and Implications

Personal care and therapies for individuals with dementia were interrupted during the early months of the pandemic, whereas nursing was only minimally impacted. Pandemic responses with the potential to disrupt home care for individuals living with dementia must balance the impacts on individuals with dementia, caregivers, and providers.

Population-Wide Peer Comparison Audit and Feedback to Reduce Antibiotic Initiation and Duration in Long-Term Care Facilities with Embedded Randomized Controlled Trial

BACKGROUND

Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents.

METHODS

We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter.

RESULTS

Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference -2.65%, 95% confidence interval [CI]: -4.93 to -.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports.

CONCLUSIONS

Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466.