Microbial Features Linked to Medication Strategies in Cardiometabolic Disease Management

Human gut microbiota are recognized as critical players in both metabolic disease and drug metabolism. However, medication-microbiota interactions in cardiometabolic diseases are not well understood. To gain a comprehensive understanding of how medication intake impacts the gut microbiota, we investigated the association of microbial structure with the use of single or multiple medications in a cohort of 134 middle-aged adults diagnosed with cardiometabolic disease, recruited from Alberta's Tomorrow Project. Predominant cardiometabolic prescription medication classes (12 total) were included in our analysis. Multivariate Association with Linear Model (MaAsLin2) was employed and results were corrected for age, BMI, sex, and diet to evaluate the relationship between microbial features and single- or multimedication use. Highly individualized microbiota profiles were observed across participants, and increasing medication use was negatively correlated with α-diversity. A total of 46 associations were identified between microbial composition and single medications, exemplified by the depletion of Akkermansia muciniphila by β-blockers and statins, and the enrichment of Escherichia/Shigella and depletion of Bacteroides xylanisolvens by metformin. Metagenomics prediction further indicated alterations in microbial functions associated with single medications such as the depletion of enzymes involved in energy metabolism encoded by Eggerthella lenta due to β-blocker use. Specific dual medication combinations also had profound impacts, including the depletion of Romboutsia and Butyriciocccus by statin plus metformin. Together, these results show reductions in bacterial diversity as well as species and microbial functional potential associated with both single- and multimedication use in cardiometabolic disease.

Reduced incidence of diabetes during the COVID-19 pandemic in Alberta: A time-segmented longitudinal study of Alberta's Tomorrow Project

AIM

To characterize the impact of the COVID-19 pandemic on diabetes diagnosis using data from Alberta's Tomorrow Project (ATP), a population-based cohort study of chronic diseases in Alberta, Canada.

MATERIALS AND METHODS

The ATP participants who were free of diabetes on 1 April 2018 were included in the study. A time-segmented regression model was used to compare incidence rates of diabetes before the COVID-19 pandemic, during the first two COVID-19 states of emergency, and in the period when the state of emergency was relaxed, after adjusting for seasonality, sociodemographic factors, socioeconomic status, and lifestyle behaviours.

RESULTS

Among 43 705 ATP participants free of diabetes (65.5% females, age 60.4 ± 9.5 years in 2018), the rate of diabetes was 4.75 per 1000 person-year (PY) during the COVID-19 pandemic (up to 31 March 2021), which was 32% lower (95% confidence interval [CI] 21%, 42%; p < 0.001) than pre-pandemic (6.98 per 1000 PY for the period 1 April 2018 to 16 March 2020). In multivariable regression analysis, the first COVID-19 state of emergency (first wave) was associated with an 87.3% (95% CI -98.6%, 13.9%; p = 0.07) reduction in diabetes diagnosis; this decreasing trend was sustained to the second COVID-19 state of emergency and no substantial rebound (increase) was observed when the COVID-19 state of emergency was relaxed.

CONCLUSIONS

The COVID-19 public health emergencies had a negative impact on diabetes diagnosis in Alberta. The reduction in diabetes diagnosis was likely due to province-wide health service disruptions during the COVID-19 pandemic. Systematic plans to close the post-COVID-19 diagnostic gap are required in diabetes to avoid substantial downstream sequelae of undiagnosed disease.

Wastewater-based surveillance as a tool for public health action: SARS-CoV-2 and beyond

Wastewater-based surveillance (WBS) has undergone dramatic advancement in the context of the coronavirus disease 2019 (COVID-19) pandemic. The power and potential of this platform technology were rapidly realized when it became evident that not only did WBS-measured SARS-CoV-2 RNA correlate strongly with COVID-19 clinical disease within monitored populations but also, in fact, it functioned as a leading indicator. Teams from across the globe rapidly innovated novel approaches by which wastewater could be collected from diverse sewersheds ranging from wastewater treatment plants (enabling community-level surveillance) to more granular locations including individual neighborhoods and high-risk buildings such as long-term care facilities (LTCF). Efficient processes enabled SARS-CoV-2 RNA extraction and concentration from the highly dilute wastewater matrix. Molecular and genomic tools to identify, quantify, and characterize SARS-CoV-2 and its various variants were adapted from clinical programs and applied to these mixed environmental systems. Novel data-sharing tools allowed this information to be mobilized and made immediately available to public health and government decision-makers and even the public, enabling evidence-informed decision-making based on local disease dynamics. WBS has since been recognized as a tool of transformative potential, providing near-real-time cost-effective, objective, comprehensive, and inclusive data on the changing prevalence of measured analytes across space and time in populations. However, as a consequence of rapid innovation from hundreds of teams simultaneously, tremendous heterogeneity currently exists in the SARS-CoV-2 WBS literature. This manuscript provides a state-of-the-art review of WBS as established with SARS-CoV-2 and details the current work underway expanding its scope to other infectious disease targets.

Effective strategies for Fecal Immunochemical Tests (FIT) programs to improve colorectal cancer screening uptake among populations with limited access to the healthcare system: a rapid review

BACKGROUND

Colorectal cancer (CRC) is one of the leading causes of cancer death globally. CRC screening can reduce the incidence and mortality of CRC. However, socially disadvantaged groups may disproportionately benefit less from screening programs due to their limited access to healthcare. This poor access to healthcare services is further aggravated by intersecting, cumulative social factors associated with their sociocultural background and living conditions. This rapid review systematically reviewed and synthesized evidence on the effectiveness of Fecal Immunochemical Test (FIT) programs in increasing CRC screening in populations who do not have a regular healthcare provider or who have limited healthcare system access.

METHODS

We used three databases: Ovid MEDLINE, Embase, and EBSCOhost CINAHL. We searched for systematic reviews, meta-analysis, and quantitative and mixed-methods studies focusing on effectiveness of FIT programs (request or receipt of FIT kit, completion rates of FIT screening, and participation rates in follow-up colonoscopy after FIT positive results). For evidence synthesis, deductive and inductive thematic analysis was conducted. The findings were also classified using the Cochrane Methods Equity PROGRESS-PLUS framework. The quality of the included studies was assessed.

RESULTS

Findings from the 25 included primary studies were organized into three intervention design-focused themes. Delivery of culturally-tailored programs (e.g., use of language and interpretive services) were effective in increasing CRC screening. Regarding the method of delivery for FIT, specific strategies combined with mail-out programs (e.g., motivational screening letter) or in-person delivery (e.g., demonstration of FIT specimen collection procedure) enhanced the success of FIT programs. The follow-up reminder theme (e.g., spaced out and live reminders) were generally effective. Additionally, we found evidence of the social determinants of health affecting FIT uptake (e.g., place of residence, race/ethnicity/culture/language, gender and/or sex).

CONCLUSIONS

Findings from this rapid review suggest multicomponent interventions combined with tailored strategies addressing the diverse, unique needs and priorities of the population with no regular healthcare provider or limited access to the healthcare system may be more effective in increasing FIT screening. Decision-makers and practitioners should consider equity and social factors when developing resources and coordinating efforts in the delivery and implementation of FIT screening strategies.

Prospective follow-up study of youth and adults with onset of functional tic-like behaviours during the COVID-19 pandemic

BACKGROUND AND PURPOSE

Very little is known about the long-term prognosis of patients with functional tic-like behaviours (FTLBs). We sought to characterize the trajectory of symptom severity over a 12-month period.

METHODS

Patients with FTLBs were included in our prospective longitudinal child and adult clinical tic disorder registries at the University of Calgary. Patients were prospectively evaluated 6 and 12 months after their first clinical visit. Tic inventories and severity were measured with the Yale Global Tic Severity Scale (YGTSS).

RESULTS

Eighty-three youths and adults with FTLBs were evaluated prospectively until April 2023. Mean YGTSS total tic severity scores were high at baseline, with a mean score of 29.8 points (95% confidence interval [CI] = 27.6-32.1). Fifty-eight participants were reevaluated at 6 months, and 32 participants were reevaluated at 12 months. The YGTSS total tic severity score decreased significantly from the first clinical visit to 6 months (raw mean difference = 8.9 points, 95% CI = 5.1-12.7, p < 0.0001), and from 6 to 12 months (raw mean difference = 6.4 points, 95% CI = 0.8-12.0, p = 0.01). Multivariable linear regression demonstrated that tic severity at initial presentation and the presence of other functional neurological symptoms were associated with higher YGTSS total tic scores at 6 months, whereas younger age at baseline, receiving cognitive behavioural therapy for anxiety and/or depression, and prescription of selective serotonin reuptake inhibitors were associated with lower YGTSS total tic scores at 6 months.

CONCLUSIONS

We observed a meaningful improvement in tic severity scores in youth and adults with FTLBs over a period of 6-12 months.

Effects of Dietary Intake of Arsenosugars and Other Organic Arsenic Species on Studies of Arsenic Methylation Efficiency in Humans

Extensive research has used dimethylarsinic acid (DMA) in urine as a marker of arsenic methylation. The premise is that humans methylate inorganic arsenicals to monomethylarsonic acid (MMA) and DMA and excrete these arsenic species into the urine. However, DMA in urine not only comes from the methylation of inorganic arsenic but also could be a result of metabolism of other arsenic species, such as arsenosugars and arsenolipids. Most environmental health and epidemiological studies of arsenic methylation might have overlooked confounding factors that contribute to DMA in urine. Here we critically evaluate reported studies that used methylation indexes, concentration ratios of methylated arsenicals, or the percentage of DMA in urine as markers of arsenic methylation efficiency. Dietary intake of arsenosugars potentially confounds the calculation and interpretation of the arsenic methylation efficiencies. Many studies have not considered incidental dietary intake of arsenosugars, arsenolipids, and other organic arsenic species. Future studies should consider the dietary intake of diverse arsenic species and their potential effect on the urinary concentrations of DMA.

Quantification and Differentiation of SARS-CoV-2 Variants in Wastewater for Surveillance

Wastewater surveillance plays an important role in the monitoring of infections of SARS-CoV-2 at the community level. We report here the determination of SARS-CoV-2 and differentiation of its variants of concern in 294 wastewater samples collected from two major Canadian cities from May 2021 to March 2023. The overall method of analysis involved extraction of the virus and viral components using electronegative membranes, in situ stabilization and concentration of the viral RNA onto magnetic beads, and direct analysis of the viral RNA on the magnetic beads. Multiplex reverse transcription quantitative polymerase chain reaction (RT-qPCR) assays, targeting specific and naturally selected mutations in SARS-CoV-2, enabled detection and differentiation of the Alpha, Beta, Gamma, Delta, and Omicron variants. An Omicron triplex RT-qPCR assay targeting three mutations, HV 69-70 deletion, K417N, and L452R, was able to detect and differentiate the Omicron BA.1/BA.3, BA.2/XBB, and BA.4/5. This assay had efficiencies of 90-104% for all three mutation targets and a limit of detection of 28 RNA copies per reaction. Analyses of 294 wastewater samples collected over a two-year span showed the concentrations and trends of Alpha, Beta, Gamma, Delta, and Omicron variants as they emerge in two major Canadian cities participating in the wastewater surveillance program. The trends of specific variants were consistent with clinical reports for the same period. At the beginning of each wave, the corresponding variants were detectable in wastewater. For example, RNA concentrations of the BA.2 variant were as high as 104 copies per 100 mL of wastewater collected in January 2022, when approximately only 50-60 clinical cases of BA.2 infection were reported in Canada. These results show that the strategy and highly sensitive assays for the variants of concern in wastewater are potentially useful for the detection of newly emerging SARS-CoV-2 variants and other viruses for future community biomonitoring.

Multiplex Assays Enable Simultaneous Detection and Identification of SARS-CoV-2 Variants of Concern in Clinical and Wastewater Samples

The targeted screening and sequencing approaches for COVID-19 surveillance need to be adjusted to fit the evolving surveillance objectives which necessarily change over time. We present the development of variant screening assays that can be applied to new targets in a timely manner and enable multiplexing of targets for efficient implementation in the laboratory. By targeting the HV69/70 deletion for Alpha, K417N for Beta, K417T for Gamma, and HV69/70 deletion plus K417N for sub-variants BA.1, BA.3, BA.4, and BA.5 of Omicron, we achieved simultaneous detection and differentiation of Alpha, Beta, Gamma, and Omicron in a single assay. Targeting both T478K and P681R mutations enabled specific detection of the Delta variant. The multiplex assays used in combination, targeting K417N and T478K, specifically detected the Omicron sub-variant BA.2. The limits of detection for the five variants of concern were 4-16 copies of the viral RNA per reaction. Both assays achieved 100% clinical sensitivity and 100% specificity. Analyses of 377 clinical samples and 24 wastewater samples revealed the Delta variant in 100 clinical samples (nasopharyngeal and throat swab) collected in November 2021. Omicron BA.1 was detected in 79 nasopharyngeal swab samples collected in January 2022. Alpha, Beta, and Gamma variants were detected in 24 wastewater samples collected in May-June 2021 from two major cities of Alberta (Canada), and the results were consistent with the clinical cases of multiple variants reported in the community.

Arsenic speciation in freshwater fish: challenges and research needs

Food and water are the main sources of human exposure to arsenic. It is important to determine arsenic species in food because the toxicities of arsenic vary greatly with its chemical speciation. Extensive research has focused on high concentrations of arsenic species in marine organisms. The concentrations of arsenic species in freshwater fish are much lower, and their determination presents analytical challenges. In this review, we summarize the current state of knowledge on arsenic speciation in freshwater fish and discuss challenges and research needs. Fish samples are typically homogenized, and arsenic species are extracted using water/methanol with the assistance of sonication and enzyme treatment. Arsenic species in the extracts are commonly separated using high-performance liquid chromatography (HPLC) and detected using inductively coupled plasma mass spectrometry (ICPMS). Electrospray ionization tandem mass spectrometry, used in combination with HPLC and ICPMS, provides complementary information for the identification and characterization of arsenic species. The methods and perspectives discussed in this review, covering sample preparation, chromatography separation, and mass spectrometry detection, are directed to arsenic speciation in freshwater fish and applicable to studies of other food items. Despite progress made in arsenic speciation analysis, a large fraction of the total arsenic in freshwater fish remains unidentified. It is challenging to identify and quantify arsenic species present in complex sample matrices at very low concentrations. Further research is needed to improve the extraction efficiency, chromatographic resolution, detection sensitivity, and characterization capability.

Aspartame-Sweetened Tap Water: Transformation Products and 2,6-Dichloro-1,4-Benzoquinone Formation

Aspartame (APM), a dipeptide of aspartic acid (ASP) and phenylalanine (PHE), is a widely used artificial sweetener in beverages. It is unclear whether residual chlorine in tap water can react with APM to form disinfection byproducts (DBPs). Therefore, we investigated the formation of DBPs from the reaction of APM with residual chlorine in authentic tap water. APM and a commercial sweetener (CS) packet containing APM were studied under authentic and simulated tap water conditions. Eight chlorinated products of APM were detected using solid-phase extraction (SPE) and high performance liquid chromatography quadrupole time-of-flight mass spectrometry (HPLC-QTOF-MS). These new chloro-products were tentatively identified based on accurate masses, isotopic patterns of 35,37Cl, and MS/MS spectra. Furthermore, we identified APM as a precursor to 2,6-dichloro-1,4-benzoquinone (DCBQ). DCBQ significantly increased to 2.3-12 ng/L with the addition of APM or CS in tap waters collected from different locations compared to 1.4-1.8 ng/L in the same tap water samples without sweetener. DCBQ and two of the chlorinated transformation products were identified in cold prepared tea containing APM. DCBQ formation was eliminated when the residual chlorine in tap water was reduced by ascorbic acid or boiling prior to the addition of APM or CS. This study found that eight new DBPs and DCBQ were produced by the reactions of residual chlorine with APM and CS. These findings show an unintended exposure source of emerging DBPs via APM sweetened beverages.

Emerging Disinfection Byproduct 2,6-Dichlorobenzoquinone-Induced Cardiovascular Developmental Toxicity of Embryonic Zebrafish and Larvae: Imaging and Transcriptome Analysis

Epidemiological studies have observed the potential association of water disinfection byproduct (DBP) exposure with cardiac defects. Aromatic DBPs represent a significant portion of total DBPs, but their effects on cardiovascular development are unclear. In this study, we examined the effects of an aromatic DBP, 2,6-dichlorobenzoquinone (DCBQ), on the cardiovascular development of zebrafish embryos. After exposure to 2, 4, and 8 μM DCBQ, morphological images of growing zebrafish embryos clearly showed cardiovascular malformation. Fluorescent images of transgenic zebrafish strains with fluorescently labeled heart and blood vessels show that DCBQ exposure resulted in deformed atrium-ventricle looping, degenerated abdomen and trunk vessels, pericardial edema, and decreased blood flow. Furthermore, the expression of the marker gene myl7 (essential for the differentiation and motility of cardiomyocytes) was inhibited in a dose-dependent manner by DCBQ exposure. Finally, transcriptome analysis found that in the 4 μM DCBQ exposure group, the numbers of differentially expressed genes (DEGs) were 113 (50 upregulated and 63 downregulated) at 24 hpf, 2123 (762 upregulated and 1361 downregulated) at 48 hpf, and 61 (11 upregulated and 50 downregulated) at 120 hpf; in the 8 μM DCBQ exposure group, the number of DEGs was 1407 (647 upregulated and 760 downregulated) at 120 hpf. The FoxO signaling pathway was significantly altered. The in vivo results demonstrate the effects of 2,6-DCBQ (0-8 μM) on cardiovascular development, contributing to the understanding of the developmental toxicity of aromatic DBP halobenzoquinones (HBQs).

The influence of place on COVID-19 vaccine coverage in Alberta: A multilevel analysis

While there is evidence of urban/rural disparities in COVID-19 vaccination coverage, there is limited data on the influence of other place-based variables. In this cross-sectional study, we analyzed population-based linked administrative health data (publicly-funded health insurance database and province-wide immunization repository) to examine vaccination coverage for 3,945,103 residents aged 12 years and above in Alberta, Canada. We used multilevel logistic regression to examine the association of vaccination coverage with various place-based variables. Furthermore, we combined information on vaccine coverage and neighborhood level COVID-19 risk to categorize forward sortation areas (FSAs) into six categories. After 4 months of widely available COVID-19 vaccine, coverage varied widely between rural and urban areas (58% to 73%) and between geographic health authority zones (55.8% to 72.8%). Residents living in neighborhoods with lower COVID-19 disease incidence had the lowest vaccination coverage (63.2%), while coverage in higher incidence neighborhoods ranged from 68.3% to 71.9%. The multilevel logistic regression model indicated that residence in metro (adjusted odds ratio [aOR] 1.37; 95% CI: 1.31-1.42) and urban areas (aOR 1.11; 95% CI: 1.08-1.14) was associated with higher vaccine coverage than residence in rural areas. Similarly, residence in Edmonton, Calgary, and South health zones was associated with higher vaccine coverage compared to residence in Central zone. Higher income neighborhoods reported higher vaccine coverage than the lowest-income neighborhoods, and the highest COVID-19 risk neighborhoods reported higher vaccine coverage than the lowest risk neighborhoods (aOR 1.52; 95% CI: 1.12-2.05). In the first four months of wider vaccine availability in Alberta, COVID-19 vaccine coverage varied according to various place-based characteristics. Vaccine distribution strategies need to consider place-based variables for program prioritization and delivery.

On-Site Viral Inactivation and RNA Preservation of Gargle and Saliva Samples Combined with Direct Analysis of SARS-CoV-2 RNA on Magnetic Beads

Samples of nasopharyngeal swabs (NPS) are commonly used for the detection of SARS-CoV-2 and diagnosis of COVID-19. As an alternative, self-collection of saliva and gargle samples minimizes transmission to healthcare workers and relieves the pressure of resources and healthcare personnel during the pandemic. This study aimed to develop an enhanced method enabling simultaneous viral inactivation and RNA preservation during on-site self-collection of saliva and gargle samples. Our method involves the addition of saliva or gargle samples to a newly formulated viral inactivation and RNA preservation (VIP) buffer, concentration of the viral RNA on magnetic beads, and detection of SARS-CoV-2 using reverse transcription quantitative polymerase chain reaction directly from the magnetic beads. This method has a limit of detection of 25 RNA copies per 200 μL of gargle or saliva sample and 9-111 times higher sensitivity than the viral RNA preparation kit recommended by the United States Centers for Disease Control and Prevention. The integrated method was successfully used to analyze more than 200 gargle and saliva samples, including the detection of SARS-CoV-2 in 123 gargle and saliva samples collected daily from two NPS-confirmed positive SARS-CoV-2 patients throughout the course of their infection and recovery. The VIP buffer is stable at room temperature for at least 6 months. SARS-CoV-2 RNA (65 copies/200 μL sample) is stable in the VIP buffer at room temperature for at least 3 weeks. The on-site inactivation of SARS-CoV-2 and preservation of the viral RNA enables self-collection of samples, reduces risks associated with SARS-CoV-2 transmission, and maintains the stability of the target analyte.

Wastewater-Based Epidemiology for Community Monitoring of SARS-CoV-2: Progress and Challenges

Wastewater-based epidemiology (WBE) is useful for the surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in communities, complementing clinical diagnostic testing of individuals. In this Review, we summarize recent progress and highlight remaining challenges in monitoring SARS-CoV-2 RNA in wastewater systems for community and environmental surveillance. Very low concentrations of viral particles and RNA present in the complicated wastewater and sewage sample matrix require efficient sample processing and sensitive detection. We discuss advantages and limitations of available methods for wastewater sample processing, including collection, separation, enrichment, RNA extraction, and purification. Efficient extraction of the viral RNA and removal of interfering sample matrices are critical to the subsequent reverse transcription-quantitative polymerase chain reaction (RT-qPCR) for sensitive detection of SARS-CoV-2 in wastewater. We emphasize the importance of implementing appropriate controls and method validation, which include the use of surrogate viruses for assessing extraction efficiency and normalization against measurable chemical and biological components in wastewater. Critical analysis of the published studies reveals imperative research needs for the development, validation, and standardization of robust and sensitive methods for quantitative detection of viral RNA and proteins in wastewater for WBE.

Prioritizing supports and services to help older adults age in place: A Delphi study comparing the perspectives of family/friend care partners and healthcare stakeholders

Background

Aging in place (AIP) is a policy strategy designed to help older adults remain in their community. While planners internationally have modified aspects of the older adult care continuum (e.g., home care, assisted living, nursing homes) to facilitate AIP, further improvements to community-based supports and services are also required. This study compared and constrasted the community-based factors (e.g., supports, services and personal strategies or characteristics) that family/friend care partners and healthcare stakeholders (i.e., planners/providers) view as most important to help older adults successfully AIP.

Methods

An initial list of factors shown to influence AIP was created from the academic literature. These factors were used to develop a Delphi survey implemented separately on care partners and healthcare stakeholders. Respondents rated the importance of each factor using a 10-point Likert Scale (1 = not important; 10 = absolutely critical). Consensus in each group was defined when at least 80% of participants scored a factor ≥8 (“very important”), with an interquartile range ≤2. Respondents suggested additional factors during Delphi round one.

Results

Care partners (N = 25) and healthcare stakeholders (N = 36) completed two and three Delphi rounds, respectively. These groups independently agreed that the following 3 (out of 27) factors were very important to help older adults age in place: keeping one’s home safe, maintaining strong inter-personal relationships, and coordinating care across formal providers. While healthcare stakeholders did not reach consensus on other factors, care partners agreed that 7 additional factors (e.g., access to affordable housing, having mental health programs) were important for AIP.

Conclusions

Compared to healthcare stakeholders, care partners felt that more and diverse community-based factors are important to support older adults to successfully AIP. Future research should replicate these findings in other jurisdictions, examine the availability and accessibility of the priority factors, and develop sustainable solutions to enhance their effectiveness.

Developing key performance indicators for prescription medication systems

OBJECTIVE

To develop key performance indicators that evaluate the effectiveness of a prescription medication system.

METHODS

A modified RAND/UCLA appropriateness method was used to develop key performance indicators (KPIs) for a prescription medication system. A broad list of potential KPIs was compiled. A multidisciplinary group composed of 21 experts rated the potential KPIs. A face-to-face meeting was held following the first rating exercise to discuss each potential KPI individually. The expert panel undertook a final rating of KPIs. The final set of KPIs were those indicators where at least 80 percent of experts rated the indicator highly i.e. rating of ≥ 7 on a scale from 1 to 9.

RESULTS

292 KPIs were identified from the published literature. After removing duplicates and combining similar indicators 71 KPIs were included. The final ranking resulted in six indicators being ranked 7 or higher by 80% of the respondents and an additional seven indicators being ranked 7 or higher by ≥70 but ≤80% of respondents. The six selected indicators include four specific disease areas, measure structural and process aspects of health service delivery, and assessed three of the domains of healthcare quality: efficiency, effectiveness, and safety.

CONCLUSIONS

These indicators are recommended as a starting point to assess the current performance of prescription medication systems. Consideration should be given to developing indicators in additional disease areas as well as indicators that measure the domains of timeliness and patient-centeredness. Future work should focus on the feasibility of measuring these indicators.

Epidemiology of pertussis in Alberta, Canada 2004-2015

BACKGROUND

We describe the epidemiology of pertussis in Alberta, Canada by person, place, and time between 2004 and 2015, identify outbreak years, and examine vaccination coverage and vaccination timeliness.

METHODS

We used health data from Alberta's Communicable Disease Registry System for the period of January 1, 2004 through August 31, 2015 to identify unique cases of pertussis. Unique cases were deterministically linked to data in Alberta's immunization repository and health care insurance plan registry. Population estimates and vaccination coverage were extracted from Alberta's online Interactive Health Data Application. We estimated pertussis incidence rates per 100,000 persons by year, age group, gender, and health zone. Outbreak years were identified using a one-sided cumulative sum (CUSUM) analysis by comparing annual incidence rates to baseline rates.

RESULTS

Over the period, 3510 cases of pertussis were confirmed by laboratory testing or epidemiological linkage. Incidence rates per 100,000 persons were highest in 2004 (20.5), 2005 (13.6), and 2015 (10.4) for all age groups. Incidence rates were highest among the youngest age groups and decreased as age groups increased. Based on CUSUM analysis, 2008 and 2012 met the criteria for outbreak years. Vaccination coverage was over 90% among the general population, however only 61% of cases received at least one dose. About 60% of cases were diagnosed 5+ years after receiving the vaccine. Approximately 87-91% of vaccinated cases did not receive the first three vaccine doses in a timely manner.

CONCLUSION

Pertussis incidence rates fluctuated over the period across all age groups. The majority of cases had no record of vaccination or were delayed in receiving vaccines. CUSUM analysis was an effective method for identifying outbreaks.

Are healthcare aides underused in long-term care? A cross-sectional study on continuing care facilities in Canada

OBJECTIVES

Over the last 10 years, appropriate workforce utilisation has been an important discussion among healthcare practitioners and policy-makers. The role of healthcare aides (HCAs) has also expanded to improve their utilisation. This evolving role of HCAs in Canada has prompted calls for standardised training, education and scope of practice for HCAs. The purpose of this research was to examine the differences in HCAs training and utilisation in continuing care facilities.

DESIGN

From June 2014 to July 2015, we conducted a mixed-method study on HCA utilisation in continuing care. This paper presents findings gathered solely from the prospective cross-sectional survey of continuing care facilities (long-term care (LTC) and supportive living (SL)) on HCA utilisation.

SETTING AND PARTICIPANTS

We conducted this study in a Western Canadian province. The managers of the continuing care facilities (SL and LTC) were eligible to participate in the survey.

PRIMARY OUTCOME MEASURES

The pattern of HCAs involvement in medication assistance and other care activities in SL and LTC facilities.

RESULTS

We received 130 completed surveys (LTC=64 and SL=52). Our findings showed that approximately 81% of HCAs were fully certified. We found variations in how HCAs were used in SL and LTC facilities. Overall, HCAs in SL were more likely to be involved in medication management such as assisting with inhaled medication and oral medication delivery. A significantly larger proportion of survey respondents from SL facilities reported that medication assistance training was mandatory for their HCAs (86%) compared with the LTC facilities (50%) (p value <0.01).

CONCLUSION

The utilisation of HCAs varies widely between SL and LTC facilities. HCAs in SL facilities may be considered better used according to their required educational training and competencies. Expanding the role of HCAs in LTC facilities may lead to a cost-effective and more efficient utilisation of workforce in continuing care facilities.

Variability of staffing and staff mix across acute care units in Alberta, Canada

BACKGROUND

The health workforce has a crucial position in healthcare, and effective distribution of the workforce is one of the critical areas for healthcare improvement. This requires a proper understanding of the allocation of healthcare providers including staffing levels and staffing variability within a healthcare system. High variability may imply significant differences in outcomes and greater opportunity to better distribute staffing and improve patient outcomes. The objective of this study was to examine staffing variation across acute care units in a large and integrated healthcare system.

METHODS

We used survey and administrative data on full time equivalencies of Registered Nurses, Licensed Practical Nurses, Health Care Aides, and allied health staff for 287 acute care units to examine staffing levels across multiple unit types. We used a subsample of 157 units in a more detailed analysis of staffing levels and staff distribution.

RESULTS

Results from the full sample indicate that staffing levels, particularly for Registered Nurses, vary substantially across unit types. Subsample analyses showed that the highest variation in staffing levels occurred in rural units, which also had higher average staffing for licensed practical nurses and allied health staff. Rural units had fewer Health Care Aides than did other units. The majority of units were staffed with a combination of all three nursing providers, but the most common arrangement in rural units was staffing of Registered Nurses and Licensed Practical Nurses only. We also found that units with the highest number Registered Nurses also tended to have higher numbers of other staff, particularly allied health providers.

CONCLUSIONS

We observed significant variation in staffing levels and mix in acute care units. Some of the differences might be attributable to differences in patient needs and unit types. However, we also observed high variability in units with similar services and patient populations. As other research has shown that staffing is linked to differences in patient outcomes, there is an important opportunity to improve staffing for greater efficiency and higher quality care.

Evaluation of the use of oseltamivir prophylaxis in the control of influenza outbreaks in long-term care facilities in Alberta, Canada: a retrospective provincial database analysis

OBJECTIVES

To evaluate the impact of oseltamivir prophylaxis in the management and control of influenza outbreaks in long-term care facilities in Alberta, Canada.

SETTING AND PARTICIPANTS

Long-term care facilities where 127 influenza outbreaks were reported to public health authorities in Alberta, Canada, during two influenza seasons from 2013 to 2015.

DESIGN AND OUTCOME MEASURES

Using routinely collected surveillance and administrative data, we examined the association between decision-making time for oseltamivir recommendation as prophylaxis strategy for influenza outbreaks in long-term care facilities (explanatory variable) and the duration of an influenza outbreak, the postprophylaxis risk of influenza-like illness and hospitalisation among residents of long-term care facilities in Alberta (outcome variables) using multivariable linear and Poisson regression models.

RESULTS

Oseltamivir prophylaxis decision-making time was positively associated with the postintervention duration of an outbreak, with a 1-day delay in making decision on oseltamivir prophylaxis associated with 2.22 (95% CI 1.37 to 3.06) more days of the duration of an outbreak after controlling for potential confounding effect of the number of residents at risk at intervention, outbreak progression time, prevalence of influenza-like illness during outbreak progression, facility location, presence of mixed strain and based on optimal timing of oseltamivir prophylaxis. Although not statistically significant, a 1-day delay in making decision on oseltamivir prophylaxis was associated with a 5% (95% CI -1% to 11%) increase in the postintervention risk of influenza-like illness, and a 6% (95% CI -8% to 22%) increase in the postintervention risk of hospitalisation after controlling for the same potential confounders.

CONCLUSIONS

Our study demonstrated benefits of using oseltamivir prophylaxis to shorten the duration of influenza outbreaks; however, there were no significant differences in the influenza-like illness and hospitalisation risk occurring after the intervention. Surveillance data may offer means of rapid evaluation of oseltamivir prophylaxis in long-term care facilities as a public health measure.

Equity in children's dental caries before and after cessation of community water fluoridation: differential impact by dental insurance status and geographic material deprivation

BACKGROUND

One of the main arguments made in favor of community water fluoridation is that it is equitable in its impact on dental caries (i.e., helps to offset inequities in dental caries). Although an equitable effect of fluoridation has been demonstrated in cross-sectional studies, it has not been studied in the context of cessation of community water fluoridation (CWF). The objective of this study was to compare the socio-economic patterns of children's dental caries (tooth decay) in Calgary, Canada, in 2009/10 when CWF was in place, and in 2013/14, after it had been discontinued.

METHODS

We analyzed data from population-based samples of schoolchildren (grade 2) in 2009/10 and 2013/14. Data on dental caries (decayed, missing, and filled primary and permanent teeth) were gathered via open mouth exams conducted in schools by registered dental hygienists. We examined the association between dental caries and 1) presence/absence of dental insurance and 2) small area index of material deprivation, using Poisson (zero-inflated) and logistic regression, for both time points separately. For small-area material deprivation at each time point, we also computed the concentration index of inequality for each outcome variable.

RESULTS

Statistically significant inequities by dental insurance status and by small area material deprivation were more apparent in 2013/14 than in 2009/10.

CONCLUSIONS

Results are consistent with increasing inequities in dental caries following cessation of CWF. However, further research is needed to 1) confirm the effects in a study that includes a comparison community, and 2) explore possible alternative reasons for the findings, including changes in treatment and preventive programming.