Edible Cannabis Legalization and Cannabis Poisonings in Older Adults

This cross-sectional study examines the association between edible cannabis legalization and emergency department visits for cannabis poisonings in older adults.

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.

The association between frailty, long-term care home characteristics and COVID-19 mortality before and after SARS-CoV-2 vaccination: a retrospective cohort study

BACKGROUND

The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC.

METHODS

We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability.

RESULTS

There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41-1.65) and 1.62 (95% CrI: 1.46-1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42-1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period.

INTERPRETATION

Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.

Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study

BACKGROUND

Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits.

METHODS

This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%).

RESULTS

A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home.

INTERPRETATION

A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.

Variations in long-term care home resident hospitalizations before and during the COVID-19 pandemic in Ontario

OBJECTIVES

To examine how the COVID-19 pandemic affected the demographic and clinical characteristics, in-hospital care, and outcomes of long-term care residents admitted to general medicine wards for non-COVID-19 reasons.

METHODS

We conducted a retrospective cohort study of long-term care residents admitted to general medicine wards, for reasons other than COVID-19, in four hospitals in Toronto, Ontario between January 1, 2018 and December 31, 2020. We used an autoregressive linear model to estimate the change in monthly admission volumes during the pandemic period (March-December 2020) compared to the previous two years, adjusting for any secular trend. We summarized and compared differences in the demographics, comorbidities, interventions, diagnoses, imaging, psychoactive medications, and outcomes of residents before and during the pandemic.

RESULTS

Our study included 2,654 long-term care residents who were hospitalized for non-COVID-19 reasons between January 2018 and December 2020. The crude rate of hospitalizations was 79.3 per month between March-December of 2018-2019 and 56.5 per month between March-December of 2020. The was an adjusted absolute difference of 27.0 (95% CI: 10.0, 43.9) fewer hospital admissions during the pandemic period, corresponding to a relative drop of 34%. Residents admitted during the pandemic period had similar demographics and clinical characteristics but were more likely to be admitted for delirium (pandemic: 7% pre-pandemic: 5%, p = 0.01) and were less likely to be admitted for pneumonia (pandemic: 3% pre-pandemic: 6%, p = 0.004). Residents admitted during the pandemic were more likely to be prescribed antipsychotics (pandemic: 37%, pre-pandemic: 29%, p <0.001) and more likely to die in-hospital (pandemic:14% pre-pandemic: 10%, p = 0.04).

CONCLUSIONS AND IMPLICATIONS

Better integration between long-term care and hospitals systems, including programs to deliver urgent medical care services within long-term care homes, is needed to ensure that long-term care residents maintain equitable access to acute care during current and future public health emergencies.

Physician home visits in Ontario: a cross-sectional analysis of patient characteristics and postvisit use of health care services

BACKGROUND

It is unknown how much of current physician home visit volume is driven by low-complexity or low-continuity visits. Our objectives were to measure physician home visit volumes and costs in Ontario from 2005/06 to 2018/19, and to compare patient characteristics and postvisit use of health care services across home visit types.

METHODS

This was a retrospective cross-sectional study using health administrative data. We examined annual physician home visit volumes and costs from 2005/06 to 2018/19 in Ontario, and characteristics and postvisit use of health care services of residents who received at least 1 home visit from any physician in 2014/15 to 2018/19. We categorized home visits as palliative, provided to a patient who also received home care services or "other," and compared characteristics and outcomes between groups.

RESULTS

A total of 4 418 334 physician home visits were performed between 2005/06 and 2018/19. More than half (2 256 667 [51.1%]) were classified as "other" and accounted for 39.1% ($22 million) of total annual physician billing costs. From 2014/15 to 2018/19, of the 413 057 home visit patients, 240 933 (58.3%) were adults aged 65 or more, and 323 283 (78.3%) lived in large urban areas. Compared to the palliative care and home care groups, the "other" group was younger, had fewer comorbidities, and had lower rates of emergency department visits and hospital admissions in the 30 days after the visit.

INTERPRETATION

About half of physician home visits in 2014/15 to 2018/19 were to patients who were receiving neither palliative care nor home care, a group that was younger and healthier, and had low use of health care services after the visit. There is an opportunity to refine policy tools to target patients most likely to benefit from physician home visits.

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.

Homebound status among older adult home care recipients in Ontario, Canada

BACKGROUND

Homebound status is associated with an increased risk of morbidity and mortality in older adults, yet little is known about homebound older adults in Canada. Our objectives were to describe time trends in the prevalence of homebound status among community-dwelling long-term home care recipients and the characteristics associated with homebound status.

METHODS

This was a retrospective cross-sectional and cohort study using linked health administrative data in Canada's most populous province, Ontario. We included adults aged 65 years and older who received at least one long-term home care assessment from 2006 to 2017 (N = 666,514). Homebound individuals were those who exited the home an average of 0-1 days/week over the previous 30 days; not homebound comparators exited the home 2-7 days per week. We compared baseline characteristics between groups and estimated the association between these characteristics and homebound status at baseline and over time.

RESULTS

From 2006 to 2017, the annual proportion of long-term home care recipients who were homebound increased from 48% to 65%. At first assessment, 50% of the cohort (331,836 of 666,514) were homebound. Among those with a 4-12 month repeat assessment, homebound status persisted over time for 80%, and developed anew in 24%. Dependency on others for locomotion, use of an assistive device, poor access to dwelling, older age, and female sex were most strongly associated with homebound status at baseline, as well as its development and persistence over time.

CONCLUSIONS

We found that half of Ontario older adult long-stay home care clients were homebound at the time of their first assessment, and that the prevalence of homebound status among home care recipients rose steadily from 2006 to 2017. This informs further research and policy development to ensure the adequacy of supports for older homebound persons.

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.

Perspectives on ageing: a qualitative study of the expectations, priorities, needs and values of older people from two Canadian provinces

BACKGROUND

Understanding the needs and values of older people is vital to build responsive policies, services and research agendas in this time of demographic transition. Older peoples' expectations and priorities for ageing, as well as their beliefs regarding challenges facing ageing societies, are multi-faceted and require regular updates as populations' age.

OBJECTIVE

To develop an understanding of self-perceptions of ageing and societal ageing among Canadian retirees of the education sector to define a meaningful health research agenda.

METHODS

We conducted four qualitative focus groups among 27 members of a Canadian retired educators' organisation. Data were analysed using an inductive thematic approach.

RESULTS

We identified four overarching themes: (1) vulnerability to health challenges despite a healthier generation, (2) maintaining health and social connection for optimal ageing, (3) strengthening person-centred healthcare for ageing societies and (4) mobilising a critical mass to enact change. Participants' preconceptions of ageing differed from their personal experiences. They prioritised maintaining health and social connections and felt that current healthcare practices disempowered them to manage and optimise their health. Although the sheer size of their demographic instilled optimism of their potential to garner positive change, participants felt they lacked mechanisms to contribute to developing solutions to address this transition.

CONCLUSION

Our findings suggest a need for health research that improves perceptions of ageing and supports health system transformations to deliver person-centred care. Opportunities exist to harness their activism to engage older people as partners in shaping solution-oriented research that can support planning for an ageing society.

Glycemic Control and Use of High-risk Antihyperglycemic Agents Among Nursing Home Residents With Diabetes in Ontario, Canada

This cohort study examines levels of glycemic control among nursing home residents with diabetes and compares rates of intensive glycemic control with high-risk antihyperglycemic agents across levels of cognitive impairment.

Facteurs de risque d’éclosion de SRAS-CoV-2 dans les résidences pour aînés en Ontario, au Canada: étude de cohorte à l’échelle de la population

CONTEXTE:

L’épidémiologie de l’infection au SRAS-CoV-2 dans les résidences pour aînés (offrant une aide à la vie autonome), est pour une bonne part inconnue. Nous avons étudié le lien entre les caractéristiques des résidences et des communautés avoisinantes et le risque d’éclosion de SRAS-CoV-2 dans les résidences pour aînés depuis le début de la première vague de la pandémie de COVID-19.

MÉTHODES:

Nous avons procédé à une étude de cohorte rétrospective dans la population des résidences pour aînés certifiées en Ontario, au Canada, entre le 1^er mars et le 18 décembre 2020. Notre paramètre principal était toute éclosion de SRAS-CoV-2 (≥ 1 cas confirmé parmi les résidents ou le personnel au moyen d’un test d’amplification des acides nucléiques). Nous avons utilisé la méthode des risques proportionnels avec prédicteurs chronologiques pour modéliser les liens entre les caractéristiques des résidences et des communautés avoisinantes et les éclosions de SRAS-CoV-2.

RÉSULTATS:

Notre cohorte a inclus l’ensemble des 770 résidences privées pour aînés (RPA) certifiées en Ontario qui hébergeaient 56 491 résidents. On a dénombré 273 (35,5 %) résidences pour aînés qui ont connu 1 éclosion de SRAS-CoV-2 ou plus; 1944 résidents (3,5 %) et 1101 employés (3,0 %) ont contracté l’infection. Ces cas étaient inégalement distribués entre les résidences. En effet, 2487 cas parmi les résidents et le personnel (81,7 %) sont survenus dans 77 résidences (10 %). Le rapport de risque ajusté d’une éclosion de SRAS-CoV-2 dans une résidence a été clairement associé aux établissements qui avaient une grande capacité d’accueil, qui comportaient des unités de soins de longue durée, qui appartenaient à de plus grandes bannières et offraient plusieurs services sur place, qui se trouvaient dans des régions marquées par une hausse de l’incidence régionale de SRAS-CoV-2 et où la concentration ethnique à l’échelle de la communauté était supérieure.

INTERPRÉTATION:

Certaines caractéristiques facilement identifiables des résidences pour aînés sont associées de manière indépendante aux éclosions de SRAS-CoV-2 et peuvent faciliter l’évaluation des risques et orienter la priorisation de la vaccination.

Baseline Frailty as a Predictor of Survival After Critical Care: A Retrospective Cohort Study of Older Adults Receiving Home Care in Ontario, Canada

BACKGROUND

The extent to which the degree of baseline frailty, as measured using standardized multidimensional health assessments before hospital admission, predicts survival among older adults after admission to an ICU, remains unclear.

RESEARCH QUESTION

Is baseline frailty an independent predictor of survival among older adults receiving care in an ICU?

STUDY DESIGN AND METHODS

Retrospective cohort study of community-dwelling older adults (age, ≥ 65 years) receiving public home services who were admitted to any ICU in Ontario, Canada, between April 1, 2009, and March 31, 2015. All individuals underwent an inter-Resident Assessment Instrument-Home Care (RAI-HC) assessment completed within 180 days of ICU admission. These assessments were linked to hospital discharge abstract records. Patients were categorized using frailty measures each calculated from the RAI-HC: a classification tree version of the Clinical Frailty Scale; the Frailty Index-Acute Care; and the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. One-year survival models were used to compare their performance. Patients were stratified based on the receipt of mechanical ventilation in the ICU.

RESULTS

Of 24,499 individuals admitted to an ICU within 180 days of a RAI-HC assessment, 26.4% (n = 6,467) received mechanical ventilation. Overall, 43.0% (95% CI, 42.4%-43.6%) survived 365 days after ICU admission. In general, among the overall cohort and both mechanical ventilation subgroups, mortality hazards increased with the severity of baseline frailty. Models predicting survival 30, 90, and 365 days after admission to an ICU that adjusted for one of the frailty measures were more discriminant than reference models that adjusted only for age, sex, major clinical category, and area income quintile.

INTERPRETATION

Severity of baseline frailty is associated independently with survival after ICU admission and should be considered when determining goals of care and treatment plans for people with critical illness.

Écart de mobilité : estimation des seuils de mobilité requis pour maîtriser le SRAS-CoV-2 au Canada

CONTEXTE:

Les interventions non pharmacologiques demeurent le principal moyen de maîtriser le coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) d’ici à ce que la couverture vaccinale soit suffisante pour donner lieu à une immunité collective. Nous avons utilisé des données de mobilité anonymisées de téléphones intelligents afin de quantifier le niveau de mobilité requis pour maîtriser le SRAS-CoV-2 (c.-à-d., seuil de mobilité), et la différence par rapport au niveau de mobilité observé (c.-à-d., écart de mobilité).

MÉTHODES:

Nous avons procédé à une analyse de séries chronologiques sur l’incidence hebdomadaire du SRAS-CoV-2 au Canada entre le 15 mars 2020 et le 6 mars 2021. Le paramètre mesuré était le taux de croissance hebdomadaire, défini comme le rapport entre les cas d’une semaine donnée et ceux de la semaine précédente. Nous avons mesuré les effets du temps moyen passé hors domicile au cours des 3 semaines précédentes à l’aide d’un modèle de régression log-normal, en tenant compte de la province, de la semaine et de la température moyenne. Nous avons calculé le seuil de mobilité et l’écart de mobilité pour le SRAS-CoV-2.

RÉSULTATS:

Au cours des 51 semaines de l’étude, en tout, 888 751 personnes ont contracté le SRAS-CoV-2. Chaque augmentation de 10 % de l’écart de mobilité a été associée à une augmentation de 25 % du taux de croissance des cas hebdomadaires de SRAS-CoV-2 (rapport 1,25, intervalle de confiance à 95 % 1,20–1,29). Comparativement à la mobilité prépandémique de référence de 100 %, le seuil de mobilité a été plus élevé au cours de l’été (69 %, écart interquartile [EI] 67 %–70 %), et a chuté à 54 % pendant l’hiver 2021 (EI 52 %–55 %); un écart de mobilité a été observé au Canada entre juillet 2020 et la dernière semaine de décembre 2020.

INTERPRÉTATION:

La mobilité permet de prédire avec fiabilité et constance la croissance des cas hebdomadaires et il faut maintenir des niveaux faibles de mobilité pour maîtriser le SRAS-CoV-2 jusqu’à la fin du printemps 2021. Les données de mobilité anonymisées des téléphones intelligents peuvent servir à guider le relâchement ou le resserrement des mesures de distanciation physique provinciales et régionales.

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain

BACKGROUND/OBJECTIVES

Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic-induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 260,344 community-dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019.

MEASUREMENTS

Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow-up among older adults prescribed gabapentin relative to those who were not.

RESULTS

Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages.

CONCLUSIONS

We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population-based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events.

Assessment of Psychotropic Drug Prescribing Among Nursing Home Residents in Ontario, Canada, During the COVID-19 Pandemic

This cross-sectional study uses data from the Ontario Drug Benefit database to assess prescribing patterns of psychotropic drugs among nursing home residents in Ontario, Canada during the coronavirus disease 2019 pandemic.

Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario, Canada: a population-level cohort study

BACKGROUND:

The epidemiology of SARS-CoV-2 infection in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between home-and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection in retirement homes since the beginning of the first wave of the COVID-19 pandemic.

METHODS:

We conducted a population-based, retrospective cohort study of licensed retirement homes in Ontario, Canada, from Mar. 1 to Dec. 18, 2020. Our primary outcome was an outbreak of SARS-CoV-2 infection (≥ 1 resident or staff case confirmed by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home– and community-level characteristics and outbreaks of SARS-CoV-2 infection.

RESULTS:

Our cohort included all 770 licensed retirement homes in Ontario, which housed 56 491 residents. There were 273 (35.5%) retirement homes with 1 or more outbreaks of SARS-CoV-2 infection, involving 1944 (3.5%) residents and 1101 staff (3.0%). Cases of SARS-CoV-2 infection were distributed unevenly across retirement homes, with 2487 (81.7%) resident and staff cases occurring in 77 (10%) homes. The adjusted hazard of an outbreak of SARS-CoV-2 infection in a retirement home was positively associated with homes that had a large resident capacity, were co-located with a long-term care facility, were part of larger chains, offered many services onsite, saw increases in regional incidence of SARS-CoV-2 infection, and were located in a region with a higher community-level ethnic concentration.

INTERPRETATION:

Readily identifiable characteristics of retirement homes are independently associated with outbreaks of SARS-CoV-2 infection and can support risk identification and priority for vaccination.

The mobility gap: estimating mobility thresholds required to control SARS-CoV-2 in Canada

BACKGROUND

Nonpharmaceutical interventions remain the primary means of controlling severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) until vaccination coverage is sufficient to achieve herd immunity. We used anonymized smartphone mobility measures to quantify the mobility level needed to control SARS-CoV-2 (i.e., mobility threshold), and the difference relative to the observed mobility level (i.e., mobility gap).

METHODS

We conducted a time-series study of the weekly incidence of SARS-CoV-2 in Canada from Mar. 15, 2020, to Mar. 6, 2021. The outcome was weekly growth rate, defined as the ratio of cases in a given week versus the previous week. We evaluated the effects of average time spent outside the home in the previous 3 weeks using a log-normal regression model, accounting for province, week and mean temperature. We calculated the SARS-CoV-2 mobility threshold and gap.

RESULTS

Across the 51-week study period, a total of 888 751 people were infected with SARS-CoV-2. Each 10% increase in the mobility gap was associated with a 25% increase in the SARS-CoV-2 weekly case growth rate (ratio 1.25, 95% confidence interval 1.20-1.29). Compared to the prepandemic baseline mobility of 100%, the mobility threshold was highest in the summer (69%; interquartile range [IQR] 67%-70%), and dropped to 54% in winter 2021 (IQR 52%-55%); a mobility gap was present in Canada from July 2020 until the last week of December 2020.

INTERPRETATION

Mobility strongly and consistently predicts weekly case growth, and low levels of mobility are needed to control SARS-CoV-2 through spring 2021. Mobility measures from anonymized smartphone data can be used to guide provincial and regional loosening and tightening of physical distancing measures.

Loneliness among older adults in the community during COVID-19: a cross-sectional survey in Canada

OBJECTIVE

Physical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those living alone. Our aim was to characterise the extent of loneliness during the first wave in a sample of older adults living in the community and assess characteristics associated with loneliness.

DESIGN

Online cross-sectional survey between 6 May and 19 May 2020.

SETTING

Ontario, Canada.

PARTICIPANTS

Convenience sample of members of a national retired educators' organisation.

PRIMARY OUTCOME MEASURES

Self-reported loneliness, including differences between women and men.

RESULTS

4879 respondents (71.0% women; 67.4% 65-79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% who felt lonely always or often. Women had increased odds of loneliness compared with men, whether living alone (adjusted OR (aOR) 1.52, 95% CI 1.13 to 2.04) or with others (2.44, 95% CI 2.04 to 2.92). Increasing age group decreased the odds of loneliness (aOR 0.69 (95% CI 0.59 to 0.81) 65-79 years and 0.50 (95% CI 0.39 to 0.65) 80+ years compared with <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26, 95% CI 3.15 to 5.76) than women (aOR 2.65, 95% CI 2.26 to 3.11). Other factors associated with loneliness included: fair or poor health (aOR 1.93, 95% CI 1.54 to 2.41), being a caregiver (aOR 1.18, 95% CI 1.02 to 1.37), receiving care (aOR 1.47, 95% CI 1.19 to 1.81), high concern for the pandemic (aOR 1.55, 95% CI 1.31 to 1.84), not experiencing positive effects of pandemic distancing measures (aOR 1.94, 95% CI 1.62 to 2.32) and changes to daily routine (aOR 2.81, 95% CI 1.96 to 4.03).

CONCLUSIONS

While many older adults reported feeling lonely during COVID-19, several characteristics-such as being female and living alone-increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness.

Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

IMPORTANCE

Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.

OBJECTIVE

To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.

EXPOSURES

The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.

MAIN OUTCOMES AND MEASURES

The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.

RESULTS

Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).

CONCLUSIONS AND RELEVANCE

In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

Importance

Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.

Objective

To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.

Design, Setting, and Participants

This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.

Exposures

The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.

Main Outcomes and Measures

The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.

Results

Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).

Conclusions and Relevance

In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.

Impact of a Public Policy Restricting Staff Mobility Between Nursing Homes in Ontario, Canada During the COVID-19 Pandemic

OBJECTIVES

To assess changes in the mobility of staff between nursing homes in Ontario, Canada, before and after enactment of public policy restricting staff from working at multiple homes.

DESIGN

Pre-post observational study.

SETTING AND PARTICIPANTS

623 nursing homes in Ontario, Canada, between March 2020 and June 2020.

METHODS

We used GPS location data from mobile devices to approximate connectivity between all 623 nursing homes in Ontario during the 7 weeks before (March 1-April 21) and after (April 22-June 13) the policy restricting staff movement was implemented. We constructed a network diagram visualizing connectivity between nursing homes in Ontario and calculated the number of homes that had a connection with another nursing home and the average number of connections per home in each period. We calculated the relative difference in these mobility metrics between the 2 time periods and compared within-home changes using McNemar test and the Wilcoxon rank-sum test.

RESULTS

In the period preceding restrictions, 266 (42.7%) nursing homes had a connection with at least 1 other home, compared with 79 (12.7%) homes during the period after restrictions, a drop of 70.3% (P < .001). Including all homes, the average number of connections in the before period was 3.90 compared to 0.77 in the after period, a drop of 80.3% (P < .001). In both periods, mobility between nursing homes was higher in homes located in larger communities, those with higher bed counts, and those part of a large chain.

CONCLUSIONS AND IMPLICATIONS

Mobility between nursing homes in Ontario fell sharply after an emergency order by the Ontario government limiting long-term care staff to a single home, though some mobility persisted. Reducing this residual mobility should be a focus of efforts to reduce risk within the long-term care sector during the COVID-19 pandemic.

Recommendations for Welcoming Back Nursing Home Visitors During the COVID-19 Pandemic: Results of a Delphi Panel

OBJECTIVES

Nursing homes became epicenters of COVID-19 in the spring of 2020. Due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. Six months into the COVID-19 pandemic, these largely remain in place. The objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors.

DESIGN

A modified 2-step Delphi process was used to generate consensus statements.

SETTING AND PARTICIPANTS

The Delphi panel consisted of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy.

METHODS

State and federal reopening statements were collected in June 2020 and the panel voted on these using a 3-point Likert scale with consensus defined as ≥80% of panel members voting "Agree." The consensus statements then informed development of the visitor guidance statements.

RESULTS

The Delphi process yielded 77 consensus statements. Regarding visitor guidance, the panel made 5 strong recommendations: (1) maintain strong infection prevention and control precautions, (2) facilitate indoor and outdoor visits, (3) allow limited physical contact with appropriate precautions, (4) assess individual residents' care preferences and level of risk tolerance, and (5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial well-being of residents.

CONCLUSIONS AND IMPLICATIONS

The COVID-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. In the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. The results of this evidence-based Delphi process will help guide policy decisions as well as inform future research.

Risque d’éclosions de COVID-19 et de décès de résidents dans les foyers de soins de longue durée à but lucratif

CONTEXTE:

Les foyers de soins de longue durée (SLD) ont jusqu’à présent été l’épicentre de la pandémie de maladie à coronavirus 2019 (COVID-19) au Canada. Selon des études antérieures, les soins offerts dans les foyers de SLD à but lucratif sont de qualité inférieure pour toute une gamme d’indicateurs de résultats et de processus, ce qui soulève la question suivante: les conséquences de la COVID-19 ont-elles été pires dans les foyers à but lucratif que dans ceux à but non lucratif?

MÉTHODES:

Une étude de cohorte rétrospective basée sur l’ensemble des foyers de SLD en Ontario a été menée pour la période du 29 mars au 20 mai 2020 à partir de la base de données sur les éclosions de COVID-19 alimentée par le ministère des Soins de longue durée de l’Ontario. Des méthodes logistiques hiérarchiques et basées sur des données de comptage ont été utilisées pour modéliser les associations entre le statut financier des foyers de SLD (à but lucratif, à but non lucratif ou municipal) et les éclosions de COVID-19 dans ces derniers, l’ampleur des éclosions (nombre de résidents infectés) et le nombre de décès de résidents attribuables à la COVID-19.

RÉSULTATS:

L’analyse portait sur les 623 foyers de SLD de l’Ontario, qui comptent 75 676 résidents. Parmi ces foyers, 360 (57,7 %) sont à but lucratif; 162 (26,0 %) sont à but non lucratif; et 101 (16,2 %) sont des foyers municipaux. Au total, 190 (30,5 %) éclosions de COVID-19 ont été enregistrées dans des foyers de SLD. Elles ont touché 5218 résidents et entraîné 1452 décès, ce qui représente un taux de létalité général de 27,8 %. Les probabilités d’une éclosion dans un foyer ont été associées à l’incidence de la COVID-19 dans la circonscription sanitaire entourant celui-ci (rapport de cotes [RC] ajusté 1,91; intervalle de confiance [IC] à 95 % 1,19–3,05), au nombre de résidents dans l’établissement (RC ajusté 1,38; IC à 95 % 1,18–1,61) et à l’application des anciennes normes d’aménagement (RC ajusté 1,55; IC à 95 % 1,01–2,38), mais pas au statut financier d’un foyer. Comparativement au statut « à but non lucratif », le statut « à but lucratif » a été associé à l’ampleur d’une éclosion dans un foyer de SLD (risque relatif [RR] 1,96; IC à 95 % 1,26–3,05) ainsi qu’au nombre de décès de résidents (RR ajusté 1,78; IC à 95 % 1,03–3,07). Ces associations s’expliquent par une plus grande prévalence des anciennes normes d’aménagement dans les foyers de SLD à but lucratif ainsi qu’à l’appartenance à une chaîne de propriétés.

INTERPRÉTATION:

Le statut « à but lucratif » est associé à l’ampleur d’une éclosion de COVID-19 et au nombre de décès de résidents dans un foyer de SLD, mais pas au risque d’éclosion. Deux principaux facteurs expliquent les différences entre les foyers à but lucratif et non lucratif, soit l’application des anciennes normes d’aménagement et l’appartenance à une chaîne de propriétés. Ceux-ci devraient être au coeur des futures mesures et politiques de lutte contre les infections.

Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis

IMPORTANCE

The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear.

OBJECTIVE

To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020.

STUDY SELECTION

Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points).

RESULTS

Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), -0.12; [95% CI, -0.20 to -0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, -1.6 [95% CI, -2.6 to -0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, -0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, -6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, -0.09 to 0.23]; I2 = 68%).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

Web and phone-based COVID-19 syndromic surveillance in Canada: A cross-sectional study

BACKGROUND

Syndromic surveillance through web or phone-based polling has been used to track the course of infectious diseases worldwide. Our study objective was to describe the characteristics, symptoms, and self-reported testing rates of respondents in three different COVID-19 symptom surveys in Canada.

METHODS

This was a cross-sectional study using three distinct Canada-wide web-based surveys, and phone polling in Ontario. All three sources contained self-reported information on COVID-19 symptoms and testing. In addition to describing respondent characteristics, we examined symptom frequency and the testing rate among the symptomatic, as well as rates of symptoms and testing across respondent groups.

RESULTS

We found that over March- April 2020, 1.6% of respondents experienced a symptom on the day of their survey, 15% of Ontario households had a symptom in the previous week, and 44% of Canada-wide respondents had a symptom in the previous month. Across the three surveys, SARS-CoV-2-testing was reported in 2-9% of symptomatic responses. Women, younger and middle-aged adults (versus older adults) and Indigenous/First nations/Inuit/Métis were more likely to report at least one symptom, and visible minorities were more likely to report the combination of fever with cough or shortness of breath.

INTERPRETATION

The low rate of testing among those reporting symptoms suggests significant opportunity to expand testing among community-dwelling residents of Canada. Syndromic surveillance data can supplement public health reports and provide much-needed context to gauge the adequacy of SARS-CoV-2 testing rates.

Health Forums and Twitter for Dementia Research: Opportunities and Considerations

BACKGROUND/OBJECTIVES

Social media platforms are promising sources for large quantities of participant-driven research data and circumvent some common challenges when conducting dementia research. This study provides a summary of key considerations and recommendations about using these platforms as research tools for dementia.

DESIGN

Mixed methods.

SETTING

Alzheimer's Society's online Dementia Talking Point forum from inception to April 17, 2018, and Twitter in February and March 2018.

PARTICIPANTS

All users of Dementia Talking Point who posted in subforums labeled "I have dementia" and "I care for a person with dementia," and Twitter users whose posts contained the keywords "dementia," "Alzheimer," or "Alzheimer's."

MEASUREMENTS

We quantified the average daily number of dementia-related posts on each platform and number of words per post. Guided by a codebook, we conducted thematic content analysis of 5% of the 15,513 posts collected from Dementia Talking Point, and 10% of the 25,948 comprehensible posts from Twitter containing "dementia," "Alzheimer," or "Alzheimer's." We also summarized research-relevant characteristics inherent to platforms and posts.

RESULTS

On average, Dementia Talking Point provided less than two new daily dementia-related posts with 213.5 to 241.5 words, compared with 7,883 new daily Twitter posts with 14.5 words. Persons with dementia (PWDs) commonly shared dementia-related concerns (75.7%), experiences (68.6%), and requests for, as well as offers of, information and support (44.3% and 38.6%, respectively). Caregivers commonly shared caregiving experience (67.0%) and requests for information and support (52.5%). Most common dementia-related Twitter posts were derogatory use of the term dementia (14.5%), advocacy, fundraising, and awareness (11.6%), and research dissemination (8.0%). Recommendations about these platforms' unique technical and ethical considerations are outlined.

CONCLUSIONS

Understanding the priorities of PWDs and their caregivers remains important to understand how clinicians can best support them. This study will help clinicians and researcher to better leverage online health forums and Twitter for such dementia-related information.

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths

BACKGROUND

Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes.

METHODS

We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19.

RESULTS

The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership.

INTERPRETATION

For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

Finding the Right Balance: An Evidence-Informed Guidance Document to Support the Re-Opening of Canadian Nursing Homes to Family Caregivers and Visitors during the Coronavirus Disease 2019 Pandemic

During the first few months of the coronavirus disease 2019 (COVID-19) pandemic, Canadian nursing homes implemented strict no-visitor policies to reduce the risk of introducing COVID-19 in these settings. There are now growing concerns that the risks associated with restricted access to family caregivers and visitors have started to outweigh the potential benefits associated with preventing COVID-19 infections. Many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. As Canada emerges from its first wave of the pandemic, nursing homes across the country have cautiously started to reopen these settings, yet there is broad criticism that emerging visitor policies are overly restrictive, inequitable, and potentially harmful. We reviewed the nursing home visitor policies for Canada's 10 provinces and 3 territories as well as international policies and reports on the topic to develop 10 provi-informed, data-driven, and expert-reviewed guidance for the re-opening of Canadian nursing homes to family caregivers and visitors.