Background: Comprehensive diagnostic imaging referral guidelines are an important tool to assist referring clinicians and radiologists in determining the safest and best-clinical-value diagnostic imaging study for their patients; the Canadian Association of Radiologists (CAR) last produced its diagnostic imaging referral guidelines in 2012. In partnership with several national organizations, referring clinicians, radiologists, and patient and family advisors from across Canada, the association is redoing its referral guidelines using a new methodology for guideline development, and these guideline recommendations will be suited for integration into clinical decision support systems. Methods: Expert panels of radiologists, referring clinicians and a patient advisor will work with epidemiologists at the CAR to create guidelines across 13 clinical sections. The expert panel for each section will first create a comprehensive list of clinical and diagnostic scenarios to include in the guidelines. Canadian Association of Radiologists epidemiologists will then conduct a systematic rapid scoping review to identify systematically produced guidelines from other guideline groups. The corresponding expert panel will develop diagnostic imaging recommendations for each clinical and diagnostic scenario using the recommendations identified from the scoping review and contextualize them to the Canadian health care systems. The expert panels will accomplish this using an adapted Grading of Recommendations Assessment, Development and Evaluation framework, which reflects the benefits and harms, values and preferences, equity, accessibility, resources and cost. Interpretation: Freely available, up-to-date, comprehensive Canadian-specific diagnostic imaging referral guidelines are needed. A transparent and structured guideline-development approach will aid the CAR and its partners in producing guidelines across its 13 sections.
Canadian immunization programs for rotavirus started in 2011. We sought to determine their effect on the burden of community-acquired admissions and hospital-acquired rotavirus at pediatric hospitals.The Canadian Immunization Monitoring Program Active (IMPACT) network conducted active surveillance for rotavirus-positive hospital admissions between 2005 and 2020 at 12 pediatric hospitals. We used yearly rates of community-acquired rotavirus per 10 000 admissions and hospital-acquired rotavirus infections per 1000 patient-days to determine changes in the pre- and post-vaccine program periods.During the 15-year study period, 5691 rotavirus hospital admissions and hospital-acquired infections were detected, including 4323 (76%) community-acquired infections and 1368 (24%) hospital-acquired infections. The average community-acquired rate in the pre-vaccine period was 60.3 (95% confidence interval [CI] 53.7-68.3) per 10 000 admissions, with a decline to 11.0 (95% CI 7.5-15.1) per 10 000 admissions in the post-vaccine period, resulting in an average reduction of 81.7% (95% CI 74.4%-87.8%). The rate of hospital-acquired rotavirus declined from 0.35 (95% CI 0.29-0.41) per 1000 patient-days in the pre-vaccine period to 0.05 (95% CI 0.03-0.07) per 1000 patient-days in the post-vaccine period, resulting in an 85.3% (95% CI 77.7%-91.9%) average decline. Herd protection was present among children aged 2-16 years.Although start dates of rotavirus vaccine programs across provinces varied, there was around an 80% average decrease in both community-acquired and hospital-acquired rotavirus infections at pediatric hospitals in Canada in the 1- to 9-year interval after implementation of rotavirus vaccine programs. Herd protection is an important aspect of rotavirus vaccines for other children who are not vaccine eligible, and rotavirus vaccines continue to provide important benefits both for children and health care systems.
BACKGROUND:Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care. METHODS:Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models. RESULTS:Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16). INTERPRETATION:Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.
BACKGROUND:Poisoning, from substances such as illicit drugs, prescribed and over-the-counter medications, alcohol, pesticides, gases and household cleaners, is the leading cause of injury-related death and the second leading cause for injury-related hospital admission in British Columbia. We examined the health and economic costs of poisoning in BC for 2016, using a societal perspective, to support public health policies aimed at minimizing losses to society.METHODS:Costs by intent, sex and age group were calculated in Canadian dollars using a classification and costing framework based on existing provincial injury data combined with data from the published literature. Direct cost components included fatal poisonings, hospital admissions, emergency department visits, ambulance attendance without transfer to hospital and calls to the British Columbia Drug and Poison Information Centre (BC DPIC) not resulting in ambulance attendance, emergency care or transfer to hospital. Indirect costs, measured as loss of earnings and informal caregiving costs, were also calculated.RESULTS:We estimate that poisonings in BC totalled $812.5 million in 2016 with $108.9 million in direct health care costs and $703.6 million in indirect costs. Unintentional poisoning injuries accounted for 84% of total costs, 46% of direct costs and 89% of indirect costs. Males accounted for higher proportions of direct costs for all patient dispositions except hospital admissions. Patients aged 25-64 years accounted for higher proportions of direct costs except for calls to BC DPIC, where proportions were highest for children younger than 15 years.INTERPRETATION:Hospital care expenditures represented the largest direct cost of poisoning, and lost productivity following death represented the largest indirect cost. Quantifying and understanding the financial burden of poisoning has implications not only for government and health care, but also for society, employers, patients and families.
Background: Endometriosis, a prevalent condition among females of reproductive age, may be associated with increased risk of cardiovascular disease (CVD) through chronic inflammation and early menopause. The objective of this study was to estimate the association between endometriosis and subsequent risk of CVD. Methods: We conducted a population-based cohort study using administrative health data from Ontario residents from 1993 to 2015. We compared the incidence of CVD and cardiovascular health outcomes between females with endometriosis and 2 age-matched females without endometriosis. The primary outcome was hospital admission for CVD. Secondary outcomes included in-hospital CVD events of interest and emergency department visits for CVD. We used Cox proportional hazards models to estimate adjusted hazard ratios (HRs) between endometriosis and CVD events. Results: We identified 166 835 eligible patients with endometriosis and matched 333 706 patients without endometriosis. The mean age of those with endometriosis was 36.4 years. Patients with endometriosis had a higher incidence of hospital admission for CVD (195 admissions/100 000 person-years) compared with those without endometriosis (163 admissions/100 000 person-years). Similarly, the incidence of secondary CVD events was slightly higher among patients with endometriosis (292 cases/100 000 person-years) than among those without endometriosis (224 cases/100 000 person-years). Females with endometriosis had an increased risk of hospital admission (adjusted HR 1.14, 95% confidence interval [CI] 1.10–1.19) and secondary CVD events (adjusted HR 1.26, 95% CI 1.23–1.30). Interpretation: In this large, population-based study, endometriosis was associated with a small increased risk of CVD events. Future studies need to investigate potential etiological mechanisms and strategies to decrease long-term CVD risk in patients with endometriosis.
Background: Racial and ethnic disparities in COVID-19 vaccination coverage have been observed in Canada and in other countries. We aimed to compare vaccination coverage for at least 1 dose of a COVID-19 vaccine between First Nations people living off reserve and Métis, Black, Arab, Chinese, South Asian and White people. Methods: We used data collected between June 2021 and June 2022 by Statistics Canada’s Canadian Community Health Survey, a large, nationally representative cross-sectional study. The analysis included 64 722 participants aged 18 years or older from the 10 provinces. We used a multiple logistic regression model to determine associations between vaccination status and race, controlling for collection period, region of residence, age, gender and education. Results: Nonvaccination against COVID-19 was more frequent in off-reserve First Nations people (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.2–2.7) and Black people (adjusted OR 1.7, 95% CI 1.1–2.6), and less frequent among South Asian people (adjusted OR 0.3, 95% CI 0.1–0.7) compared to White people. Interpretation: This analysis showed significant inequalities in COVID-19 vaccine uptake between racial/ethnic populations in Canada. Further research is needed to understand the sociocultural, structural and systemic facilitators of and barriers to vaccination across racial groups, and to identify strategies that may improve vaccination uptake among First Nations and Black people.
BACKGROUND:Although research briefly mentions that family members have encountered unexpected experiences during the medical assistance in dying (MAiD) process, from keeping MAiD a secret, to being judged and feeling guilty, the potential implications of these are less understood. This study's aim was to examine guilt, judgment and secrecy as part of the MAiD experiences of family members in Canada.METHODS:We conducted a qualitative descriptive study with 1-hour semistructured interviews by telephone or video from December 2020 to December 2021. Through local and national organizations, we recruited Canadian family members with MAiD experience. A subset analysis of unexpected experiences was conducted, which identified 3 categories: guilt, judgment and secrecy. Similar codes were grouped together within each category into themes. Participants were sent the draft manuscript and their suggestions were integrated.RESULTS:A total of 45 family members from 6 provinces who experienced MAiD from 2016 to 2021 participated. Many people who had MAiD were diagnosed with cancer, comorbidities or neurologic disease. Some participants unexpectedly found themselves managing guilt, judgment and/or secrecy, which may complicate their grieving and bereavement. Numerous participants experienced judgment from relatives, friends, religious people and/or health care professionals. Many kept MAiD secret because they were not allowed to tell or for religious reasons, and/or selectively told others.INTERPRETATION:Family members said they were ill-prepared to manage their experiences of guilt, judgment and secrecy during the MAiD process. MAiD programs and assessors/providers could provide family-specific information to help lessen these burdens and better prepare relatives for common, yet unexpected, experiences they may encounter.
Background: Public health guidelines for chlamydia testing are not sex specific, but young females test at a disproportionally higher rate than males and other age groups. This study aims to describe testing trends across age and sex subgroups, then estimate a test-adjusted incidence of chlamydia in these subgroups to identify gaps in current testing practices. Methods: We used a population-based study to examine observed chlamydia rates by age and sex subgroups: 15–19 years, 20–29 years, 30–39 years and older than 40 years. The study included diagnostic test results recorded by Public Health Ontario Laboratories between Jan. 1, 2010, and Dec. 31, 2018, for individuals living in Peel region, Ontario. We then employed meta-regression models as a method of standardization to estimate the effect of sex and age on standardized morbidity ratio, testing ratio and test positivity, then calculate a test-adjusted incidence of chlamydia for each subgroup. Results: Over the study period, infection, testing and test positivity varied across age and sex subgroups. Observed incidence and testing were highest in females aged 20–29 years, whereas males had the highest standardized test positivity across all age groups. After estimating test-adjusted incidence for each age–sex subgroup, males in the 15–19-year and 30–39-year age groups had an increase in incidence of 60.2% and 9.7%, respectively, compared with the observed incidence. Interpretation: We found that estimated test-adjusted incidence was higher than observed incidence in males aged 15–19 years and 30–39 years. This suggests that infections in males are likely being missed owing to differential testing, and this may be contributing to the persistent increase in reported cases in Canada. Public health programming that targets males, especially in high-risk settings and communities, and use of innovative partner notification methods could be critical to curbing overall rates of chlamydia.
BACKGROUND:Addressing the risk of people from gender and sexual minority (GSM) groups experiencing inequities throughout the cancer continuum requires a robust evidence base. In this scoping review, we aim to map the literature on cancer outcomes among adults from GSM groups and the factors that influence them along the cancer continuum. METHODS:This mixed-methods scoping review will follow the approach outlined by JBI. We will systematically search electronic databases for literature in collaboration with a health sciences librarian. Two reviewers will screen titles and abstracts to determine eligibility based on inclusion criteria, and then retrieve full text articles for data extraction. Results will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Quantitative data will be qualitized through a narrative interpretation and pooled with qualitative data. We will use meta-aggregation to synthesize findings. This protocol was developed in collaboration with GSM patient and public advisors. We will engage people from GSM groups, community organizations and knowledge users in disseminating results. INTERPRETATION:This review will direct future research efforts by expanding the wider body of research examining cancer disparities across the cancer continuum that GSM groups experience, identifying literature gaps and limitations, and highlighting relevant social determinants of health that influence cancer outcomes for adults from GSM groups.
BACKGROUND:Little is understood of the consequences of restrictive visitor policies that were implemented in hospitals to minimize risk of infection during the COVID-19 pandemic. The objective of this study was to describe physician experiences with these policies and reflections of their effects.METHODS:We conducted semistructured phone interviews from September 2020 to March 2021 with physicians practising in Ontario hospitals, recruited via professional networks and snowball sampling. We audio-recorded, transcribed and analyzed interviews to describe and interpret overarching themes by thematic analysis.RESULTS:We interviewed 21 physicians (5 intensivists, 5 internists, 11 specialists in palliative care). Four main thematic categories emerged, including provider, system, patient and caregiver effects. Provider-related factors included increased time and effort on communication with a need to establish limits; increased effort to develop rapport with caregivers; lack of caregiver input on patient care; the need to act as a caregiver surrogate; and the emotional toll of being a gatekeeper or advocate for visitors, exacerbated by lack of evidence for restrictions and inconsistent enforcement. System effects included the avoidance of hospital admission and decreased length of stay, leading to readmissions, increased deaths at home and avoidance of transfer to other facilities with similar policies. Patient-related factors included isolation and dying alone; lack of caregiver advocacy; and prioritization of visitor presence that, at times, resulted in a delay or withdrawal of aspects of care. Caregiver-related factors included inability to personally assess patient health, leading to poor understanding of patient status and challenging decision-making; perceived inadequate communication; difficulty accessing caregiver supports; and increased risk of complicated grief. Participants highlighted a disproportionate effect on older adults and people who did not speak English.INTERPRETATION:Our study highlights substantial negative consequences of restrictive visitor policies, with heightened effects on older adults and people who did not speak English. Research is required to identify whether the benefits of visitor restrictions on infection control outweigh the numerous deleterious consequences to patients, families and care providers.
BACKGROUND:Since the onset of the COVID-19 pandemic, there has been concern about the impact of SARS-CoV-2 infection among individuals with mental illnesses. We analyzed the SARS-CoV-2 vaccination status of Ontarians with and without a history of mental illness.METHODS:We conducted a population-based cross-sectional study of all community-dwelling Ontario residents aged 19 years and older as of Sept. 17, 2021. We used health administrative data to categorize Ontario residents with a mental disorder (anxiety, mood, substance use, psychotic or other disorder) within the previous 5 years. Vaccine receipt as of Sept. 17, 2021, was compared between individuals with and without a history of mental illness.RESULTS:Our sample included 11 900 868 adult Ontario residents. The proportion of individuals not fully vaccinated (2 doses) was higher among those with substance use disorders (37.7%) or psychotic disorders (32.6%) than among those with no mental disorders (22.9%), whereas there were similar proportions among those with anxiety disorders (23.5%), mood disorders (21.5%) and other disorders (22.1%). After adjustment for age, sex, neighbourhood income and homelessness, individuals with psychotic disorders (adjusted prevalence ratio 1.19, 95% confidence interval [CI] 1.18-1.20) and substance use disorders (adjusted prevalence ratio 1.35, 95% CI 1.34-1.35) were more likely to be partially vaccinated or unvaccinated relative to individuals with no mental disorders.INTERPRETATION:Our study found that psychotic disorders and substance use disorders were associated with an increased prevalence of being less than fully vaccinated. Efforts to ensure such individuals have access to vaccinations, while challenging, are critical to ensuring the ongoing risks of death and other adverse consequences of SARS-CoV-2 infection are mitigated in this high-risk population.
BACKGROUND:Accurate coding of diagnoses of SARS-CoV-2 infection in administrative data benefits population-based studies about the epidemiology, treatment and outcomes of COVID-19. We describe the validity of diagnoses of SARS-CoV-2 infection recorded in hospital discharge abstracts, emergency department records and outpatient physician service claims from 3 Canadian provinces. METHODS:In this cohort study, population-based inpatient, emergency department and outpatient records were linked to SARS-CoV-2 polymerase chain reaction (PCR; reference standard) test results from British Columbia, Manitoba and Ontario for Apr. 1, 2020, to Mar. 31, 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of diagnoses of SARS-CoV-2 infection were estimated for each quarter in the study period, overall and by province, age group and sex. RESULTS:Our study encompassed more than 13 million SARS-CoV-2 PCR test results. Specificity and NPV of diagnoses of SARS-CoV-2 infection were consistently high (i.e., most estimates were > 95%). Overall sensitivity estimates were 86.2%, 60.4% and 20.3% in the first quarter for inpatient, emergency department and outpatient cohorts, and 66.2%, 47.5% and 25.0% in the last quarter, respectively. For inpatients, overall PPV estimates ranged from 50.0% to 66.4%. For emergency department patients, overall PPV estimates were 76.9% and 68.3% in the first and last quarters, respectively. For outpatients, PPV estimates were 6.8% and 29.1% in the first and last quarters, respectively. INTERPRETATION:We found variations in the validity of diagnoses for SARS-CoV-2 infection recorded in different health care settings, geographic areas and over time. Our multiprovince validation study provides evidence about the potential use of inpatient and emergency department records as an alternative to population-based laboratory data for identification of patients with SARS-CoV-2 infection, but does not support the use of outpatient claims for this purpose.
BACKGROUND:Patient death is an inevitability during medical training, with subsequent psychologic distress, decreased empathy and worse learning outcomes. We aimed to explore resident experiences with patient death early in training, including the immediate and delayed impacts of these experiences, preparedness of trainees for these events and coping strategies used, potentially identifying gaps and opportunities to further support trainees during difficult or traumatic events.METHODS:We performed a qualitative study using phenomenology methodology to understand trainees' personal experiences with patient death. Resident physicians who had completed an internal medicine rotation at McMaster University, Hamilton, Ontario, were invited to participate from December 2020 to April 2021. Semistructured interviews were conducted to understand circumstances, emotional responses, support, coping mechanisms and preparedness regarding the patient death experience. Interviews were transcribed and coded to identify emerging themes with the use of thematic and interpretive analysis.RESULTS:Eighteen participants were interviewed. On average, the interviews were 40 minutes in length. The participants' mean age was 27 years. The majority of trainees (10 [56%]) were in their first year of residency, with 5 (28%) from family medicine and 4 (22%) from internal medicine. Most participants (13 [72%]) had experienced their first patient death during medical school. Three themes were identified: patient death circumstances, immediate and delayed emotional impact, and preparedness and coping mechanisms. Unexpected death, pronouncing death, cardiopulmonary resuscitation and communicating with families were common challenges. Feelings of guilt, helplessness and grief followed the events. Feeling underprepared contributed to emotional consequences, including difficulties sleeping, intrusive thoughts and emotional distancing; however, these experiences were consistently normalized by participants.INTERPRETATION:Patient death during medical training can be traumatic for trainees and may perpetuate loss of empathy, changes to practice and residual emotional effects. Educational initiatives to prepare trainees for patient death and teach adaptive coping strategies may help mitigate psychologic trauma and loss of empathy; further research is required to explore these strategies.
BACKGROUND:Although clinical empathy - the ability of a physician to understand a patient's illness experience, communicate this understanding and act collaboratively to create a treatment plan - provides substantial benefits to both physicians and patients, medical students typically experience a decline in empathy during training. The primary objective of this study was to generate a model of clinical empathy grounded in the perspectives of people with chronic illness living in Canada, to promote empathy-focused curricular development in Canadian medical education.METHODS:We conducted a qualitative focus group study using a constructivist grounded theory approach. We recruited adults (age ≥ 18 yr) with chronic illness who had recently seen a physician in Canada from virtual support groups. Six semistructured virtual focus groups with 3-5 participants each were scheduled between June and September 2021. We coded the transcripts using the constant comparative method, allowing for the construction of an overarching theory.RESULTS:Twenty patients (17 women and 3 men) participated in the focus groups; 1 group had 2 participants because 1 participant failed to appear. The majority of participants (14 [70%]) had at least a college degree. The mean rating for overall satisfaction with the Canadian health care system was 5.4/10.0 (median 5.0). The emergent theory showed that the perceived presence of physician empathy engendered positive internal processing by patients, leading to increased health care efficacy and enhanced mental health outcomes. Negative patient processing in response to the perceived absence of empathy led to reduced quality of health care delivery (e.g., ineffective referrals and more appointments), increased use of health care resources, disruptions in patients' personal lives, and negative physical and mental health outcomes.INTERPRETATION:Clinical empathy can have life-altering impacts on patients, and its absence may increase resource use. As empathy involves understanding patients' lived experiences, any valid intervention to improve clinical empathy must be informed by patient perspectives.
BACKGROUND:Systematic guidance for considering health equity in guidelines is lacking. This scoping review aims to synthesize current best practices for integrating health equity into guideline development and the benefits or drawbacks of these practices.METHODS:We searched Ovid MEDLINE ALL and Embase Classic+Embase on the Ovid platform, CINAHL on EBSCO, and Web of Science (Core Collection) from 2010 to 2022. We searched grey literature from 2015 to 2022, using the Canadian Agency for Drugs and Technologies in Health Grey Matters checklist and searches of potentially relevant websites. Articles were screened independently by 1 reviewer. Proposed best practices, advantages and disadvantages, and tools were extracted independently by 1 reviewer and qualitatively synthesized based on the relevant steps of a comprehensive checklist covering the stages of guideline development.RESULTS:We included 26 articles that proposed best practices for incorporating health equity within the guideline development process. These practices were organized under different stages of the development process, including guideline planning, evidence review, guideline development and dissemination. Included studies provided best practices from guideline producers, articles discussing health equity in current guidelines, articles addressing strategies to increase equity in the guideline implementation process, and literature reviews of promising health equity practices.INTERPRETATION:Our scoping review identified best practices to incorporate health equity considerations at each phase of guideline development. Identified practices may be used to inform equity-promoting strategies with the guideline development process; however, guideline producers should carefully consider the advantages and disadvantages of best practices when integrating health equity.
Background: Although evidence-based smoking cessation guidelines are available, the applicability of these guidelines for the cessation of electronic cigarette and dual e-cigarette and combustible cigarette use is not yet established. In this review, we aimed to identify current evidence or recommendations for cessation interventions for e-cigarette users and dual users tailored to adolescents, youth and adults, and to provide direction for future research. Methods: We systematically searched MEDLINE, Embase, PsycINFO and grey literature for publications that provided evidence or recommendations on vaping cessation for e-cigarette users and complete cessation of cigarette and e-cigarette use for dual users. We excluded publications focused on smoking cessation, harm reduction by e-cigarettes, cannabis vaping, and management of lung injury associated with e-cigarette or vaping use. Data were extracted on general characteristics and recommendations made in the publications, and different critical appraisal tools were used for quality assessment. Results: A total of 13 publications on vaping cessation interventions were included. Most articles were youth-focused, and behavioural counselling and nicotine replacement therapy were the most recommended interventions. Whereas 10 publications were appraised as “high quality” evidence, 5 articles adapted evidence from evaluation of smoking cessation. No study was found on complete cessation of cigarettes and e-cigarettes for dual users. Interpretation: There is little evidence in support of effective vaping cessation interventions and no evidence for dual use cessation interventions. For an evidence-based cessation guideline, clinical trials should be rigorously designed to evaluate the effectiveness of behavioural interventions and medications for e-cigarette and dual use cessation among different subpopulations.
Background: Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. Methods: We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. Results: Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients’ homes than enrolling physicians’ offices (0 to < 3 km: 32% v. 22%, SMD 0.21). Interpretation: Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.
BACKGROUND:Medical assistance in dying (MAiD) was legalized in Canada in 2016, with legislation updated in 2021. It is unclear whether resources are available to help patients make this difficult decision; therefore, we sought to identify and quality appraise Canadian MAiD resources for supporting patients making this decision.METHODS:We conducted an environmental scan by searching Canadian websites for online MAiD resources that were published after the 2016 MAiD legislation, patient targeted, publicly accessible and able to inform decisions about MAiD in Canada. We excluded resources that targeted health care professionals or policy-makers, service protocols and personal narratives. Two authors appraised resources using the International Patient Decision Aids Standards (IPDAS) criteria and the Patient Education Materials Assessment Tool (PEMAT) for health literacy. Descriptive analysis was conducted. We defined resources as patient decision aids if 7 IPDAS defining criteria were met, and we rated resources as adequate for understandability or actionability if the PEMAT score was 70% or greater.RESULTS:We identified 80 MAiD resources. As of March 2023, 62 resources (90%) provided eligibility according to the 2021 legislation and 11 did not discuss any eligibility criteria. The median IPDAS score was 3 out of 7; 52% discussed alternative options and none provided benefits or harms. Of 80 resources, 59% were adequate for understandability and 29% were adequate for actionability.INTERPRETATION:Although many resources on MAiD were updated with 2021 legislation, few were adequate to support patients with lower health literacy. There is a need to determine whether a patient decision aid would be appropriate for people in Canada considering MAiD.
Background: The COVID-19 pandemic and nonpharmaceutical interventions that reduced the spread of infection had impacts on social interaction, schooling and employment. Concerns have been raised about the impact of these disruptions on the mental health of high-risk groups, including birthing parents of young children. Methods: This population-based, repeated cross-sectional study used health administrative databases in Ontario, Canada, to link children to birth parents and to measure subsequent mental health visits of birthing parents of younger (age 0–5 yr) and school-aged (6–12 yr) children. We used a repeated cross-sectional study design to estimate expected rates for visits to physicians for mental health diagnoses, based on prepandemic trends (March 2016–February 2020), and to compare those to observed visit rates during the March 2020–November 2021 period of the pandemic. Results: We identified 2 cohorts: 986 870 birthing parents of younger children and 1 012 997 birthing parents of school-aged children. In both cohorts, observed visit rates were higher than expected in the June 2020–August 2020 quarter (incidence rate ratio [IRR] 1.13, 95% confidence interval [CI] 1.10–1.16; and IRR 1.10, 95% CI 1.07–1.13, respectively), peaked in December 2020–February 2021 (IRR 1.24, 95% CI 1.20–1.27; and IRR 1.20, 95% CI 1.16–1.23) and remained higher than expected in September 2021–November 2021 (IRR 1.12, 95% CI 1.08–1.16; and IRR 1.09, 95% CI 1.06–1.13). The increases were driven mostly by visits for mood and anxiety disorders, and trends in increases were similar across physician type, birthing-parent age and deprivation quintile. Interpretation: The COVID-19 pandemic was associated with increased mental health visits for parents of young children. This raises concerns about mental health impacts and highlights the need to address these concerns.
BACKGROUND:Challenges in timely access to one's usual primary care physician and the ongoing use of walk-in clinics have been major health policy issues in Ontario for over a decade. We sought to determine the association between patient-reported timely access to their usual primary care physician or clinic and their use of walk-in clinics.METHODS:We conducted a cross-sectional study of Ontario residents who had a primary care physician by linking population-based administrative data to Ontario's Health Care Experience Survey, collected between 2013 and 2020. We described sociodemographic characteristics and health care use for users of walk-in clinics and nonusers. We measured the adjusted association between self-reported same-day or next-day access and after-hours access to usual primary care physicians or clinics and the use of walk-in clinics in the previous 12 months.RESULTS:Of the 60 935 total responses from people who had a primary care physician, 16 166 (weighted 28.6%, unweighted 26.5%) reported visiting a walk-in clinic in the previous 12 months. Compared with nonusers, those who used walk-in clinics were predominantly younger, lived in large and medium-sized urban areas and reported a tight, very tight or poor financial situation. Respondents who reported poor same-day or next-day access to their primary care physician or clinic were more likely to report having attended a walk-in clinic in the previous 12 months than those with better access (adjusted odds ratio [OR] 1.23, 95% confidence interval [Cl] 1.13-1.34). Those who reported being unaware that their primary care physician offered after-hours care had a higher likelihood of going to a walk-in clinic (adjusted OR 1.14, 95% Cl 1.07-1.21).INTERPRETATION:In this population-based health survey, patient-reported use of walk-in clinics was associated with a reported lack of access to same-day or next-day care and unawareness of after-hours care by respondents' usual primary care physicians. These findings could inform policies to improve access to primary care, while preserving care continuity.
