IntroductionPulmonary exercise testing, including six-minute walk tests, exercise oximetry, and independent exercise assessments, are critical tools for managing chronic respiratory and cardiac conditions, evaluating treatment response, and determining long-term oxygen therapy needs. During the COVID-19 pandemic, testing was reduced to limit viral spread. This study aimed to evaluate post-pandemic trends of pulmonary exercise testing utilization in Ontario overall and across demographic groups.MethodsWe conducted a population-based cohort study using Ontario administrative data between April 2015 and December 2023 to evaluate pulmonary exercise testing before, during, and after the COVID-19 pandemic. We used an Auto-Regressive Integrated Moving Average Model (ARIMA) model and incidence rate ratios to evaluate recovery trends. Subgroup analysis examined if trends were similar in different groups.ResultsDuring the study period, 505,902 tests were performed for 362,888 individuals. As of December 2023, testing rates were still 21% below pre-pandemic levels (IRR 0.79, 95%CI 0.70-0.89). Recovery was lower in males (IRR 0.76, 95%CI 0.66-0.86) and individuals living in lower socioeconomic status neighborhoods (IRR 0.71, 95%CI 0.58-0.86). Northern Ontario saw the most pronounced shortfall compared to other regions, with testing rates one-third of pre-pandemic levels (IRR 0.33, 95% CI 0.26-0.43).ConclusionMore than three years after the pandemic began, pulmonary exercise testing rates have yet to return to pre-pandemic levels, with certain groups disproportionately affected. This highlights a significant and ongoing disruption in diagnostic capacity and quality of care for people with respiratory and cardiac diseases.

Background Schizophrenia is associated with substantial physical and psychiatric comorbidities that increase the risk of severe outcomes in COVID-19 infection. However, few studies have examined the differences in care and outcomes among people with schizophrenia throughout the pandemic. We hypothesized that rates of in-hospital mortality, admission to the intensive care unit (ICU), and length of stay differed among people with and without schizophrenia. Study design We conducted a population-based retrospective cohort study using administrative health data from Ontario, Canada, which included individuals hospitalized for COVID-19 between February 2020 and October 2023. We compared mortality, ICU admission, and length of stay using regression models adjusted for age, sex, comorbidities, vaccination status, and sociodemographic characteristics. Study results We evaluated 66 959 hospital admissions, 4.3% (2884) of which involved people with schizophrenia. People with schizophrenia had a significantly decreased rate of ICU admission (adjusted Odds Ratio [OR]: 0.74 [0.67, 0.82]), a longer length of stay (adjusted RR: 1.25 [1.21, 1.30]), but a similar risk of mortality (adjusted OR: 1.09 [0.98, 1.22]) as people without schizophrenia. Age modified the relationship between schizophrenia and ICU admission. People with schizophrenia aged 60-75 were substantially less likely to be admitted to the ICU relative to those without (18.4% vs 26.5%, P < .001). Conclusions Our findings underscore disparities in care among people with and without schizophrenia. These disparities vary by age and suggest that people with schizophrenia may not be receiving the same level of care as people without schizophrenia hospitalized for COVID-19.

BACKGROUND:Pulmonary Function Tests are critical in diagnosing and managing respiratory conditions such as chronic obstructive pulmonary disease and asthma. However, because they generate aerosols, they were restricted in laboratories and offices during the COVID-19 pandemic to prevent virus spread. OBJECTIVE:To determine whether Pulmonary Function Test capacity had returned to pre-pandemic levels overall and across demographic groups in a large North American cohort. METHODS:We conducted a population cohort study in individuals aged 7 and older from 2015 to 2023 in Ontario, Canada, using provincial health administrative data. Incidence rate ratios (IRR) were used to compare observed rates to rates that would have been expected if the pandemic had never occurred and to assess whether test utilization returned to pre-pandemic levels. Subgroup analyses were conducted across various demographic characteristics. MAIN FINDINGS:There were 8,302,872 tests performed on 2,683,844 people during the study period. As of December 2023, testing rates were still 27% lower than they were prior to the pandemic (IRR 0.73, 95% CI 0.63 - 0.87). Recovery was lower in males (IRR 0.72, 95%CI 0.62-0.86), those aged 18-65 (IRR 0.68, 95%CI 0.59-0.82), urban residents (IRR 0.72, 95%CI 0.62-0.86), and individuals of lower socioeconomic status (IRR 0.68, 95%CI 0.59-0.81). CONCLUSION:More than three years after the pandemic onset, pulmonary function test rates in Ontario still have not recovered to pre-pandemic levels, with certain groups more affected than others. These findings suggest persistent reductions in PFT utilization and disparities in care for people with respiratory conditions.

Background: Adolescent depression is associated with adverse social, academic, and health outcomes. This study compared depression-related primary care visits among adolescents before, during, and after COVID-19, and identified affected age and sex groups across countries. Methods: Retrospective repeated cross-sectional study using routinely collected data from primary care settings in Australia, Brazil, Canada, Israel, Norway, Peru, Singapore, Spain, Sweden, the UK, and the USA. Depression-related visits among adolescents aged 10–19 years from 2018–2023 were compared across pre-pandemic (Jan 2018–Mar 2020), pandemic (Apr 2020–Dec 2021), and recovery (Jan 2022–Dec 2023) periods. Negative binomial regression estimated rate ratios (RRs) and 95% confidence intervals (CIs), overall and stratified by sex and age group (10–14 and 15–19 years). Findings: Among 145·3 million adolescent visits, 1·7 million (1·2%) were depression related. Most countries showed increases in depression-related visit rates during the pandemic compared with the pre-pandemic period, ranging from RR 1·14 (95% CI 1·04–1·25) in Spain to RR 2·23 (95% CI 1·97–2·52) in Singapore. Recovery-period rates remained higher than pre-pandemic rates in several countries. Females and older adolescents had the highest visit rates. Larger relative increases during the pandemic among younger adolescents were observed in Australia, Brazil, Canada, and the USA, in both sexes. Interpretation: Depression-related visits increased during the pandemic and often remained above pre-pandemic levels. Larger relative increases among younger adolescents highlight the need for targeted strategies.

New immigrants often face barriers when navigating the healthcare system, which can create unmet healthcare needs and contribute to health inequities. Primary care practices, as the gateway to the healthcare system, could use information about their patients' immigrant status to ensure accessible care and equitable resource allocation. However, this is not routinely collected or documented in primary care. The objective of this study was to explore two approaches (regular expression and machine learning) to determine patient-reported immigrant status from primary care electronic medical records (EMRs). De-identified EMR data from the St. Michael's Hospital Academic Family Health Team in Toronto, Ontario, Canada was used, including the reference set of patient-reported responses to a health equity questionnaire. Two approaches were tested and compared: 1) a regular expression classifier (using key text terms), and 2) supervised machine learning classifier (specifically XGBoost). Discrimination and calibration metrics were calculated using self-reported immigrant status from the patient surveys. Among eligible patients in the analytic cohort (N = 12,998), 44.5% reported being born outside of Canada. Although the XGBoost model outperformed the regular expression approach (XGBoost sensitivity = 53.1% and positive predictive value = 72.6%; regular expression sensitivity = 5.2% and positive predictive value = 96.8%), neither approach was accurate enough for use in practice. While understanding patients' immigrant status is important for the provision of high quality, comprehensive primary health care, our work demonstrates the challenges of using EMR data to derive immigrant status. For now, primary care practices should continue to rely on obtaining immigrant status through initial patient intakes or surveys.

BACKGROUND:Inhalers are essential for respiratory disease management, but commonly used metered-dose inhalers (MDIs) can often be replaced, when clinically appropriate, with lower-emission alternatives such as dry powder inhalers (DPIs) or soft mist inhalers (SMIs). The COVID-19 pandemic may have influenced prescribing patterns. We aim to describe changes in inhaler prescription trends and determine whether MDI use decreased during the pandemic. METHODS AND FINDINGS:Retrospective cohort study using Ontario's health administrative data. Individuals aged 65 and older with new inhaler prescription instances from April 1, 2017, to March 31, 2023, were included. Monthly prescription event rates by inhaler type and socioeconomic factors were modeled for pre-pandemic (April 2017-March 2020) and pandemic (April 2020-March 2023) periods using interrupted time series and Generalized Additive Models to account for autocorrelation and seasonality. 750,517 new inhaler prescriptions were made during the study period. A significant drop was observed at the pandemic's onset. MDIs were the predominant type of inhaler initially prescribed for both pre-pandemic ~77% and pandemic ~70% periods. The proportion of DPI initial prescriptions modestly increased from ~17% to ~23% and SMI initial prescriptions remained similar. Inhaler prescription rates did not significantly differ across sex, income quintiles, or rurality. CONCLUSIONS:The COVID-19 pandemic disrupted inhaler prescribing patterns in Ontario, leading to a temporary decline in new prescriptions. Despite environmental and guideline recommendations, MDIs continued to dominate prescribing practices. These findings underscore the need for targeted interventions to align clinical practices with current guidelines and environmental sustainability goals.

Neurofibromatosis type 1 (NF1) is a multisystemic disease, characterized by cutaneous manifestations and peripheral nerve sheath tumors. Patients also have a high prevalence of learning disability, gliomas, as well as other malignancies, and require specialized follow up and surveillance. However, there are limited data regarding how people with NF1 use the healthcare system. We aimed to assess the use of different health services in individuals with NF1 compared to the general population. This population-based, matched cohort study in Ontario, Canada, used a registry of individuals with confirmed NF1 from pediatric and adult clinics between 1990 and December 31, 2020, linked to administrative health databases. Each patient was matched 1:5 to population controls, by date of birth, sex, income quintile and geographic area of residence. We compared outpatient primary and specialty claims, hospitalizations, emergency department (ED) visits, same-day surgeries, overall healthcare costs and use of disability benefits. 1,210 individuals with NF1 were matched to 6,050 controls, mean follow up was 19.6 ± 8.7 and 18.8 ± 8.5 years, respectively; at the end of the study window, mean age was 26.2 ± 16.9 years. More adults with NF1 received disability benefits than controls (17.6

Background Metabolic dysfunction-associated steatotic liver disease (MASLD) is a multisystem condition, yet the relevance of comorbidity composition and co-occurrence to liver-related outcomes is poorly understood. We evaluated associations of comorbidity burden, individual conditions, disease pairs, and latent patterns with liver-related events (LREs). Methods We conducted a prospective analysis of 137,607 UK Biobank participants with MASLD. We assessed 51 comorbidities, eligible pairs among 1,275 combinations, and comorbidity patterns identified by latent class analysis. Associations with incident LREs were estimated using multivariable Cox regression. Results During a median follow-up of 14.7 years, 9,948 participants developed LREs. Compared with the lowest Charlson Comorbidity Index tertile, the highest tertile had an adjusted hazard ratio (aHR) for LREs of 1.41 (95% CI 1.31–1.51). Compared with no comorbidities, having ≥ 3 comorbidities was associated with an aHR of 1.54 (95% CI 1.43–1.65). Solid organ cancers and diabetes exhibited the strongest associations with LREs. Pairwise analyses identified multiple associations, including hypertension with substance use disorder (aHR 1.51, 95% CI 1.37–1.65), hypertension with solid organ cancers (aHR 1.44, 95% CI 1.31–1.57), diabetes with hyperlipidemia (aHR 1.43, 95% CI 1.27–1.60), and diabetes with depression (aHR 1.40, 95% CI 1.24–1.59). Three classes were identified in addition to a minimal-comorbidity class. Compared with minimal-comorbidity class, psychiatric-respiratory, hypertension-centered metabolic, and cardiovascular-kidney-metabolic classes had aHRs of 1.39, 1.40, and 2.08, respectively. Conclusion Comorbidity composition and co-occurrence patterns were associated with LRE risk in MASLD. These findings suggest that multidimensional comorbidity assessment may complement liver-focused risk stratification.

Background The cardiovascular-kidney-metabolic (CKM) syndrome, first proposed by the American Heart Association (AHA) in 2023, represents a groundbreaking conceptual framework that integrates these three interrelated conditions into a unified clinical entity. Despite growing research on its prevalence, risk factors, and clinical management, the regional burden of CKM syndrome remains poorly characterised. To address this gap, we aimed to estimate the prevalence of CKM syndrome, providing critical insights into the regional impact of this novel disease definition. Methods In this study, we conducted literature retrieval in both English (PubMed, Web of Science and Wiley Online Library) and Chinese databases (CNKI and Wangfang), as well as the journal official websites (e.g., American Heart Association (AHA) and American Society of Nephrology (ASN)) from database inception until January 20, 2025, followed by an update search until April 1, 2025. Grey literature such as posters and preprint articles, and citations from the identified reviews were also searched for. Cross sectional and cohort studies were included without language limitation. Studies employing other study designs or were done in people who were not representative of the general population (e.g., people with specific diseases) were excluded. Summary data were obtained from included studies. The primary outcomes were the prevalence of CKM syndrome and its different stages (stages 0-4) among general population. The combined prevalence was obtained with Freeman-Tukey Double Arcsine Transformation method. The estimated annuls percentage change (EAPC) was employed to explore the trend of CKM syndrome. This study is registered with PROSPERO (CRD420251037912). Findings From 2,708 identified 2,708 related articles, 28 studies with 29 datapoints, encompassing 1,561,209 individuals, were included. The overall pooled prevalence of CKM syndrome (Stages 1-4) in the general population was 0.88 [95% CI 0.86-0.91]. This estimate was 0.85 [95% CI 0.76-0.91] in a sensitivity analysis selecting one representative study per database to test the magnitude of potential duplicate bias. The combined prevalence of stages 1, 2, 3 and 4 was 0.23 [95% CI 0.19-0.27], 0.46 [95% CI 0.41-0.51], 0.08 [95% CI 0.05-0.11], 0.07 [95% CI 0.04-0.12], respectively, displaying as the Stage 2 patients were the majority of CKM syndrome. The EAPC of CKM syndrome in the period of 1991-2021 was (-0.55% [95% CI -0.90 to 0.21], p=0.0024), displaying a significant decreased trend. Stratified by countries, the pooled estimates were 0.91 [95% CI 0.90-0.93] for USA, 0.90 [95% CI 0.87-0.93] for China, and 0.77 [95% CI 0.69-0.84] for other countries (UK, Italy and South Korea). CKM syndrome prevalence demonstrated an increasing trend with a higher proportion of males (male/female ratio <0.98) and with increasing mean age (up to 56.5 years). Statistically significant disparities were observed across social development index (SDI) level, data source and countries. Interpretation This study provides the pooled regional prevalence of CKM syndrome in the general population; these findings are valuable for understanding the current burden of CKM syndrome and facilitating more research into the clinical management and prevention. While a slight decreasing temporal trend was observed based on the included studies, the relatively high combined prevalence suggests more epidemiological research into missing regions, such as Africa and South America, to verify this finding. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement L. L was supported by the InnoHK Project at the Hong Kong Centre for Cerebro-cardiovascular Health Engineering (COCHE). J.D.Z was supported by HKU Seed Fund for New Staff Basic Research (No. 103034014) and HKU Daniel and Mayce Yu Medical Development Fund for Research Start-Up (No. 200010837). K.T receives a Chair in Family and Community Medicine Research in Primary Care at UHN and a Research Scholar Award from the Department of Family and Community Medicine at the University of Toronto. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The summary table of extracted data from the included studies is provided in Table 1 and Table 2. All datasets generated and analyzed, including the search strategy, data extracted, and quality assessment, are available in the Article and on request from the corresponding author (JDZ, jdzhou{at}hku.hk).

BACKGROUND:Atrial fibrillation (AF) that is first diagnosed during hospitalization for other causes can subside with resolution of the inciting stressor. OBJECTIVE:To describe the risk for stroke after newly diagnosed AF during hospitalization for other causes. DESIGN:Population-based retrospective cohort study. SETTING:Ontario, Canada. PARTICIPANTS:Patients aged 66 years or older discharged alive from the hospital between April 2013 and March 2023 with a first diagnosis of AF. INTERVENTION:Newly diagnosed AF during hospitalization for other causes, categorized into cardiac medical, noncardiac medical, cardiac surgical, and noncardiac surgical. MEASUREMENTS:The primary outcome was hospitalization for stroke. The cumulative incidence function was used to estimate crude incidence, censoring on anticoagulant dispensation. Inverse probability of censoring weights were used to account for informative censoring. RESULTS:Atrial fibrillation was diagnosed in 20 639 patients (mean age, 77.1 years; 58.1% male) while hospitalized for other causes: 8340 (40.4%) for noncardiac medical, 7097 (34.4%) for cardiac surgical, 3553 (17.2%) for noncardiac surgical, and 1649 (8.0%) for cardiac medical diagnoses. At 1 year, anticoagulants were being dispensed to 26.4% of patients with CHA2DS2-VA scores of 1 to 4 and 35.2% of those with CHA2DS2-VA scores of 5 to 8. The 1-year risk for stroke without anticoagulation was 1.3% (95% CI, 0.7% to 2.3%) for cardiac medical, 1.2% (CI, 0.9% to 1.5%) for noncardiac medical, 1.1% (CI, 0.8% to 1.7%) for noncardiac surgical, and 1.0% (CI, 0.7% to 1.3%) for cardiac surgical patients. Patients with CHA2DS2-VA scores of 1 to 4 had a 1-year stroke risk of 0.7% (CI, 0.6% to 1.0%) without anticoagulation, compared with 1.8% (CI, 1.4% to 2.2%) at CHA2DS2-VA scores of 5 to 8. LIMITATION:Long-standing AF may have been misclassified as newly diagnosed, leading to overestimation of stroke risk. CONCLUSION:Among patients with newly diagnosed AF during hospitalization for other causes, a substantial proportion with low CHA2DS2-VA scores receive anticoagulation, with modest increases in this proportion at higher scores. The stroke risk in patients with CHA2DS2-VA scores greater than 4 approximated the 2% threshold commonly used to initiate anticoagulation in AF. PRIMARY FUNDING SOURCE:Canadian Cardiovascular Society.

There is a growing need to document sociodemographic factors in electronic medical records to produce representative cohorts for medical research and to perform focused research for potentially vulnerable populations. The objective of this work was to assess the content of family physicians’ electronic medical records and characterize the quality of the documentation of sociodemographic characteristics. Descriptive statistics were reported for each sociodemographic characteristic. The association between the completeness rates of the sociodemographic data and the various clinics, electronic medical record vendors, and physician characteristics was analyzed. Supervised machine learning models were used to determine the absence or presence of each characteristic for all adult patients over the age of 18 in the database. Documentation of marital status (51.0%) and occupation (47.2%) were significantly higher compared to the rest of the variables. Race (1.4%), sexual orientation (2.5%), and gender identity (0.8%) had the lowest documentation rates with a 97.5% missingness rate or higher. The correlation analysis for vendor type demonstrated that there was significant variation in the availability of marital and occupation information between vendors (χ2 > 6.0, P < 0.05). Variability in documentation between clinics indicated that the majority of characteristics exhibited high variation in completeness rates with the highest variation for occupation (median: 47.2, interquartile range: 60.6%) and marital status (median: 45.6, interquartile: 59.7%). Finally, physician sex, years since a physician graduated, and whether a physician was a foreign vs a Canadian medical graduate were significantly associated with documentation rates of place of birth, citizenship status, occupation, and education in the electronic medical records. Our findings suggest a crucial need to implement better documentation strategies for sociodemographic information in the healthcare setting. To improve completeness rates, healthcare systems should monitor, encourage, enforce, or incentivize sociodemographic data collection standards.

BACKGROUND:Individuals with autism spectrum disorder (ASD) may be at increased risk of both obesity and underweight. OBJECTIVE:To examine the association between ASD and weight status in children and adolescents, adjusting for individual- and neighbourhood-level sociodemographic factors. METHODS:We conducted a cross-sectional study of children and adolescents ≥2 and ≤18 years old using health administrative and demographic data from Ontario, Canada. Using growth measurements from a large primary care database between 2011 and 2016, we categorized weight status using World Health Organization definitions. We defined ASD based on a previously validated algorithm. RESULTS:We included 568 children and adolescents with ASD and 32 967 without ASD. Comparing those with ASD to those without ASD, prevalence of underweight was 3.5% versus 1.9%, overweight 19.0% versus 18.2%, obesity 12.9% versus 7.3%, and severe obesity 5.8% versus 2.2%. In the fully adjusted multinomial logistic regression model, ASD remained associated with underweight (adjusted odds ratio [aOR] 2.02; 95% confidence interval [CI] 1.27-3.20), obesity (aOR 1.87; 95% CI 1.44-2.43) and severe obesity (aOR 2.62; 95% CI 1.81-3.80). CONCLUSION:Children and adolescents with ASD are at increased risk of underweight, obesity, and severe obesity, independent of sociodemographic characteristics. Strategies addressing growth and weight status are warranted in this population.

Individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) experienced worsening symptoms during the COVID-19 pandemic resulting in increased demand for healthcare services. However, it is unclear how those with and without ADHD utilized these services during the COVID-19 pandemic. This study examined healthcare utilization among individuals with and without ADHD and as a secondary objective, investigated these trends among female and male subgroups, from April 1, 2014-March 31, 2023. We conducted a population-based longitudinal retrospective cohort study among ADHD cases identified using a validated algorithm, and controls from Ontario, Canada over the same study period. We matched ADHD cases 1:1 to controls by sex, birth year, and geographical area. Outcomes were number of outpatient visits per person per fiscal year to family physicians, for mental health and to emergency departments, stratified by sex and age group over the follow-up period. Crude visit rate differences between sex-specific cases and controls were calculated with 95% confidence intervals (CI). We matched 427 716 ADHD cases to 427 716 controls. ADHD cases were 163 528 ≤ 17 years (32% female), and 264 188 adults (52% female). From 2013-2024, where March 17, 2020 marked the onset of the COVID-19 pandemic, females aged 1-17 years with ADHD appeared to have higher visit rate differences to family physicians, emergency departments, and increased mental health services, relative to their controls, particularly in 2020 [2.66 (95% CI: 2.65-2.68)]. In the same year, males with ADHD still had a higher mental health visit rate difference, [2.02 (95% CI: 2.01-2.02)] in 2020, but lower than that observed in females. Adult females with ADHD had the highest mental health visit rate difference in 2020 [5.09 (95% CI: 5.07-5.11)] and males with ADHD had 4.41 (95% CI: 4.40-4.43). These higher service utilization differences likely reflected greater health needs among females with ADHD while males underutilized these services.

OBJECTIVES:Our primary objectives were (1) to develop and validate an administrative data algorithm for the identification of hand trauma cases using clinical diagnoses documented in medical records as the reference standard and (2) to estimate the incidence of hand trauma in a universal public healthcare system from 1993 to 2023 using a population-based research cohort constructed using a validated case identification algorithm. DESIGN:A population-based retrospective validation study. SETTING:Ontario, Canada, from 2022 to 2023 (validation) and from 1993 to 2023 (estimation). PARTICIPANTS:Our reference standard was the known hand trauma status of 301 patients (N=147 with hand trauma) who presented to an urban tertiary-care hand trauma centre in Toronto, Ontario. PRIMARY AND SECONDARY OUTCOME MEASURES:(1) The sensitivity, specificity, positive and negative predictive values of the optimal algorithm to identify hand trauma using provincial health administrative data and (2) age-standardised and sex-standardised incidence rates of hand trauma among men and women, by age, and by area of patient residence. RESULTS:The optimal algorithm had a sensitivity of 73.8% (95% CI 66.6% to 81.0%), specificity of 80.1% (95% CI 73.8% to 86.5%), positive predictive value of 78.1% (95% CI 71.2% to 85.0%) and negative predictive value of 76.1% (95% CI 69.5% to 82.7%). Over the study period, the age-standardised and sex-standardised incidence of hand trauma increased from 384 to 530 per 100 000. The greatest increase was observed in males and individuals aged 0-19 and 80+, with higher incidence rates in Southern compared with Northern Ontario. CONCLUSIONS:Our algorithm enabled identification of hand trauma cases using health administrative data suitable for population-level surveillance and health services research, revealing a rising burden of hand trauma from 1993 to 2023. These findings can support improved surveillance, resource allocation and care delivery for this public health problem.

Sociodemographic factors are critical determinants of health outcomes and disparities, yet their documentation in electronic medical records is often sparse and confined to unstructured clinical text. This poses substantial challenges for automated extraction and integration into clinical decision-making. In this study, we systematically evaluate and compare 6 convolutional neural network architectures, including hybrid models that integrate traditional classifiers, for binary classification of multiple sociodemographic characteristics from EMR text using data from 4375 patients across 96 primary care clinics. The goal was to assess how model complexity and lexical diversity influence classification performance. Manual annotation achieved high inter-rater reliability (kappa: 0.98 for documentation status, 0.96 for documented information). We report performance using F1 score, precision, recall, area under the precision-recall curve, and Matthews correlation coefficient. Results showed that simpler architectures, particularly a single-layer CNN, consistently outperform deeper or hybrid models across most characteristics (F1 score: 90.99%), especially under conditions of data imbalance and varied documentation patterns. While hybrid models offered gains for well-documented factors like marital status, they were less effective for sparse or diverse characteristics. These findings provide a practical framework for developing efficient, interpretable clinical NLP pipelines and inform model selection strategies for real-world health equity and EMR research applications.

Introduction: Although sodium-glucose cotransporter 2 inhibitors (SGLT2i) are guideline-directed medical therapy for heart failure, their safety in patients with acute decompensated heart failure (ADHF) remains uncertain. This study compared the risk of adverse events between early versus late initiation of SGLT2is following ADHF hospitalization. Methods: We conducted a retrospective cohort study emulating a target trial using linked administrative data from Ontario, Canada. Adults aged ≥66 years discharged after hospitalization for ADHF between April 1, 2016, and March 31, 2021 were included. Patients with prior SGLT2i use or with prior heart failure hospitalizations were excluded. We compared two strategies for initiating SGLT2is: early initiation (within 30 days post-discharge), and late initiation (between days 31 and 365 after discharge). The primary outcome was a composite of eight prespecified adverse events requiring hospitalization or emergency department visit within one year of discharge (diabetic ketoacidosis, genitourinary infections, hypotension/syncope, dehydration, acute kidney injury, and falls/fractures). We applied a clone-censor-weight approach, using inverse probability weighted Cox regression models to estimate cause-specific hazard ratios (csHR) and cumulative incidence functions to account for the competing risk of death. Multiple imputation was used to deal with missing values of serum creatinine. Results: The mean number of included patients across 32 imputed datasets was 58,744 (median age, 83 years [IQR 77–89]; 53.4% women). In the overall cohort, during the 1-year follow-up, 18.2% experienced at least one adverse event, most commonly genitourinary infections (5.9%) and acute kidney injury (4.9%). At one year, no difference in the risk of adverse events was observed between the early and late initiation strategies (cumulative incidence at 1 year was 14.5% in the early and 18.7% in the late initiation strategies; absolute risk difference: 4.1%; csHR: 0.96; 95% CI 0.90 to 1.01; p=0.13). Sensitivity analyses using alternative definitions of early and late initiation yielded similar results. Conclusions: In this population-based target trial emulation study, there was no difference in the risk of one-year adverse events with early initiation of SGLT2i within 30 days post-discharge for ADHF compared with delayed initiation. These findings support the safety of early SGLT2i initiation in patients recently hospitalized for ADHF.

BACKGROUND:A lack of consensus exists across guidelines as to which risk model should be used for the primary prevention of cardiovascular disease (CVD). Our objective was to determine potential improvements in the number needed to treat (NNT) and number of events prevented (NEP) using different risk models in patients eligible for risk stratification. METHODS AND RESULTS:A retrospective observational cohort was assembled from primary care patients in Ontario, Canada, between 1 January 2010 and 31 December 2014 and followed for up to 5 years. Risk estimation was undertaken in patients 40-75 years of age, without CVD, diabetes, or chronic kidney disease using the Framingham Risk Score (FRS), the Pooled Cohort Equations (PCEs), a recalibrated FRS (R-FRS), the Systematic Coronary Risk Evaluation 2 (SCORE2), and the low-risk region recalibrated SCORE2 (LR-SCORE2). The cohort consisted of 47 399 patients (59% women, mean age 54 years). The NNT with statins was lowest for the SCORE2 at 40, followed by the LR-SCORE2 at 41, the R-FRS at 43, the PCEs at 55, and the FRS at 65. Models that selected for individuals with a lower NNT recommended statins to fewer, but higher-risk patients. For instance, the SCORE2 recommended statins to 7.9% of patients (5-year CVD incidence 5.92%). The FRS, however, recommended statins to 34.6% of patients (5-year CVD incidence 4.01%). Accordingly, the NEP was highest for the FRS at 406 and lowest for the SCORE2 at 156. CONCLUSIONS:Newer models such as the SCORE2 may improve statin allocation to higher-risk groups with a lower NNT but prevent fewer events at the population level.

The COVID-19 pandemic required a rapid transition to virtual care as a key strategy to maintain healthcare access while minimizing virus transmission risks. However, the impact of this shift on hospitalizations and emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs) remains unclear. This study aims to assess the relationship between the modality of outpatient care for ACSCs and their outcomes in Ontario, Canada. In this population-based retrospective cohort study, we analyzed hospitalization and ED visit data for ACSCs, including diabetes, epilepsy, congestive heart failure, hypertension, and angina, during the pandemic (April 2020 to April 2023) and post-pandemic (May 2023 to August 2023) periods. Monthly trends in hospitalizations and ED visits were evaluated using Generalized Additive Models and Generalized Additive Mixed Models, accounting for the effects of virtual and in-person care within 30 days and 60 days preceding each event. Despite a notable decrease in virtual visits and a corresponding rise in in-person visits, overall hospitalizations and ED visits for ACSCs remained relatively stable. Our analysis found no significant association between care modality and changes in hospitalizations and ED visits, suggesting that virtual care, particularly during the early pandemic, effectively supported chronic disease management and contributed to the stability of acute care needs. In conclusion, virtual care proved to be a sustainable component of ACSC management during and after the COVID-19 pandemic, complementing in-person care.

BACKGROUND:Albuminuria is associated with increased stroke risk in atrial fibrillation (AF), but its relationship with heart failure (HF) and other adverse outcomes in AF is less well understood. METHODS:Using linked administrative databases, we conducted a retrospective cohort study of individuals aged ≥66 years who were newly diagnosed with AF between April 2009 and March 2019 in Ontario, Canada. Albuminuria was assessed using (1) urine albumin-to-creatinine ratio (UACR, mg/g) and (2) dipstick proteinuria (negative, trace, 1+, 2+, ≥3+). Cause-specific hazards regression estimated adjusted hazard ratios (HRs) for HF hospitalizations or emergency department visits, stroke hospitalizations, bleeding hospitalizations, and death over 1 year. RESULTS:We included 64 717 individuals with UACR data and 110 430 with dipstick proteinuria data. Relative to UACR 5 mg/g, the HRs for UACR 30 mg/g (below the microalbuminuria threshold) were 1.39 (95% CI, 1.28-1.50) for HF, 1.22 (95% CI, 1.07-1.40) for bleeding, and 1.35 (95% CI, 1.27-1.42) for death. A UACR of 30 mg/g versus 5 mg/g was associated with an HR of 1.16 (95% CI, 0.99-1.36) for stroke but the HR was significantly elevated at UACR values ≥65 mg/g. Increasing dipstick proteinuria was also associated with increases in the HR for adverse outcomes. A UACR of 30 mg/g was associated with greater HF risk (versus 5 mg/g) than all CHA₂DS₂VASc components except age >75 years and prior HF. CONCLUSIONS:Albuminuria is associated with increased hazards of HF, stroke, bleeding, and death in patients with AF even at low UACR levels. Albuminuria may enhance risk stratification in AF beyond traditional scores.

Purpose: This study investigated the impact of the COVID-19 pandemic on homecare service use among individuals with physical disabilities, stratified by age, sex, and mental health conditions. Methods: Monthly utilization of personal support and nursing services was assessed using linked health administrative databases from ICES in Ontario, Canada, over two periods: pre-pandemic (March 2015 to February 2020) and during the pandemic (March 2020 to June 2022). Predictive Autoregressive Integrated Moving Average (ARIMA) models were used to estimate changes in service use. Results: During the pandemic, personal support service use declined significantly across multiple subgroups with some groups experiencing greater impacts. Significant decreases were observed in 78.5% of months for males, 14.3% for females, 78.5% for individuals aged 65 years and younger, 17.9% for those older than 65 years, and 78.5% for individuals with mental health conditions. In contrast, nursing service use increased significantly, with significant increases observed in 85.7% of months for males, 60.7% for females, 60.7% for those aged 65 years and younger, 17.9% for those older than 65 years, 85.7% for individuals with mental health conditions, and 28.6% for those without mental health conditions. Conclusion: The findings highlight substantial variation in the pandemic's impact across subpopulations, with certain groups disproportionately affected. Targeted strategies are needed to mitigate these disparities and ensure equitable access to homecare services. Further research is warranted to explore the long-term implications and the underlying factors contributing to these differences.