Importance:Systemic treatments for psoriatic disease affect the immune system and may increase infection risk. Older adults are at high risk for infection, and the relative safety of systemic treatments for them is unknown. Objective:To evaluate the association of systemic treatments for psoriatic disease with rates of serious infection among older adults. Design, Setting, and Participants:This cohort study used linked population-based health administrative data from 2002 to 2021 in Ontario, Canada. Participants included Ontario residents 66 years and older with psoriatic disease who were dispensed their first systemic medication between April 1, 2002, and December 31, 2020. Data were analyzed between November 2021 and August 2024. Exposure:Time-varying use of systemic medications categorized as (1) methotrexate; (2) other older systemic medications; (3) anti-tumor necrosis factor (anti-TNF) biologics; (4) other biologics (targeting interleukin [IL]-12, IL-23, and IL-17); and (5) tofacitinib. Main Outcomes and Measures:The main outcome was time to serious infection, defined as hospitalization for any infectious cause occurring up to March 2021. Multivariable Andersen-Gill recurrent event regression was used to estimate the association between each medication category and serious infection rates. The relative rates (RRs) of serious infection with 95% CIs for time actively using each medication category vs time not using that medication category were calculated. Results:Of 11 641 new users of systemic therapy, 6114 (53%) were female, and the median (IQR) age was 71 (68-76) years. There were 1967 serious infections during a median (IQR) of 4.8 (2.3-8.4) years of follow-up. There were 2.7 serious infections per 100 person-years using methotrexate, 2.5 per 100 person-years using other older systemic drugs, 2.2 per 100 person-years using anti-TNF biologics, 1.4 per 100 person-years using other biologics, and 8.9 per 100 person-years using tofacitinib. In the multivariable-adjusted model, methotrexate (RR, 0.95 [95% CI, 0.85-1.07]), other older systemic medications (RR, 0.92 [95% CI, 0.79-1.07]), and anti-TNF biologics (RR, 0.87 [95% CI, 0.69-1.10]) were not associated with serious infection compared to person-time not using those respective medications. Other biologics (RR, 0.65 [95% CI, 0.48-0.88]) were associated with lower rates of serious infection, whereas tofacitinib (RR, 2.89 [95% CI, 1.14-7.34]) was associated with higher rates of serious infection. Conclusions and Relevance:In this cohort study, biologics targeting IL-12, IL-23, or IL-17 were associated with a lower rate of serious infection among older adults with psoriatic disease. These biologics may have important safety benefits for older adults with higher infection risk.

Alcohol use and alcohol-attributable hospitalizations increased during the COVID-19 pandemic; however, whether hospitalizations were more severe during the pandemic years is unknown. To examine the severity of alcohol-related hospitalizations following the onset of the COVID-19 pandemic. We conducted a retrospective cohort study of alcohol-attributable hospital admissions between March 2016 and February 2022 in Ontario, Canada. Using established databases, we identified residents aged 18 to 105 years with an alcohol-related hospital admission. We excluded patients with a missing or invalid health card and non-Ontario residents. The primary exposure was the onset of the COVID-19 pandemic (March 2020). The study period included two phases: before the pandemic (2016 to 2020) and during the pandemic (2020 to 2022). We used generalized estimating equations with a negative binomial distribution to compare the average length of stay and other secondary outcomes (critical care admissions, in-hospital mortality, 30-day mortality, 1-year mortality, 30-day readmission) during the two study periods. We identified 107,030 hospitalizations in the pre-pandemic period and 57,971 in the pandemic period. The mean length of hospital stay was 13.1 days (standard deviation [SD] 43.3) before the pandemic, and 12.1 days (SD 29.7) during the pandemic. After adjustment, length of stay was marginally shorter during the pandemic (relative risk [RR] 0.94; 0.91 to 0.97), driven by shorter mental health admissions. Compared to pre-pandemic, admissions during the pandemic were characterized by an increased risk of 30-day mortality (aRR 1.09; 1.04 to 1.14), 1-year mortality (aRR 1.13; 1.08 to 1.18), 30-day readmission (aRR 1.09; 1.06 to 1.14), and a decreased risk of ICU admission (aRR 0.95; 0.93 to 0.98). Compared to alcohol-related hospitalizations pre-pandemic, hospital length of stay during the pandemic was slightly shorter. Admissions in more recent years were associated with other increased risks of re-admission and mortality.

BACKGROUND:Prescribed safer opioid supply (SOS) programmes are novel harm reduction interventions. We examined health outcomes among people receiving SOS over time and relative to a similar group of people receiving methadone. METHODS:We conducted a population-based cohort study among new SOS and methadone recipients in Ontario, Canada, who commenced treatment between Jan 1, 2016 and Dec 31, 2021. People receiving SOS were matched (1:1) to new methadone recipients based on age (within 3 years), sex, location of residence (public health unit), and propensity score (within 0·2 SDs). Primary outcomes were hospital-treated opioid-related toxicities, emergency department visits and inpatient hospitalisations, incident infections, and health-care costs (in CA$, excluding costs related to primary care services and medications) over 1 year of follow-up. Outcome rates were calculated over the follow-up period, with censoring on death, discontinuation of SOS or methadone, or end of follow-up (360 days). Within-group changes in outcomes were assessed using interrupted time-series analysis, and Prentice-Williams-Peterson regression was used to assess between-group differences in recurrent events. FINDINGS:Of the 991 new recipients prescribed SOS and 25 116 new methadone recipients who met the eligibility criteria, 856 (86·4%) people receiving SOS were matched to 856 people receiving methadone. In the within-group analysis, matched SOS recipients had significant improvements in the monthly rate of opioid toxicities (step change -1·09 events per 100 individuals [95% CI -2·12 to -0·07]; p=0·037), all-cause emergency department visits (-8·85 per person-year [-13·5 to -4·20]; p=0·0002), all-cause inpatient hospitalisations (-2·08 per person-year [-3·41 to -0·75]; p=0·0022), incident infections (-0·68 per person-year [-1·22 to -0·14]; p=0·013), and non-primary-care-related health-care costs (-$91 699 per person-year [-112 749 to -70 650]; p<0·0001). Results were consistent for methadone recipients. In the between-group analysis, individuals commencing SOS had significantly higher hazards of opioid toxicity (hazard ratio 2·83 [95% CI 1·97 to 4·06]), emergency department visits (1·16 [1·05 to 1·29]), and inpatient admissions (1·50 [1·13 to 1·99]), no significant difference in the rate of incident infection (1·51 [0·87 to 2·61]), and were less likely to discontinue treatment than those commencing methadone (0·62 [0·55 to 0·70]). When treatment discontinuation was removed as a censoring criterion, we found no difference between groups in the hazard of any of the primary outcomes except opioid toxicity (1·65 [1·38 to 1·97]). INTERPRETATION:SOS and methadone were associated with improvements in health outcomes, including reduced opioid toxicities and health-care use, in the year after treatment initiation. The findings suggest SOS programmes play an important, complementary role to traditional opioid agonist treatment in expanding the options available to support people who use drugs. FUNDING:Canadian Institutes of Health Research and Ontario SPOR Support Unit.

Background: People with cystic fibrosis (pwCF) are living longer and with an increased risk of malignancies, preventative cancer screening is crucial. The objectives of this study were to determine cancer screening rates for pwCF compared to the general population, and assess the impact of primary care provider (PCP) involvement on screening rates among those with CF. Methods: This population-based cohort study linked Canadian CF Registry data with health administrative databases. Four screening cohorts were identified: breast, cervical, colorectal pre-transplant, colorectal post-transplant. PCP involvement was defined using billing codes. Screening rates were calculated as the number screened divided by the number of person-years individuals were eligible for screening. Poisson regression was used to describe rates. Results: In the CF cohort, 74/110 (67.3 %) were screened for breast cancer, and 321/541 (59.3 %) for cervical cancer. 186/402 (46.3 %) in the pre-transplant cohort were screened with colonoscopy and 75/148 (50.7 %) in the post-transplant cohort. Those with CF were significantly more likely to be screened for breast cancer (RR 3.39, 95 % CI 2.70-4.26) and colorectal cancer pre-transplant (RR 1.58, 95 % CI 1.37-1.82) compared to the non-CF cohort. Having a PCP increased the likelihood that pwCF received screening for breast cancer (RR 3.6, 95 % CI 1.13-11.44), cervical cancer (RR 1.71, 95 % CI 1.13-2.57), and colorectal cancer (pre-transplant population only) (RR 1.57, 95 % CI 1.06-2.32). Conclusions: Screening rates for cancers in CF remain suboptimal. These results highlight opportunities to improve screening uptake through better integration of PCP in CF care models and to increase awareness of cancer risk.

OBJECTIVE:Phenotype hospital, physician, and emergency department (ED) visits by diagnoses and specialty up to 29 years pre-multiple sclerosis (MS) onset versus a matched population without MS. METHODS:We identified people with MS (PwMS) using population-based administrative data from Ontario, Canada (1991-2020). The first MS/demyelinating diagnostic code defined MS onset (the index date). Annual rates of healthcare use (hospital, physician, ED) by primary diagnosis (chapter-level) and physician specialty pre-index were compared between PwMS and up to 5 matched population comparators using overdispersed-Poisson regression. RESULTS:Up to 35,018 PwMS and 136,007 population comparators were included. Consistently elevated yearly physician visit rate ratios (RRs) were observed 28 years pre-index for: mental-health (RR > 1.29) and ill-defined signs/symptoms (RR > 1.15), 24 years for: nervous (RR > 1.47), musculoskeletal (RR > 1.21), injury, and respiratory-related issues (RR > 1.07), and 22 years for digestive-system (RR > 1.18). The magnitude increased as the index date approached, peaking the year pre-index for physician, hospital, and ED visit RRs for: nervous-system (range: 12.06-17.13); ill-defined signs/symptoms (range: 3.51-5.45), mental-health (range: 2.13-2.70), musculoskeletal (range: 1.84-2.96), injury (range: 1.58-2.27), digestive-system (range: 1.49-1.78) and respiratory-system (range: 1.37-2.06). By specialty, yearly visit RRs for primary care were > 1.08 for 28 years pre-index, internal medicine exceeded 1.19 for 25 years, and psychiatry and neurology > 1.52 for 24 years pre-index. INTERPRETATION:Higher healthcare use was evident for over two decades before the first demyelinating event. Mental-related, ill-defined signs/symptoms and primary care visits were consistently elevated the longest (28 years pre-index), followed by nervous-system, musculoskeletal, injury, respiratory-related, and digestive-system (22-24 years pre-index). Health-related phenotypical differences appear early in the MS disease process.

Acute kidney injury (AKI) remains a critical clinical condition with high morbidity and mortality. Continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) are commonly employed renal support modalities. This study aimed to compare the therapeutic efficacy and clinical outcomes of CRRT and IHD in patients with AKI. A retrospective cohort study was conducted at a single tertiary care center from January 2022 to December 2024. A total of 256 patients diagnosed with AKI were included, comprising 136 patients treated with CRRT and 120 with IHD. Patients were selected based on Kidney Disease: Improving Global Outcomes criteria, excluding those with stage 4 to 5 chronic kidney disease (CKD), prior renal transplantation, significant comorbidities, or concurrent enrollment in other clinical trials. Key outcome measures included changes in hemodynamic parameters (mean arterial pressure and heart rate), renal function markers (serum creatinine and blood urea nitrogen), and Acute Physiology and Chronic Health Evaluation II scores. Statistical analyses were performed using SPSS version 27.0 (IBM Corporation, Armonk), with independent t tests and Chi-square tests applied where appropriate. Following treatment, mean arterial pressure decreased slightly in the CRRT group, whereas a statistically significant greater reduction was observed in the IHD group (P < .05). Heart rate increased in both groups; however, the elevation was significantly more pronounced in the IHD group. Both modalities resulted in improved renal function and a significant reduction in Acute Physiology and Chronic Health Evaluation II scores. The incidence of treatment-related complications was comparatively lower in the CRRT group. Survival analysis indicated that survivors were significantly younger and exhibited a lower prevalence of multi-organ dysfunction. Compared to IHD, CRRT was associated with improved hemodynamic tolerance, lower complication rates, and potentially better short-term outcomes in patients with AKI. These findings support the preferential use of CRRT in critically ill patients with hemodynamic instability and warrant validation through prospective, multicenter studies.

Rationale: People with cystic fibrosis (pwCF) are living longer with increasing comorbidities. Objectives: To estimate the rate of emerging nonpulmonary comorbidities in adults with cystic fibrosis (CF) and to compare these rates with the non-CF population. Methods: This is a population-based cohort study of adults using Canadian Cystic Fibrosis Registry data linked with health administrative databases in Ontario. Cases of cardiovascular disease (CVD) and symptomatic kidney stones were identified using diagnostic and procedural codes. Chronic kidney disease (CKD) was defined as estimated glomerular filtration rate  <60 ml/min/1.73 m2. Cancer cases were obtained using the Ontario Cancer Registry. Poisson regression was used to estimate the rates per 1,000 person-years of follow-up. Results: The age- and sex-adjusted rates of CVD, CKD, kidney stones, and cancer per 1,000 person-years in the non-lung transplantation cohort were 24.5 (95% confidence interval [CI], 21.5-28.0), 3.7 (95% CI, 2.7-5.2), 7.4 (95% CI, 6.1-9.0), and 5.8 (95% CI, 4.5-7.6) respectively. pwCF who underwent lung transplantation had higher rates of all four conditions, and cancer and CKD occurred earlier compared with the nontransplantation cohort. When comparing the CF and non-CF populations, pwCF without lung transplantation had higher age- and sex-adjusted rates of CVD (relative risk [RR], 2.9 [95% CI, 2.6-3.4]), CKD (RR, 2.1 [95% CI, 1.5-2.9]), kidney stones (RR, 2.9 [95% CI, 2.4-3.6]), and cancer (RR, 1.9 [95% CI, 1.5-2.5]). These events occurred at a median age of at least 20 years earlier in the CF cohort. In the post-transplantation population, there were no significant differences in the rates of CVD, kidney stones, and cancers between pwCF and the non-CF population, but events occurred earlier in pwCF. Conclusions: Nonpulmonary complications occur at a high rate and at a younger age in pwCF compared with the non-CF population, which highlights the importance of incorporating these issues in CF care models.

BACKGROUND AND OBJECTIVES:Peripartum mood and anxiety disorders constitute the most frequent form of maternal morbidity in the general population, but little is known about peripartum mental illness in mothers with multiple sclerosis (MS). We compared the incidence and prevalence of peripartum mental illness among mothers with MS, epilepsy, inflammatory bowel disease (IBD), and diabetes and women without these conditions. METHODS:Using linked population-based administrative health data from ON, Canada, we conducted a cohort study of mothers with MS, epilepsy, IBD, and diabetes and without these diseases (comparators) who had a live birth with index dates, defined as 1 year before conception, between 2002 and 2017. Using validated definitions, we estimated the incidence and prevalence of mental illness (any, depression, anxiety, bipolar disorder, psychosis, substance use, suicide attempt) during the prenatal (PN) period (from conception to birth) and 3 years postpartum. We compared incidence and prevalence estimates between cohorts using simple incidence ratios (IRs) and prevalence ratios with 95% CIs and using Poisson regression models adjusting for confounders. RESULTS:We included 894,852 mothers (1,745 with MS; 5,954 with epilepsy; 4,924 with IBD; 13,002 with diabetes; 869,227 comparators). At conception, the mean (SD) maternal age was 28.6 (5.7) years. Any incident mental illness affected 8.4% of mothers with MS prenatally and 14.2% during the first postpartum year; depression and anxiety were the most common incident disorders. The first postpartum year was a higher risk period than the PN period (any mental illness IR 1.27; 95% CI 1.08-1.50). After adjustment, mothers with MS had an increased incidence of any mental illness during the PN (IR 1.26; 95% CI 1.11-1.44) and postpartum (IR 1.33; 95% CI 1.20-1.47, first postpartum year) periods than comparator mothers. Similarly, mothers with MS had an increased incidence of all specific mental illnesses except suicide attempt during the PN period vs comparator mothers. Any prevalent mental illness affected 42% of mothers with MS prenatally and 50.3% in the first postpartum year. DISCUSSION:Mothers with MS had an elevated incidence and prevalence of peripartum mental illness compared with comparator mothers, although residual confounding cannot be excluded. These findings emphasize the need for preventive interventions and early treatment of mental illness.

Abstract Objective Elevated healthcare use before multiple sclerosis (MS) onset suggests earlier opportunity to identify MS. Yet their timing and sociodemographic effects are unclear. We examined rates of healthcare use (and by age/sex) for >two decades pre‐MS onset. Methods We identified people with MS (PwMS) using administrative data from Canada (Ontario) and Sweden (1991–2020) (“administrative” cohort), and the Swedish MS Registry (“clinical” cohort). The first MS/demyelinating diagnostic code (administrative) or symptom onset (clinical) defined MS onset. We compared annual rates of healthcare use (hospital, physician, and emergency‐room [ED]) pre‐onset between PwMS and up to five matched population controls using negative binomial regression, and by age/sex. Results The administrative cohort = 35,018/136,007 PwMS/controls (Ontario), and 10,269/51,297 (Sweden). Rates of healthcare use were higher for PwMS than controls up to 28 (of 29) years (Ontario) and up to 15 (of 19) years (Sweden) pre‐onset. Annual healthcare use rose steadily as onset approached, particularly escalating 7 years pre‐onset in Ontario (e.g., hospital visit rate ratios [RRs] exceeded 1.30), and 6 years in Sweden (physician visit RRs > 1.10). RRs peaked the year pre‐onset (ED visits [Ontario] = 3.04; 95% CI: 2.94–3.13, physician visits [Sweden] = 2.51; 95% CI: 2.44–2.59). In the year pre‐onset, RRs were disproportionately higher for males (ED RRs [Ontario] = 3.30; 95% CI: 3.13–3.48 vs. females = 2.90; 95% CI: 2.79–3.02), and dropped steadily by age (physician visit RRs [Sweden] = 2.61/2.27/1.97/1.72 for 50/40/30/20‐year‐olds). The smaller clinical cohort (7604/37,974 PwMS/controls) exhibited similar patterns, albeit more modest, with RRs elevated up to 5 years pre‐onset (physician visit RR [year‐5] = 1.08; 95% CI: 1.02–1.14; RR [year‐1] = 1.39;1.33–1.46). Interpretation Higher healthcare use was evident decades before MS onset, escalating 6–7 years pre‐onset, peaking the year before, being disproportionately higher for males and older PwMS.

BACKGROUND:Investigations of a prodrome in multiple sclerosis (MS) usually have included adults. OBJECTIVE:To compare rates and reasons for health care use in youth with and without MS, considering time relative to the MS index date and to birth. METHODS:This retrospective cohort study used population-based administrative data (1991-2020) from Ontario, Canada. We matched youth (<18 years) with MS up to 5:1 to youth without MS by sex, birth year, region, and duration of observation (full cohorts). Subcohorts had data from birth to MS index date (first demyelinating disease claim). We compared health services use, adjusting for age, sex, area-level income, region, and year. RESULTS:We included 451 individuals with pediatric-onset MS and 1422 without MS. As of 6 years pre-index, the full MS cohort had higher physician services use (year 6: rate ratio (RR) = 1.45; 95% confidence interval (95% CI) = 1.25-1.67) and hospitalizations (RR = 2.79; 95% CI = 1.31-5.94). Findings were similar in subcohorts. The MS subcohort had elevated physician visit rates in early life that rose as the MS index date approached. DISCUSSION:Youth with pediatric-onset MS exhibit increased health care use from birth. Early life may be a risk period for MS. A prodromal phase may emerge 6 years before the onset of typical MS symptoms.

AimTo test whether an audit and feedback-based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.MethodsMulti-centre, quasi-experimental pre-post study of an AF-based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence-informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population-based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre-implementation (June 2018-May 2019); early-implementation (June 2019-September 2020); and late-implementation (October 2020-September 2021). Multivariable linear regression models were fit separately in each cohort.ResultsThere were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late-implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre-implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.ConclusionsWe found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers.

Background: Oxycodone is increasingly prescribed for postpartum analgesia in lieu of codeine owing to concerns regarding the neonatal safety of codeine during lactation. We examined whether initiation of oxycodone after delivery was associated with an increased risk of persistent opioid use relative to initiation of codeine. Methods: We conducted a population-based cohort study of people who filled a prescription for either codeine or oxycodone within 7 days of discharge from hospital after delivery between Sept. 1, 2012, and June 30, 2020. The primary outcome was persistent opioid use, defined as 1 or more additional prescriptions for an opioid within 90 days of the first postpartum prescription and 1 or more additional prescriptions in the 91 to 365 days thereafter. We used inverse probability of treatment weighting to assess the risk of persistent postpartum opioid use, comparing people who initiated oxycodone with those who initiated codeine. Results: Over the 8-year study period, we identified 70 607 people who filled an opioid prescription within 7 days of discharge from hospital: 21 308 (30.2%) received codeine and 49 299 (69.8%) oxycodone. Compared with people who filled a prescription for codeine, receipt of oxycodone was not associated with persistent opioid use (relative risk [RR] 1.04, 95% confidence interval [CI] 0.91–1.20). We found an association between a prescription for oxycodone and persistent use after vaginal delivery (RR 1.63, 95% CI 1.31–2.03), but not after cesarean delivery (RR 0.85, 95% CI 0.73–1.00). Interpretation: Initiation of oxycodone (v. codeine) was not associated with an increased risk of persistent opioid use, except after vaginal delivery.

Introduction Respiratory-related morbidity and mortality were evaluated in relation to incident prescription oral synthetic cannabinoid (nabilone, dronabinol) use among older adults with chronic obstructive pulmonary disease (COPD). Methods This was a retrospective, population-based, data-linkage cohort study, analysing health administrative data from Ontario, Canada, from 2006 to 2016. We identified individuals aged 66 years and older with COPD, using a highly specific, validated algorithm, excluding individuals with malignancy and those receiving palliative care (n=185 876 after exclusions). An equivalent number (2106 in each group) of new cannabinoid users (defined as individuals dispensed either nabilone or dronabinol, with no dispensing for either drug in the year previous) and controls (defined as new users of a non-cannabinoid drug) were matched on 36 relevant covariates, using propensity scoring methods. Cox proportional hazard regression was used. Results Rate of hospitalisation for COPD or pneumonia was not significantly different between new cannabinoid users and controls (HR 0.87; 95% CI 0.61–1.24). However, significantly higher rates of all-cause mortality occurred among new cannabinoid users compared with controls (HR 1.64; 95% CI 1.14–2.39). Individuals receiving higher-dose cannabinoids relative to controls were observed to experience both increased rates of hospitalisation for COPD and pneumonia (HR 2.78; 95% CI 1.17–7.09) and all-cause mortality (HR 3.31; 95% CI 1.30–9.51). Conclusions New cannabinoid use was associated with elevated rates of adverse outcomes among older adults with COPD. Although further research is needed to confirm these observations, our findings should be considered in decisions to use cannabinoids among older adults with COPD.

Chronic obstructive pulmonary disease (COPD) poses a significant but heterogeneous burden to individuals and healthcare systems. Policymakers develop targeted policies to minimize this burden but need personalized tools to evaluate novel interventions and target them to subpopulations most likely to benefit. We developed a platform to identify subgroups that are at increased risk of emergency department visits, hospitalizations and mortality and to provide stratified patient input in economic evaluations of COPD interventions. We relied on administrative and survey data from Ontario, Canada and applied a combination of microsimulation and multi-state modeling methods. We illustrated the functionality of the platform by quantifying outcomes across smoking status (current, former, never smokers) and by estimating the effect of smoking cessation on resource use and survival, by comparing outcomes of hypothetical cohorts of smokers who quit at diagnosis and smokers that continued to smoke post diagnosis. The cumulative incidence of all-cause mortality was 37.9% (95% CI: 34.9, 41.4) for never smokers, 34.7% (95% CI: 32.1, 36.9) for current smokers, and 46.4% (95% CI: 43.6, 49.0) for former smokers, at 14 years. Over 14 years, smokers who did not quit at diagnosis had 16.3% (95% CI: 9.6, 38.4%) more COPD-related emergency department visits than smokers who quit at diagnosis. In summary, we combined methods from clinical and economic modeling to create a novel tool that policymakers and health economists can use to inform future COPD policy decisions and quantify the effect of modifying COPD risk factors on resource utilization and morality.

Opioids have been increasingly associated with suicide, but whether they are independent contributors is unclear. Oxycodone and hydromorphone are commonly prescribed high-potency opioids that can differentially affect mood. The objective of this study was to explore whether oxycodone and hydromorphone are differentially associated with suicide. We conducted a retrospective population-based case-control study in Ontario, Canada, from 1992 to 2014. Using coronial data, we defined case subjects as individuals who died by suicide involving an opioid overdose. Each of these was matched with up to four controls who died of accidental opioid overdose. We ascertained exposure to oxycodone, hydromorphone, and other opioids from postmortem toxicology testing. We used odds ratios and 95% confidence intervals to examine whether opioid-related suicide was disproportionately associated with oxycodone relative to hydromorphone. We identified 438 suicides and 1212 accidental deaths, each of which involved either oxycodone or hydromorphone but not both. The median age at death was 49 years and 51% were men. After adjusting for a history of self-harm, psychiatric illness, and exposure to other opioids, we found that oxycodone was more strongly associated with suicide than hydromorphone (adjusted odds ratio 1.59; 95% confidence interval 1.20–2.11). In a secondary analysis, we observed a trend of similar magnitude in which combined exposure to oxycodone and hydromorphone was more strongly associated with suicide than hydromorphone alone (adjusted odds ratio 1.68; 95% confidence interval 0.92–3.09). While preliminary, these findings support the possibility that some high-potency opioids might independently influence the risk of suicide in susceptible individuals.

Rationale: Although opioids are frequently prescribed in chronic obstructive pulmonary disease (COPD), there is poor understanding regarding which individuals will experience pulmonary harm upon exposure. Objectives: We sought to identify patient characteristics and opioid drug properties predictive of opioid-related adverse pulmonary events among older adults with chronic COPD. Methods: A retrospective, population-based, cohort study design was used, analyzing Ontario heath administrative data. Individuals aged 66 years and older, with validated, physician-diagnosed COPD receiving a new opioid drug were included. Adverse pulmonary events (defined as an emergency room visit, hospitalization, or death related to either COPD or pneumonia) occurring within 30 days following new opioid receipt were considered. Multivariable-adjusted, cause-specific hazard modeling was used to identify predictors of adverse pulmonary events. Results: Out of 169,517 older adults with COPD receiving a new opioid, 4,861 (2.9%) experienced an adverse pulmonary event within 30 days. Factors independently predisposing to adverse pulmonary events included older age (>= 85 yr old: hazard ratio [IR], 1.37; 95% confidence interval [CI], 1.26-L49), long-term-care home residence (HR, 1.32; 95% CI, 1.21-1.44), severe COPD exacerbation within the preceding year (HR, 2.96; 95% CI, 2.77-3.17), comorbidities (including non-COPD lung disease [IR, 1.16; 95% CI, 1.09-1.23], congestive heart failure [FIR, 1.22; 95% a, 1.14-1.30], sleep disorder [FIR, 1.22; 95% CI, 1.15-1.30], and dementia [HR, 1.14; 95% CI, 1.05-1.24]); other psychoactive medication receipt, including benzodiazepines (FIR, 1.27; 95% CI, 1.19-1.35) and serotonergic antidepressants (HR, 1.10; 95% CI, 1.03-1.19), and receipt of an opioid-only agent (HR, 1.35; 95% CI, 1.26-1.46). Factors that independently protected from adverse pulmonary events included female sex (FIR, 0.78; 95% CI, 0.73-0.82), surgery within the preceding year (HR, 0.70; 95% CI, 0.64-0.77), and musculoskeletal disease (HR, 0.75; 95% CI, 0.70-0.80). No significant associations were observed between adverse pulmonary events and opioid halflife duration or opioid daily dosage. Conclusions: Patient and opioid drug factors predictive of opioid-related adverse pulmonary events among older adults with COPD were identified, which may assist with safer opioid prescribing.

Background In-hospital medication review has been linked to improved outcomes after discharge, yet there is little evidence to support the use of community pharmacy-based interventions as part of transitional care. Objective To determine whether receipt of a postdischarge community pharmacy-based medication reconciliation and adherence review is associated with a reduced risk of death or re-admission. Design Propensity score-matched cohort study. Setting Ontario, Canada Participants Patients over age 66 years discharged home from an acute care hospital from 1 April 2007 to 16 September 2016. Exposure MedsCheck, a publicly funded medication reconciliation and adherence review provided by community pharmacists. Main outcome The primary outcome was time to death or re-admission (defined as an emergency department visit or urgent rehospitalisation) up to 30 days. Secondary outcomes were the 30-day count of outpatient physician visits and time to adverse drug event. Results MedsCheck recipients had a lower risk of 30-day death or re-admission (23.4% vs 23.9%, HR 0.97, 95% CI 0.95 to 1.00, p=0.02), driven by a decreased risk of death (1.7% vs 2.1%, HR 0.79, 95% CI 0.73 to 0.86) and rehospitalisation (11.0% vs 11.4%, HR 0.96, 95% 0.93-0.99). In a post hoc sensitivity analysis with pharmacy random effects added to the propensity score model, these results were substantially attenuated. There was no significant difference in 30-day return to the emergency department (22.5% vs 22.8%, HR 0.99, 95% CI 0.96 to 1.01) or adverse drug events (1.5% vs 1.5%, HR 1.03, 95% CI 0.94 to 1.12). MedsCheck recipients had more outpatient visits (mean 2.11 vs 2.09, RR 1.01, 95% CI 1.00 to 1.02, p=0.02). Conclusions and relevance Among older adults, receipt of a community pharmacy-based medication reconciliation and adherence review was associated with a small reduced risk of short-term death or re-admission. Due to the possibility of unmeasured confounding, experimental studies are needed to clarify the relationship between postdischarge community pharmacy-based medication review and patient outcomes.

Background Synthetic oral cannabinoids (nabilone and dronabinol) may have adverse respiratory effects. Our purpose was to describe the scope, pattern, and patient characteristics associated with incident off-label synthetic oral cannabinoid use among older adults with chronic obstructive pulmonary disease (COPD) compared to older adults without COPD. Methods This was a retrospective, population-based, cohort study using Ontario, Canada, heath administrative data. Individuals aged 66 years or older were included, and physician-diagnosed COPD was identified using a previously validated, highly specific algorithm. Incident off- label oral cannabinoid use was examined between April 1, 2005 and March 31, 2015. Descriptive statistics were used to describe drug use patterns. Multiple logistic regression was used to identify patient characteristics associated with incident drug use. Results There were 172,282 older adults with COPD and 1,068,256 older adults without COPD identified between April 1, 2005 and March 31, 2015. Incident synthetic oral cannabinoid use during this period occurred with significantly greater (p < 0.001) frequency among older adults with COPD (0.6%) versus older adults without COPD (0.3%). Compared to those without COPD, older adults with COPD used synthetic cannabinoids for significantly longer durations and more frequently at higher doses. Conclusions Although incident off-label oral cannabinoid use was relatively low among all older Ontarian adults, this drug class was used with greater frequency and more often in potentially concerning ways among older adults with COPD. These findings raise possible safety concerns, but further research on the respiratory safety of oral cannabinoids among individuals with COPD is needed.