It is not known whether non-ABO antibodies confer any protective effect against SARS-CoV-2 infection or COVID-19 severe illness alone or in conjunction with O blood group. This cohort study included 413 576 persons in Ontario, Canada with known ABO blood group and non-ABO antibody screen status, who subsequently underwent SARS-CoV-2 viral RNA polymerase chain reaction testing between January and November 2020. The risk of SARS-CoV-2 infection or COVID-19 severe illness was not associated with the presence of non-ABO antibodies, even among persons with O blood group.

Persons with non-O blood group (i.e., A, AB or B) may be at higher risk of venous thromboembolism (VTE) than those with O blood (odds ratio 1.79, 95% CI 1.56 to 2.05). Non-O blood groups may also be predisposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During the recent SARSCoV-2 pandemic, a high rate of VTE was observed among infected patients. Lung tissue specimens from coronavirus disease 2019 (COVID-19) patients showed a preponderance of alveolar capillary microthrombi. A unique COVID-19associated predisposing coagulopathy (CAC) was proposed. It is not known whether SARS-CoV-2 infected patients with nonO blood groups are especially at higher risk of VTE. This population-based retrospective cohort study was performed across Ontario, Canada, where health care is universal. Patient-level datasets capturing all inpatients, emergency department and outpatient visits, medical imaging billings, and SARS-CoV-2 laboratory tests were linked using unique encoded identifiers and analyzed at ICES (Table S1). The determination of pulmonary embolism (PE) or deep vein thrombosis (DVT) required a coded diagnosis of either condition, in conjunction with performance of objective imaging (Table S1). Included were individuals aged 16þ years, who had undergone ABO determination between January 2007 and December 2019, and who then underwent SARS-CoV-2 viral RNA PCR testing between January 15, 2020 and June 30, 2020. First, the overall risk of PE or DVT was determined in relation to non-O vs. O blood groups. Next, PE or DVT risk was assessed in association with SARS-CoV-2 positivity vs. negativity. Third, the influence of O blood group was stratified by those with a positive or negative SARS-CoV-2 test. Cox proportional hazard models generated incidence rates and hazard ratios (HR) and 95% CI, with time zero (t0) first set to the date of ABO testing, and then re-set to the date of SARSCoV-2 specimen collection. Censoring, starting on the date of SARS-CoV-2 testing, was on death or arrival to the end of the study period of July 31, 2020. HR were adjusted for demographics and comorbidities. In total, 222,670 individuals were included in the final cohort. Their mean age was 51 years at ABO testing and 54 years at SARS-CoV-2 testing; 71% were female (Table 1). No important differences were seen in the rate of prior VTE, or for any other comorbidities (Table 1). Starting t0 from ABO testing, the aHR was higher for PE (1.14, 1.06 to 1.23) and DVT (1.12, 1.05 to 1.19) comparing O vs. non-O blood groups (Table 2). Starting t0 from SARS-CoV-2 testing, the overall incidence rate of VTE rose considerably. Those with vs. without SARSCoV-2 had a higher aHR of PE (1.64, 1.15 to 2.33), but not DVT (0.74, 0.45 to 1.22) (Table 2). The aHR for PE was higher among non-O blood groups in patients without SARS-CoV-2 infection (1.33, 1.13 to 1.56), but not those with SARS-CoV-2 infection (1.14, 95% CI 0.56 to 2.31) (Table 2). These findings confirm a higher risk of PE and DVT with non-O blood groups. The risk of PE, but not DVT, was elevated in those with SARS-CoV-2, as also suggested elsewhere, possibly due to pulmonary immunothrombi arising in situ.

Introduction:Health care systems have faced unprecedented challenges due to the COVID-19 pandemic. Access to timely population-based data has been vital to informing public health policy and practice.Methods:We describe how ICES, an independent not-for-profit research and analytic institute in Ontario, Canada, pivoted existing research infrastructure and engaged health system stakeholders to provide near real-time population-based data and analytics to support Ontario's COVID-19 pandemic response.Results:Since April 2020, ICES provided the Ontario COVID-19 Provincial Command Table and public health partners with regular and ad hoc reports on SARS-CoV-2 testing and COVID-19 vaccine coverage. These reports: 1) helped identify congregate care/shared living settings that needed testing and prevention efforts early in the pandemic; 2) provided early indications of inequities in testing and infection in marginalized neighbourhoods, including areas with higher proportions of immigrants and visible minorities; 3) identified areas with high test positivity, which helped Public Health Units target and evaluate prevention efforts; and 4) contributed to altering the province's COVID-19 vaccine roll-out strategy to target high-risk neighbourhoods and helping Public Health Units and community organizations plan local vaccination programs. In addition, ICES is a key component of the Ontario Health Data Platform, which provides scientists with data access to conduct COVID-19 research and analyses.Discussion and Conclusion:ICES was well-positioned to provide rapid analyses for decision-makers to respond to the evolving public health emergency, and continues to contribute to Ontario's pandemic response by providing timely, relevant reports to health system stakeholders and facilitating data access for externally-funded COVID-19 research.

Introduction Probabilistic Record Linkage of large databases requires a substantial amount of time and resources, resulting in significant costs. In addition, the process is subject to error, particularly during manual grey area resolution of uncertain matched pairs. Objectives and Approach The objective of this semi-experimental desinged study was to compare the accuracy and efficiency of different record linkage approaches. Four different record linkage software packages were selected: AutoMatch, G-Link, SAS Data Quality (DataFlux) and LinxMart. A large data set with all required linkage variables (e.g., first and last name, date of birth and gender) and a common unique identifier with the ICES linkage spine (registry) was chosen to represent our ground truth. Four non-overlapping cohorts were randomly selected from this data source, representing small (n=10,000), medium (n=250,000) and large (n=5,000,000) data sets. Simulated errors were inserted into each cohort to represent a real linkage scenario. The smallest cohort was used to run a complete record linkage for each software package. Where the software allowed for manual grey area resolution, linkage was replicated by two different linkage analysts who were blinded to the simulated errors included in the data set. The time spent by each analyst on processing, programming and manual grey area resolution was recorded. The larger cohorts were used to measure accuracy and processing time taken by each of the software packages. In order to analyse possible errors, detailed output from each software package was generated to compare accepted and rejected pairs with our ground truth. Results This project is still ongoing. Evaluation of AutoMatch, G-Link and SAS Data Quality has largely been completed. The remaining analyses will be completed by August 2020. Conclusion / Implications The outcome of this project can inform the record linkage strategy at organizations and data centres such as ICES and help identify more efficient methods that preserve an acceptable level of accuracy for their needs.

ICES was founded in 1992 to study the health care system and promote effective, efficient and equitable health care. Over 27 years later, the goal remains largely unchanged, though the institute has grown in size and impact. Created as an independent not-for-profit research institute and given what was, at the time, unprecedented access to administrative health data records for the population of Ontario, ICES’ initial focus was to better understand the delivery of hospital services and translate its findings into better health care and policy. From modest beginnings with a handful of researchers located in a few hospital offices, ICES has grown to encompass a community of almost 500 scientists and staff across a network of seven physical sites in Ontario. The original focus on hospital-based services has expanded significantly and now includes research and analysis of community-based health services, health policy, Indigenous health, social determinants of health, and data science.

Objectives To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time.Design Population-based cohort study using health administrative data.Setting Ontario, Canada from 1 April 2007 to 31 March 2014.Participants 62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity.Main outcome measures Rates of health service use, long-term care placement and mortality over time.Results After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI −0.6 to 1.9 increase per year).Conclusions While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.

Introduction A significant amount of valuable information in Electronic Health Records (EHR) such as laboratory test results or echocardiogram interpretations is embedded in lengthy free-text fields. Often patients’ personal information is also included in these narratives. Privacy legislation in different jurisdictions requires de-identification of this information prior to making it available for research. This process can be challenging and time-consuming. In particular, rule-based algorithms may lead to over-masking of essential medical terms, conditions, or devices that are named after individuals. Objectives and Approach We aimed to enhance ICES’ existing rule-based application to make it contextually-driven by applying Artificial Intelligence (AI). The ICES team collaborated with computer scientists at the University of Manchester who had already published work in this area and Evenset, a Toronto-based software company. Based on the Manchester University de-identification framework for name entity recognition, three machine learning-based algorithms for name entity recognition were implemented: CRF, BiLSTM recurrent neural networks with GLoVe and ELMo word embeddings. The models were trained on three different types of ICES data: Laboratory results, Electronic Medical Record (EMR) and echocardiogram data. Evenset developed the user interface and the masking modules. Results Preliminary tests have generated very promising results. To improve accuracy of the models, additional data annotation to expand the training datasets is currently being undertaken at ICES. The final framework will be available as an open-source tool for public. Conclusion / Implications A collaborative approach for solving complex problems like de-identification of text-based medical data is highly efficient, especially where there are unique sets of expertise, resources, data and clinical knowledge among stakeholders.

This cohort study examines whether ABO and Rh blood groups are associated with the risk for SARS-CoV-2 infection and severe COVID-19 illness using data from the entire province of Ontario, Canada.

Abstract Health systems strive to enable persons with Alzheimer’s and related dementias to remain at home to maximize their quality of life. There is limited evidence describing long-term trajectories of health system use by persons with dementia as they remain in the community over time. A cohort of 62,622 community-dwelling older adults was followed for seven years and matched to persons without dementia (controls) based on age, sex and comorbidities. Overall, persons with dementia were more likely than controls to use health services, particularly home care and hospitalizations with discharge delay; and were more likely to be admitted to a nursing home. As they remained in the community over time, persons with dementia used home care at an increasingly intensive rate. Our approach to examine trajectories of health system use among persons with dementia is of particular value to capacity planning initiatives to anticipate future health service needs of this population.

Overall objectives or goal Most of the organizations that use population administrative data for research purposes have internal repository of validated definitions and algorithms of their own. Many of these concepts and definitions are applicable or at least adaptable to other organizations and jurisdictions. A comprehensive National (and potentially International) Concept Dictionary could help investigators to carry out methodologically sound work using consistent and validated algorithms using a shared pool of knowledge and resources. The Institute for Clinical Evaluative Sciences (ICES) in Ontario, Canada has recently modernized its internal Concept Dictionary by adopting standard templates based on the Manitoba Centre for Health Policy (MCHP) Concept Dictionary, reviewing and updating existing content and tagging the concept entries with appropriate MeSH terms and data sources, and adding standard computer code (e.g., SAS coding) where appropriate. A SharePoint® web-based application has been developed to provide advanced tagging, searching and browsing features. We envision a wiki-based Concept Dictionary hosted on a cloud-based environment with very granular access controls to provide enough flexibility for each participating organization to control their own content. This means each organization will be able to decide on how to share their own concepts (or part of them) with the public or internal users. All content will be tagged with MeSH terms and as well with the organization’s name that initially posts each entry. Other organizations which find the same concept applicable to their own use can tag the same entry with their organization name or refer to a secondary adapted entry if adaptation to fit their data and methodologies is required. The Search feature will allow refining the search criteria by MeSH terms, data sources, and also organization/jurisdiction name. Multiple layers of access controls will allow each organization to have their own groups of users with different standard privileges such as Local Administrators, Authors and Approvers (or Publishers). The Approver (Publisher) users within each organization can publish each entry for internal or public view. This way, for example, a definition/algorithm can be viewable only within the organization until the validation process is complete, and then the entry can be made publically available, while some sections, such as computer code, can remain restricted to the organization. We will discuss challenges in developing and maintaining such a platform including the costs, governance, intellectual property rights, copyrights and liabilities for the participating organizations. The intended output or outcome We aim to use this opportunity to form a working group from the interested organizations that are ready to participate and commit in developing this collaborative platform. After the conference, there will be follow up sessions with the members of the working group to plan and develop the online application.

ABSTRACTObjectivesThere is a growing need to broaden access to administrative health data in order to support decision making and planning by health system stakeholders. An initiative funded by the Ontario Ministry of Health and Long-Term Care, the Applied Health Research Question (AHRQ) portfolio leverages the linked administrative health data holdings and the scientific and clinical expertise at ICES to answer questions generated by stakeholders that will have a direct impact on health care policy, planning or practice. ApproachEligible requesters include government ministries, health care providers and planners. Requests detail the purpose of the research question, the related scientific literature, and the planned use and intended impact of the research findings. An internal review team meets monthly to adjudicate; requests demonstrably needing research findings rapidly are adjudicated on an ad hoc basis. Eligible requests are those that aim to inform evidence-based decision making, do not advocate for a particular answer and are feasible in terms of data availability. All projects are reviewed by the internal privacy office to ensure that use of the administrative health data is in accordance with both data sharing agreements and legislation governing use of personal health information. At no cost to the requesting organization, ICES scientists and research staff formulate the analysis plan, conduct the analysis and prepare the research product (data tables, a slide deck and/or a written report); and, may opt to publish noteworthy findings. All research products must be cleared for risk of re-identification prior to being shared externally. ResultsRequests have steadily increased from 43 submissions in fiscal year 2012/13, to 59 in 2014/15 and 74 to date in 2015/16. In fiscal year 2014/15, provincial government and government agencies were the most frequent requesters (39%), followed by hospitals and other health care providers (19%), disease advocacy groups (12%) and professional associations (10%). Requests include assessment of health care utilization; health system performance and evaluation; and chronic disease prevalence and treatment. Time to complete reports varies from 5 days to 24 months, depending on project complexity and requirements. Requesters report that AHRQ research findings have influenced decision-making, policy development and health care practice; and have inspired future research. ConclusionThis initiative demonstrates the value and feasibility of using the linked administrative health data to answer questions to meet the unique needs of health planners and policymakers, and presents an opportunity for collaboration beyond the academic research community.

Background: Antibiotic stewardship is a required organizational practice for Canadian acute care hospitals, yet data are scarce regarding the quantity and composition of antibiotic use across facilities. We sought to examine the variability, and risk-adjusted variability, in antibiotic use across acute care hospitals in Ontario, Canada’s most populous province. Methods: Antibiotic purchasing data from IMS Health, previously demonstrated to correlate strongly with internal antibiotic dispensing data, were acquired for 129 Ontario hospitals from January to December 2014 and linked to patient day (PD) denominator data from administrative datasets. Hospital variation in DDDs/1000 PDs was determined for overall antibiotic use, class-specific use and six practices of clinical or ecological significance. Multivariable risk adjustment for hospital and patient characteristics was used to compare observed versus expected utilization. Results: There was 7.4-fold variability in the quantity of antibiotic use across the 129 acute care hospitals, from 253 to 1873 DDDs/1000 PDs. Variation was evident within hospital subtypes, exceeded that explained by hospital and patient characteristics, and included wide variability in proportion of broad-spectrum antibiotics (IQR 36%–48%), proportion of fluoroquinolones among respiratory antibiotics (IQR 40%–62%), proportion of ciprofloxacin among urinary anti-infectives (IQR 44%–60%), proportion of antibiotics with highest risk for Clostridium difficile (IQR 29%–40%), proportion of ‘reserved-use’ antibiotics (IQR 0.8%–3.5%) and proportion of anti-pseudomonal antibiotics among antibiotics with Gram-negative coverage (IQR 26%–40%). Conclusions: There is extensive variability in antibiotic use, and risk-adjusted use, across acute care hospitals. This could motivate, focus and benchmark antibiotic stewardship efforts.

ABSTRACT Objective Efforts to enable persons with dementia to remain at home longer, and to reduce use of costly acute care resources, are at the forefront of policy agendas internationally. Foundational to planning appropriate health system supports is the ongoing, comparable and accurate estimation of the prevalence and incidence of dementia across regions, as well as associated patterns of health services use and cost. Our objective was to explore emerging approaches to using population data in dementia research and demonstrate the policy contribution of the resulting new knowledge. Approach Using population-based health administrative data and an algorithm that was validated using electronic medical records, we developed a series of repeated, cross-sectional cohort studies to examine trends in dementia prevalence, incidence and publicly-funded health service use and costs between 2004/05 and 2013/14 among adults aged 65 years and older in Ontario, Canada. Trends in yearly rates of health service use were assessed using regression models for serially correlated data and compared to a 1:1 matched control group based on age, sex, geographic region and comorbidity level. Results Over time, age- and sex-adjusted prevalence of dementia increased by 18.2% (from 63.0 to 74.5 per 1,000 persons; p-value < 0.001) and age- and sex-adjusted incidence decreased slightly (from 18.2 to 17.0 per 1,000 persons; p-value = 0.05). Community-dwelling persons with dementia were more likely than matched controls to be placed in long-term care (11.8% vs. 1.5% in 2013; p<0.001) and use home care (45.8% vs 23.2%; p<0.001) but equally likely to visit family physicians (93.9% vs. 94.8% in 2013) and specialists (87.1% vs. 89.4%). Median costs associated with one year of health system use were $19,468 (interquartile range (IQR) $4,490 to $47,726) for prevalent cases in 2012/13 and $16,549 (IQR $5,070 to $47,899) for incident cases. Long-term care and hospital care accounted for the largest portion of total costs in both groups. Conclusion The prevalence of dementia has increased in Ontario, Canada over time and, given slightly declining incidence rates, is likely attributable to improved survival. Surveillance of dementia with health administrative data is a cost-effective tool for describing and monitoring trends in incidence and prevalence over time, and for supporting health system capacity planning. This comparative information is critical to understanding the impact of policy decisions designed to address dementia-related health care needs at a population level.

OBJECTIVES:Evidence is mixed regarding the impact of false-positive (FP) newborn bloodspot screening (NBS) results on health care use. Using cystic fibrosis (CF) as an example, we determined the association of FP NBS results with health care use in infants and their mothers in Ontario, Canada.METHODS:We conducted a population-based cohort study of all infants with FP CF results (N = 1564) and screen-negative matched controls (N = 6256) born between April 2008 and November 2012 using linked health administrative data. Outcomes included maternal and infant physician and emergency visits and inpatient hospitalizations from the infant's third to 15th month of age. Negative binomial regression tested associations of NBS status with outcomes, adjusting for infant and maternal characteristics.RESULTS:A greater proportion of infants with FP results had >2 outpatient visits (16.2% vs 13.2%) and >2 hospital admissions (1.5% vs 0.7%) compared with controls; CF-related admissions and emergency department visits were not different from controls. Differences persisted after adjustment, with higher rates of outpatient visits (relative risk 1.39; 95% confidence interval 1.20-1.60) and hospital admissions (relative risk 1.67; 95% confidence interval 1.21-2.31) for FP infants. Stratified models indicated the effect of FP status was greater among those whose primary care provider was a pediatrician. No differences in health care use among mothers were detected.CONCLUSIONS:Higher use of outpatient services among FP infants may relate to a lengthy confirmatory testing process or follow-up carrier testing. However, increased rates of hospitalization might signal heightened perceptions of vulnerability among healthy infants.

Background We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions. Methods Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators. Results Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26). Conclusions These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.

IMPORTANCEFetal safety of magnetic resonance imaging (MRI) during the first trimester of pregnancy or with gadolinium enhancement at any time of pregnancy is unknown.OBJECTIVETo evaluate the long-term safety after exposure to MRI in the first trimester of pregnancy or to gadolinium at any time during pregnancy.DESIGN, SETTING, AND PARTICIPANTSUniversal health care databases in the province of Ontario, Canada, were used to identify all births of more than 20 weeks, from 2003-2015.EXPOSURESMagnetic resonance imaging exposure in the first trimester of pregnancy, or gadolinium MRI exposure at any time in pregnancy.MAIN OUTCOMES AND MEASURESFor first-trimester MRI exposure, the risk of stillbirth or neonatal death within 28 days of birth and any congenital anomaly, neoplasm, and hearing or vision loss was evaluated from birth to age 4 years. For gadolinium-enhanced MRI in pregnancy, connective tissue or skin disease resembling nephrogenic systemic fibrosis (NSF-like) and a broader set of rheumatological, inflammatory, or infiltrative skin conditions from birth were identified.RESULTSOf 1 424 105 deliveries (48% girls; mean gestational age, 39 weeks), the overall rate of MRI was 3.97 per 1000 pregnancies. Comparing first-trimester MRI (n = 1737) to no MRI (n = 1 418 451), there were 19 stillbirths or deaths vs 9844 in the unexposed cohort (adjusted relative risk [RR], 1.68; 95% CI, 0.97 to 2.90) for an adjusted risk difference of 4.7 per 1000 person-years (95% CI, -1.6 to 11.0). The risk was also not significantly higher for congenital anomalies, neoplasm, or vision or hearing loss. Comparing gadolinium MRI (n = 397) with no MRI (n = 1 418 451), the hazard ratio for NSF-like outcomes was not statistically significant. The broader outcome of any rheumatological, inflammatory, or infiltrative skin condition occurred in 123 vs 384 180 births (adjusted HR, 1.36; 95% CI, 1.09 to 1.69) for an adjusted risk difference of 45.3 per 1000 person-years (95% CI, 11.3 to 86.8). Stillbirths and neonatal deaths occurred among 7 MRI-exposed vs 9844 unexposed pregnancies (adjusted RR, 3.70; 95% CI, 1.55 to 8.85) for an adjusted risk difference of 47.5 per 1000 pregnancies (95% CI, 9.7 to 138.2).CONCLUSIONS AND RELEVANCEExposure to MRI during the first trimester of pregnancy compared with nonexposure was not associated with increased risk of harm to the fetus or in early childhood. Gadolinium MRI at any time during pregnancy was associated with an increased risk of a broad set of rheumatological, inflammatory, or infiltrative skin conditions and for stillbirth or neonatal death. The study may not have been able to detect rare adverse outcomes.

Dementia contributes to nursing home admission and, for quality of life and cost saving reasons, health systems are interested in expanding services to support living at home longer. The study objectives were to describe the level and trend in health care service use by community-dwelling adults with dementia in Ontario. Population-based, repeated cross-sectional cohorts of community-dwelling adults aged 40 years and older with pre-existing dementia were identified on April 1st of each year from 2007 to 2013 using a validated algorithm in linked administrative data. Persons with dementia were compared to a 1:1 matched control group based on age, sex, geographic region and comorbidity level. Trends in yearly rates of health service use were assessed using regression models for serially correlated data. Rates accounted for transitions from the community (long-term care placement (LTC) and death). Community-dwelling persons with dementia were more likely than matched controls to be placed in LTC (11.8% vs. 1.5% in 2013; p<0.001) and use home care (45.8% vs 23.2%; p<0.001) but equally likely to visit family physicians (93.9% vs. 94.8% in 2013) and specialists (87.1% vs. 89.4%). Overall, LTC placement decreased slightly among community-dwelling persons with dementia, from 13.3% to 11.8% between 2007 and 2013 (p<0.001), while the proportion who died in the community remained stable (7.3% in 2013). Rates of personal/homemaking home care increased over time (41.6 to 67.9 visits per person-year; p<0.001), rates of family physician visits decreased (14.1 to 12.3 visits per person-year; p<0.001) and rates of acute care (0.39 to 0.40 hospitalizations per person-year) remained stable. Trends were similar for matched controls. These data suggest rates of LTC placement may be declining while access to home care appears to be growing. Health care service utilization in other sectors is similar to matched controls. Further research is required to understand transitions to LTC and optimizing care in the community for persons with dementia.

Objectives: To evaluate maternal world region of birth, as well as maternal country of origin, and the associated risk of admission of 1) a mother to a maternal ICU, 2) her infant to a neonatal ICU, or 3) both concurrently to an ICU. Design: Retrospective population-based cohort study. Setting: Entire province of Ontario, Canada, from 2003 to 2012. Patients: All singleton maternal-child pairs who delivered in any Ontario hospital. Measurements and Main Results: We explored how maternal world region of birth, and specifically, maternal country of birth for the top 25 countries, was associated with the outcome of 1) neonatal ICU, 2) maternal ICU, and 3) both mother and newborn concurrently admitted to ICU. Relative risks were adjusted for maternal age, parity, income quintile, chronic hypertension, diabetes mellitus, obesity, dyslipidemia, drug dependence or tobacco use, and renal disease. Compared with infants of Canadian-born mothers (110.7/1,000), the rate of neonatal ICU admission was higher in immigrants from South Asia (155.2/1,000), Africa (140.4/1,000), and the Caribbean (167.3/1,000; adjusted relative risk, 1.41; 95% CI, 1.36–1.46). For maternal ICU, the adjusted relative risk was 1.79 (95% CI, 1.43–2.24) for women from Africa and 2.21 (95% CI, 1.78–2.75) for women from the Caribbean. Specifically, mothers from Ghana (adjusted relative risk, 2.71; 95% CI, 1.75–4.21) and Jamaica (adjusted relative risk, 2.74; 95% CI, 2.12–3.53) were at highest risk of maternal ICU admission. The risk of both mother and newborn concurrently admitted to ICU was even more pronounced for Ghana and Jamaica. Conclusions: Women from Africa and the Caribbean and, in particular, Ghana and Jamaica, are at higher risk of admission to ICU around the time of delivery, as are their newborns.

The Institute for Clinical Evaluative Sciences (ICES) is one of only a few organizations in Ontario permitted to access, link and analyze health administrative data for the purpose of generating evidence to inform decisions in policy and practice. Although ICES is a leading research institute, its access to the data has historically been restricted to scientists with an ICES affiliation. This requirement, designed to meet ICES' data privacy and security obligations, created barriers with respect to the widespread use of Ontario's data assets. In 2014, as part of the government's commitment to the Strategy for Patient-Oriented Research, ICES launched the Data & Analytic Services platform, which is aimed at increasing access to data and analytic services to investigators external to ICES. In making the data widely available to the broader research community, this initiative engages investigators involved in front-line care, stimulates new avenues of research and fosters collaboration that was previously challenging or unfeasible.

STUDY OBJECTIVE:In 2008, a pay-for-performance program was implemented in sequential waves in Ontario emergency departments (EDs), with the aim of reducing length of stay. We seek to evaluate its effects on ED length of stay and quality of care.METHODS:This was a retrospective observational study of ED visits in Ontario from April 1, 2007, to March 31, 2011, using multivariable difference-in-differences analysis. Pay-for-performance hospitals and matched control sites were selected for each of 3 waves of the program. The primary outcome was 90th percentile ED length of stay; we also examined quality-of-care indicators.RESULTS:Pay-for-performance hospitals had a modest reduction in overall adjusted 90th percentile ED length of stay in wave 1 (-36 minutes; 95% confidence interval [CI] -50 to -21 minutes), but not in wave 2 (-14 minutes; 95% CI -30 to 2 minutes) or wave 3 (-7 minutes; 95% CI -23 to 8 minutes). ED admitted patients had a pronounced reduction in adjusted 90th percentile length of stay in wave 1 (-225 minutes; 95% CI -263 to -188 minutes) and wave 2 (-133 minutes; 95% CI -175 to -91 minutes). Nonadmitted low-acuity patients had reductions in adjusted 90th percentile ED length of stay in wave 1 (-24 minutes; 95% CI -29 to -18 minutes) and wave 3 (-19 minutes; 95% CI -24 to -14 minutes). The program did not negatively affect ED quality-of-care measures, such as 30-day mortality or readmission rates.CONCLUSION:Pay-for-performance was associated with modest overall benefits for ED length of stay without adversely affecting quality of care.