QuestionIs an acute heart failure risk algorithm and strategy for post-emergency department care and/or hospital admission similarly beneficial in females and males at reducing the composite outcome of cardiovascular hospitalization or death?FindingsIn this prespecified secondary analysis of a stepped-wedge, cluster-randomized clinical trial of 5452 patients (2461 female and 2991 male), the adjusted hazard ratio for the primary outcome was 0.88 in both sexes. There was no effect modification for the trial intervention by sex.MeaningThese findings suggest that the strategy of acute heart failure care may be of similar benefit in both females and males. This prespecified secondary analysis of a randomized clinical trial explores whether an emergency department-based strategy for disposition decisions and rapid postdischarge transitional care might be similarly applicable to female and male patients presenting to the emergency department with acute heart failure. ImportanceFemale patients with heart failure (HF) are older and more often present with preserved left ventricular ejection fraction (LVEF), whereas male patients present with more ischemic disease. Despite these differences, an emergency department-based acute HF strategy may be equally applicable to both sexes.ObjectiveTo determine whether the strategy for acute HF management in the Comparison of Outcomes and Access to Care for Heart Failure (COACH) trial differed by sex.Design, Setting, and ParticipantsThis prespecified secondary analysis of the multicenter COACH stepped-wedge, cluster-randomized clinical trial included 10 acute care hospitals in Ontario, Canada. Data were collected from January 15, 2017, to January 15, 2019. Participants included patients presenting to a study emergency department with acute HF. Cox proportional hazards regression with interactions was used to evaluate whether intervention effects differed for females and males and to estimate sex-specific association with treatment. Data were analyzed from July 2024 to May 2025.InterventionRisk stratification for disposition decisions from the emergency department and risk-guided postdischarge transitional care, examining sex interactions.Main Outcomes and MeasuresComposite of death or cardiovascular hospitalizations at 30 days (primary outcome) and during extended follow-up to 20 months (co-primary outcome).ResultsA total of 5452 patients were included in the analysis (median age, 78.0 [IQR, 68.0-85.0] years). The 2461 females were older (median age, 80.0 [IQR, 71.0-87.0] years) than the 2991 males (median age, 76.0 [IQR, 66.0-84.0] years). Females had more preserved LVEF (>= 50%) compared with males (1107 [45.0%] vs 885 [29.6%]; standardized mean difference, 0.32). Males had more prior myocardial infarction compared with females (565 [18.9%] vs 338 [13.7%]; standardized mean difference, 0.14). There was no interaction by sex at 30 days (hazard ratios [HRs] for primary outcome, 0.88 [95% CI, 0.68-1.14] for females and 0.88 [95% CI, 0.71-1.08] for males; P = .98 for interaction) or 20 months (HRs for co-primary outcome, 0.99 [95% CI, 0.90-1.09] in females and 0.92 [95% CI, 0.85-1.00] in males; P = .38 for interaction). There was a significant interaction by sex for 20-month HF readmissions (P = .01 for interaction), with adjusted HRs of 0.92 (95% CI, 0.72-1.19) in females and 0.71 (95% CI, 0.58-0.87) in males. There were no sex interactions for other outcomes at either time point.Conclusions and RelevanceIn this secondary analysis of a stepped-wedge, cluster-randomized clinical trial, risk stratification for emergency department-based decision-making for disposition decisions and rapid postdischarge transitional care was similarly beneficial in males and females, with comparable outcomes after accounting for multiplicity.Trial RegistrationClinicalTrials.gov Identifier: NCT02674438

Importance:Female patients with heart failure (HF) are older and more often present with preserved left ventricular ejection fraction (LVEF), whereas male patients present with more ischemic disease. Despite these differences, an emergency department-based acute HF strategy may be equally applicable to both sexes. Objective:To determine whether the strategy for acute HF management in the Comparison of Outcomes and Access to Care for Heart Failure (COACH) trial differed by sex. Design, Setting, and Participants:This prespecified secondary analysis of the multicenter COACH stepped-wedge, cluster-randomized clinical trial included 10 acute care hospitals in Ontario, Canada. Data were collected from January 15, 2017, to January 15, 2019. Participants included patients presenting to a study emergency department with acute HF. Cox proportional hazards regression with interactions was used to evaluate whether intervention effects differed for females and males and to estimate sex-specific association with treatment. Data were analyzed from July 2024 to May 2025. Intervention:Risk stratification for disposition decisions from the emergency department and risk-guided postdischarge transitional care, examining sex interactions. Main Outcomes and Measures:Composite of death or cardiovascular hospitalizations at 30 days (primary outcome) and during extended follow-up to 20 months (co-primary outcome). Results:A total of 5452 patients were included in the analysis (median age, 78.0 [IQR, 68.0-85.0] years). The 2461 females were older (median age, 80.0 [IQR, 71.0-87.0] years) than the 2991 males (median age, 76.0 [IQR, 66.0-84.0] years). Females had more preserved LVEF (≥50%) compared with males (1107 [45.0%] vs 885 [29.6%]; standardized mean difference, 0.32). Males had more prior myocardial infarction compared with females (565 [18.9%] vs 338 [13.7%]; standardized mean difference, 0.14). There was no interaction by sex at 30 days (hazard ratios [HRs] for primary outcome, 0.88 [95% CI, 0.68-1.14] for females and 0.88 [95% CI, 0.71-1.08] for males; P = .98 for interaction) or 20 months (HRs for co-primary outcome, 0.99 [95% CI, 0.90-1.09] in females and 0.92 [95% CI, 0.85-1.00] in males; P = .38 for interaction). There was a significant interaction by sex for 20-month HF readmissions (P = .01 for interaction), with adjusted HRs of 0.92 (95% CI, 0.72-1.19) in females and 0.71 (95% CI, 0.58-0.87) in males. There were no sex interactions for other outcomes at either time point. Conclusions and Relevance:In this secondary analysis of a stepped-wedge, cluster-randomized clinical trial, risk stratification for emergency department-based decision-making for disposition decisions and rapid postdischarge transitional care was similarly beneficial in males and females, with comparable outcomes after accounting for multiplicity. Trial Registration:ClinicalTrials.gov Identifier: NCT02674438.

Objective and ApproachWe analyzed barriers and enablers to accessing pan-Canadian health sector data and data analytic services for three distinct user groups: 1) academic researchers, 2) health-system knowledge users (KUs), and 3) private sector researchers. Specifically, we a) conducted a legislative and policy scan regarding use of health administrative data for research, quality improvement, and health system management and b) systematically consulted with data centre directors and staff, privacy and legal experts, knowledge users (KUs), private sector entities, and university and government officials. ResultsKUs and private sector organizations face unique barriers because structures and regulations related to data access and use are set at multiple university and government institutions and are primarily designed for academic research. Additionally, data repositories often have specific policy/legislative barriers to working with KUs and/or private sector researchers. However, all groups face common issues including variations in regional regulations and policies making harmonized and streamlined processes challenging; lengthy data access and ethics review processes; and regional variations in data availability. Enablers included diverse expertise and initiatives across Canada such as: initiatives to streamline ethics reviews for multi-regional research, expand data holdings, increase standardization and harmonization, and implement systems for federated analyses. ConclusionsAccess to health system data and analytics in Canada varies by user group and across regions. Although each user group faces unique challenges, they also all have many barriers and enablers in common. ImplicationsImproving health system data access for one use group has the potential to benefit the others.

ObjectiveStewards of population-level data have an obligation to serve the public interest. As one such publicly funded data steward, our Public Advisory Council (PAC) co-led and determined the focus of an analysis project using population-level administrative health data. We describe our engagement strategies herein. ApproachThe 20-member PAC was involved in each stage of the project, from research question formulation to knowledge translation planning over 18 months, consisting of 12 meetings with both large and smaller groups. Our approach to engagement applied the International Association for Public Participation’s Framework as the foundation for an ‘empowerment’ level of engagement and adapted approaches from the James Lind Alliance and the ‘Plan-Do-Study-Act’ cycle. ResultsThe PAC chose to focus their analysis project on factors related to mental health and addiction service use. Four strategies were used and co-designed by members to foster engagement throughout: providing education and guidance, shared and guided brainstorming, building consensus, and responsiveness to feedback and evaluation. PAC members directed how and when these strategies were used, with challenges and lessons learned currently being co-developed into a publicly accessible report. ConclusionsOur work demonstrates the importance and value of public-driven research outputs and the feasibility of integrating public members in the work of data stewards. ImplicationsThe insights and practical strategies generated from this project will be used to guide effective engagement of the public for future analysis projects and to improve trust and social license for other initiatives using population-level data.

The December highlights from the Circulation

Objective There is growing recognition of the importance of community data governance to build accountability of research institutions to communities. Our organization, a steward of health and administrative population-level data, has previously implemented community governance structures for Indigenous data. This scoping initiative explores development and implementation of an additional community governance structure for race-related data. Approach We conducted a scoping review of peer-reviewed and grey literature to identify existing practices of community data governance. We also conducted key informant interviews with thirteen racialized community stakeholders, who addressed open-ended questions on potential co-design processes as well as governance mandates, scopes, barriers, and facilitators. Results The scoping review identified eight community data governance examples. Two of these pertained to race-related data, while the remaining six pertained to other data that identified “community” geographically, by disease condition, life stage, and/or economic circumstance. Governance structures were diverse, ranging from one-time crowd-design of a data-sharing agreement to quarterly meetings of a governing board to review project-level data requests. Key informant interviews provided four themes to guide implementation in the context of our organization: exploring organizational readiness, considering who should be involved, defining the scope and mandate, and drafting an approach and process. Conclusion We are committed to implementing a community governance structure for race-related, population-level data. However, there are limited examples of similar structures in the existing literature. Implications The identified examples and the advice of community stakeholders will guide co-design of a preliminary structure, scope, and mandate for community governance of race-related, population-level data.

There is growing recognition of the importance of patient, public and community engagement in health research, which has not been used widely in analyzing health administrative datasets. In Ontario, health data are stewarded by ICES, whose strategic decision making is guided by a diverse Public Advisory Council (PAC). In a first foray into publicly led projects, the ICES PAC undertook an analysis project on mental health and addiction health service use. Public members guided the project through all stages of research. This generated critical lessons for ICES on improving participation, collaboration and trust.

Aim We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system.Methods and resultsIn a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age <= 65 or >= 66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p <= 0.001). Younger residents (age <= 65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (>= 66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived.Conclusion Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.

Background: Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits.Methods: We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk.Results: Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines.Conclusions: History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.

IntroductionAround the world, many organisations are working on ways to increase the use, sharing, and reuse of person-level data for research, evaluation, planning, and innovation while ensuring that data are secure and privacy is protected. As a contribution to broader efforts to improve data governance and management, in 2020 members of our team published 12 minimum specification essential requirements (min specs) to provide practical guidance for organisations establishing or operating data trusts and other forms of data infrastructure. Approach and AimsWe convened an international team, consisting mostly of participants from Canada and the United States of America, to test and refine the original 12 min specs. Twenty-three (23) data-focused organisations and initiatives recorded the various ways they address the min specs. Sub-teams analysed the results, used the findings to make improvements to the min specs, and identified materials to support organisations/initiatives in addressing the min specs. ResultsAnalyses and discussion led to an updated set of 15 min specs covering five categories: one min spec for Legal, five for Governance, four for Management, two for Data Users, and three for Stakeholder & Public Engagement. Multiple changes were made to make the min specs language more technically complete and precise. The updated set of 15 min specs has been integrated into a Canadian national standard that, to our knowledge, is the first to include requirements for public engagement and Indigenous Data Sovereignty. ConclusionsThe testing and refinement of the min specs led to significant additions and improvements. The min specs helped the 23 organisations/initiatives involved in this project communicate and compare how they achieve responsible and trustworthy data governance and management. By extension, the min specs, and the Canadian national standard based on them, are likely to be useful for other data-focused organisations and initiatives.

BACKGROUND: Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS: Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS: Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95–1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03–1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS: In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

Background: The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups. Methods: This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health–related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale. Results: The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: "short duration" (frequent, regularly spaced visits), "older patients" (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), "young mental health" (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health–related and alcohol-related visits) and "injury" (increased prevalence of injury-related visits). Interpretation: From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.

Background Community-dwelling older adults living with dementia visit the emergency department (ED) more frequently than other older adults, but research on the reasons for repeated visits is lacking. We examined the rate of repeated ED visits and reasons for visits in a cohort of individuals with dementia. Methods We conducted a population-based retrospective cohort study of community-dwelling older adults (>= 66 years) living with dementia in Ontario, Canada, who visited the ED and were discharged home between April 1, 2010, and March 31, 2019. We calculated the proportion of the population with one, two, and three or more repeat ED visits within 1 year of the baseline visit and the categorized the reason for the visits. Results Our cohort contained 175,863 individuals with dementia who visited the ED at least once. Overall, 66.1% returned at least once to the ED within 1 year, 39.4% returned twice, and 23.5% returned 3 or more times. Visit reasons were heterogenous and were most frequently related to general signs and symptoms (25.3%) while being infrequently due to cognitive or behavioral reasons (5.9%). Individuals typically visited for different reasons across successive visits. Conclusions Community-dwelling older adults with dementia who visited an ED were very likely to return to the ED within a year, with a substantial proportion visiting multiple times. The high frequency of repeated visits for different reasons highlights the complexity of caring for this population and indicates greater need for comprehensive community and primary care as well as timely communication between the ED and the community.

Background: Community-dwelling people with dementia have been affected by COVID-19 pandemic health risks and control measures that resulted in worsened access to health care and service cancellation. One critical access point in health systems is the emergency department. We aimed to determine the change in weekly rates of visits to the emergency department of community-dwelling people with dementia in Ontario during the first 2 waves of the COVID-19 pandemic compared with historical patterns. Methods: We conducted a population-based repeated cross-sectional study and used health administrative databases to compare rates of visits to the emergency department among community-dwelling people with dementia who were aged 40 years and older in Ontario during the first 2 waves of the COVID-19 pandemic (March 2020–February 2021) with the rates of a historical period (March 2019–February 2020). Weekly rates of visits to the emergency department were evaluated overall, by urgency and by chapter from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. We used Poisson models to compare pandemic and historical rates at the week of the lowest rate during the pandemic period and the latest week. Results: We observed large immediate declines in rates of visits to the emergency department during the COVID-19 pandemic (rate ratio [RR] 0.50, 95% confidence interval [CI] 0.47–0.53), which remained below historical levels by the end of the second wave (RR 0.88, 95% CI 0.83–0.92). Rates of both nonurgent (RR 0.33, 95% CI 0.28–0.39) and urgent (RR 0.51, 95% CI 0.48–0.55) visits to the emergency department also declined and remained low (RR 0.68, 95% CI 0.59–0.79, RR 0.91, 95% CI 0.86–0.96), respectively. Visits for injuries, and circulatory, respiratory and musculoskeletal diseases declined and remained below historical levels. Interpretation: Prolonged reductions in visits to the emergency department among people with dementia during the first 2 pandemic waves raise concerns about patients who delay seeking acute care services. Understanding the long-term effects of these reductions requires further research.