Background: The FoodRx randomized controlled trial (RCT) studied the impact of a healthy food incentive program among adults with type 2 diabetes and food insecurity (including an Indigenous subset), and engaged an advisory board (All My Relations [AMR]) to advise on aspects relevant to Indigenous Peoples. We sought to explore the evolution of the board's role and its contribution and influence on the RCT. Methods: We conducted a qualitative process evaluation within community-based participatory research. We conducted semistructured interviews with AMR board members and FoodRx academic members, and sourced AMR board meeting notes. We analyzed these data iteratively using directed content analysis and continuous engagement with the AMR board. Results: Seven AMR board members, 3 FoodRx academic members, and 4 AMR board members and FoodRx academics participated in interviews. Our analysis showed 4 key interconnected themes: Culture and ceremony (celebrating the importance of Indigenous languages, naming ceremonies, and spiritual practices fostering inclusivity and connection); Transformative environment (emphasizing a sacred gathering space where voices are equal, trust thrives, and personal growth is cultivated); Indigenous Ways of Knowing (embracing the application of Indigenous wise practices, challenging Western research ideals, and advocating for RCT design equity); and Equitable partnership (affirming the centrality of relationship building, acknowledging Indigenous knowledge, redistributing decision-making power, and increasing transparency). Interpretation: Our findings emphasized the importance of authentic involvement of Indigenous community representatives in the conduct of research. Research involving Indigenous participants requires a commitment to respect for Indigenous values and incorporating Indigenous Ways of Knowing, as well as involving Indigenous partners early in the planning of the project.

BACKGROUND:Emerging blood-based tests have potential to complement current breast imaging to increase early-stage detection for women with dense breasts. This analysis examines the cost-effectiveness of potential pathways using preliminary data from an emerging blood test to inform future research. MATERIALS AND METHODS:Preliminary accuracy results for the blood test were modeled in combination, and in comparison, with mammography for biennial screening starting at age 40 for women with dense breasts using a lifetime Markov model. Costs, life years (LYs) and quality-adjusted life-years (QALYs) of each screening pathway were compared. The primary results were probabilistic incremental cost-effectiveness ratios (ICER). RESULTS:Modeling showed the blood test generating 22.40 LYs, 18.78 QALYs per individual, and lifetime costs of $21,642. Combination of blood test and mammography produced higher LYs, QALYs, and costs comparatively (22.42 LYs, 18.80 QALYs, $24,986), resulting in an ICER of $169,384 per QALY compared to blood test alone. Two-way sensitivity analysis showed positive net monetary value for a range of blood test sensitivities and specificities. CONCLUSIONS:The blood test may represent a cost-effective option relative to mammography alone or in combination for biennial screening of women with dense breasts, supporting the rationale for continued evidence generation.

Objectives: Decision-analytic models assessing the value of emerging Alzheimer's disease (AD) treatments are challenged by limited evidence on short-term trial outcomes and uncertainty in extrapolating long-term patient-relevant outcomes. To improve understanding and foster transparency and credibility in modeling methods, we cross-compared AD decision models in a hypothetical context of disease-modifying treatment for mild cognitive impairment (MCI) due to AD. Methods: A benchmark scenario (US setting) was used with target population MCI due to AD and a set of synthetically generated hypothetical trial efficacy estimates. Treatment costs were excluded. Model predictions (10-year horizon) were assessed and discussed during a 2-day workshop. Results: Nine modeling groups provided model predictions. Implementation of treatment effectiveness varied across models based on trial efficacy outcome selection (clinical dementia rating-sum of boxes, clinical dementia rating-global, mini-mental state examination, functional activities questionnaire) and analysis method (observed severity transitions, change from baseline, progression hazard ratio, or calibration to these). Predicted mean time in MCI ranged from 2.6 to 5.2 years for control strategy and from 0.1 to 1.0 years for difference between intervention and control strategies. Predicted quality-adjusted life-year gains ranged from 0.0 to 0.6 and incremental costs (excluding treatment costs) from 2US$66 897 to US$11 896. Conclusions: Trial data can be implemented in different ways across health-economic models leading to large variation in model predictions. We recommend (1) addressing the choice of outcome measure and treatment effectiveness assumptions in sensitivity analysis, (2) a standardized reporting table for model predictions, and (3) exploring the use of registries for future AD treatments measuring long-term disease progression to reduce uncertainty of extrapolating short-term trial results by health-economic models.

Background:Financial incentives may improve diet quality and reduce food insecurity, but how incentives align with population preferences for delivery (mode, structure) and shopping habits (frequency, spending) remains unclear. Methods:A July 2022 cross-sectional survey of 1,601 Canadian adults (excluding Quebec) examined incentive preferences, shopping frequency and healthy food spending shortfalls using Poisson and generalized linear models. Results:Weekly instant loyalty card discounts were most preferred. The median spending gap was $12.50 (mean $21.48), with food-insecure participants reporting the largest gaps. Conclusion:Aligning incentive design with population preferences and shopping habits may enhance uptake. Higher-value incentives may be needed to more fully engage food-insecure populations.

Introduction:People with diabetes experiencing homelessness face barriers to self-management, contributing to suboptimal glycemia and reduced screening for microvascular complications. The objective of the study was to assess whether a history of homelessness is associated with kidney-related outcomes among people with diabetes. Methods:A propensity-matched cohort study using administrative health data from Ontario, Canada, was conducted, including residents with diabetes who had ≥1 hospital encounter during the study period (2008-2020). Having a history of homelessness was identified using a validated algorithm. Outcomes of interest included nephrologist visits, reduction in estimated glomerular filtration rate (eGFR), initiation of renal replacement therapy, and acute care visits for kidney-related ambulatory care-sensitive conditions. Negative binomial regression and Cox proportional hazard models were used to assess outcomes. Results:Of 659,877 eligible people with diabetes living in Ontario, 3366 had a history of homelessness, with 2650 successfully matched to non-homeless controls. People with a history of homelessness had similar rates of nephrologist visits compared with those with no history of homelessness (rate ratio [RR] = 1.27; 95% confidence interval [CI]: 0.82-1.97), but had higher rates of hospitalization for chronic kidney disease (CKD)-related conditions, including volume overload (RR = 3.13; 95% CI: 1.62-6.04), hyperkalemia (RR = 3.01; 95% CI: 2.07-4.39), and heart failure (RR = 2.06; 95% CI: 1.62-2.63). They had a higher hazard of eGFR decline (hazard ratio [HR] = 1.71; 95% CI: 1.56-1.88), and renal replacement therapy (HR = 1.65; 95% CI: 1.04-2.60) compared with nonhomeless controls. Conclusion:Homelessness is associated with higher rates of kidney-related adverse events in people living with diabetes, supporting the need for tailored approaches that reduce barriers to accessing diabetes care.

To estimate the association between publicly provided take-home naloxone kits and opioid-related deaths. We analyzed 2732 opioid-related deaths and the distribution of 147,814 naloxone kits between January 2015 and June 2019 across five health zones in Alberta, Canada. We used a Poisson pseudo-maximum likelihood regression model with fixed effects to estimate the association between the number of kits in circulation and the number of monthly opioid-related deaths, controlling for population demographics, socio-economic indicators, other harm reduction strategies, police seizures of fentanyl and carfentanil, and an estimate of awareness. Every 10,000 kits in circulation was associated with a 23.9

Background: In the last decade, options for treatment of sickle cell disease (SCD) have grown remarkably with the development of new disease modifying agents, expanding use of hematopoietic cell transplantation (HCT) and the recent development of gene therapy. Previous reports have evaluated cost effectiveness of various disease modifying agents and have compared costs of HCT and gene therapy to medical management of SCD. These studies have demonstrated a significant upfront cost that varies depending on the stem cell source and conditioning regimen applied, but significant reduction in subsequent cost and healthcare utilization occurs. However, these studies have largely been performed in the United States (US), while the limited studies of HCT costs in other countries report much lower cost for HCT. The aim of the current study was to compare the costs of transplant for SCD between centers in the US that have a primarily private insurance and utilise myeloablative or reduced toxicity conditioning with a center in Canada that has a universal healthcare plan and employ a non-myeloablative regimen. Methods Three centers participated in the study, two from the US (Children's Healthcare of Atlanta and St. Jude Children's Research Hospital) and one from Canada (Alberta Children's Hospital, Calgary). Any child or young adult who received an HCT for SCD from a matched sibling donor and consented to data sharing was eligible to take part. Data was collected retrospectively from hospital-based financial datasets. Additionally, chart review of the Canadian participants was performed manually for validation of that dataset. Individuals transplanted from 2013-2022 had encounter level data abstracted to include the 6 weeks prior to HCT and two years post. Data was categorised into groups: clinical care: relating to inpatient and outpatient care visits as well as provider fees; investigation expenses including laboratory and diagnostic imaging costs; and pharmaceutical costs. The overall cost of HCT as well as for each group were compared between countries. Outlier data underwent chart review to determine accuracy. Canadian costs were adjusted to US dollars based on the exchange rate in 2022 at the time of initial analysis. Results Seventy-seven children were included in the study, 54 from the US and 23 subjects from Canada. Overall, the median cost per patient of HCT for the US sites was $130,604 (IQR $111,667-$2,231,007) while that in Calgary was $107, 925 (IQR $96,447-$131,294) and the difference was not statistically significant (p= 0.15). Comparison of cost categories revealed significant differences in clinical (US: $9,052 [IQR $6,116-$221,383]; Canada: $55,675 [IQR $47,010-$68,707]; p=<0.05), imaging (US: $806 [IQR $275-$14,646]; Canada: $495 [IQR $45-$752]; p=<0.05), and pharmacy costs (US: $39,967 [IQR $32,366-$306,959]; Canada: $6,622 [IQR $5,861-$7,722]; p= <0.05). Laboratory costs were not statistically significant (US $26,320 [IQR $18,945-$1,697,889]; Canada: $31,310 [IQR $28,224-$44,332]). Conclusions The total cost of HCT for SCD in the US is similar to that in Canada. This suggests that current HCT approaches and/or supportive care in the US may provide a cost reduction that mitigates prior published differences in HCT costs between the two countries. However significant differences in categories of cost remain suggesting opportunities to identify potential inefficiencies and reduce costs further in both countries. In particular, while the conditioning intensity may explain some of the differences, a substantial difference in pharmaceutical and investigative cost was demonstrated. The difference in pharmaceutical expenses may owe to diverse health financing frameworks and pricing systems. Given these updated costs of HCT a more comprehensive present era cost benefit analysis of SCD treatment options is warranted.

Objective Approximately 25% of long-term care (LTC) residents are transferred to an emergency department (ED) when experiencing an acute change in health status. This can place strain on health care resources and negatively impact residents. Many residents’ conditions could be managed within LTC if appropriate supports were provided. This implementation study objective was to optimize and evaluate processes followed when considering acute care management and transfer decisions for residents in LTC. Design A randomized stepped-wedge design was used to implement a standardized LTC-to-ED care and referral pathway, supported by 2 INTERACT tools. The pathway was implemented within 9 cohorts of (4-5) LTC facilities every 3 months, supported by an implementation coach. Implementation strategies considered local LTC context and barriers, as well as pandemic-related challenges. Setting and Participants 40 LTC facilities and 4 EDs within Calgary, Canada. Methods The primary outcome was change in transfers from LTC to ED; secondary outcomes included hospital admissions, use of facilitated telephone consultation between LTC and ED physicians, and community paramedic visits. Analysis used negative binomial regression to estimate the incident rate (per 1000 residents), while adjusting for the different cohorts. An economic evaluation was conducted using a unit cost analysis. Results A reduction in the incident rate of LTC-to-ED transfers was observed with the intervention (1.70 postintervention vs 1.91 preintervention; P < .001), along with reduction in hospital admission (0.94 vs 1.08; P < .001). There was an increase in use of facilitated telephone consultations between MDs but no increase in community paramedic visits. The intervention saved the health care system CAD$7.9 million over the postimplementation evaluation period. Conclusion and Implications Implementation of a standardized LTC-to-ED care and referral pathway appears to reduce ED transfers and hospitalizations among LTC residents, while realizing cost savings to the health care system. Reducing unnecessary transfers from LTC to ED, and instead focusing on earlier identification and management of acute medical issues within LTC, looks to be a feasible, patient-centered, and resource-optimized approach to care.

OBJECTIVE:To estimate the rates of screening, diagnosis, treatment, and outcomes related to diabetic retinopathy among persons with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless controls. METHODS:A propensity score-matched cohort study was conducted using administrative health data from Ontario. Eligible persons required a diagnosis of diabetes and at least 1 hospital encounter between April 2006 and March 2019. Homeless status was determined using a validated algorithm that identified whether individuals were homeless at the time of any acute care encounter during the study period. Each person who experienced homelessness was matched to a nonhomeless control based on sociodemographic and clinical characteristics. Rate ratios (RR) and differences in proportions were calculated for screening, diagnosis, and treatment of diabetic retinopathy, as well as for the outcome of vision loss using generalized linear models with a negative binomial distribution and robust standard errors. RESULTS:1,069,493 people met the inclusion criteria, of which, 6 944 had a history of homelessness. A suitable nonhomeless match was found for 5 712 individuals. The rate of diabetic retinopathy screening was lower in those with a history of homelessness when compared to controls (RR = 0.75; 95% CI: 0.72-0.78), while the rate of having billing codes representing diabetic retinopathy was higher (RR = 1.42; 95% CI: 1.02-1.97). There was no significant difference in rates of treatment or vision loss. CONCLUSIONS:The disparities in rates of screening and diagnosis of diabetic retinopathy in those with lived experience of homelessness presents an area for targeted interventions to improve health outcomes in this population.

Background Randomized clinical trials have shown that semaglutide is associated with a clinically relevant reduction in body weight and a lower risk of adverse cardiovascular events in those who are overweight or obese with a history of cardiovascular disease but no diabetes. The objective of this study was to assess the cost-effectiveness of semaglutide for this indication. Methods A decision analytic Markov model was used to compare the lifetime benefits and costs of semaglutide 2.4-mg subcutaneous weekly vs standard care in a hypothetical cohort of patients who were overweight or obese with preexisting cardiovascular disease (and no diabetes) from the health care payer perspective. Our model included ischemic stroke, heart failure hospitalization and/or urgent visit or myocardial infarction, and death over monthly transition cycles. Model outcomes included costs (2023 CAD$), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Results Base case analysis showed that the incremental cost-effectiveness ratio for semaglutide compared with standard care was $72,962 per QALY gained with a 14% likelihood of cost-effectiveness adopting a $50,000 per QALY gained willingness to pay threshold. Factors with the greatest influence on cost-effectiveness were medication efficacy on mortality and medication cost. When the price of semaglutide was reduced by 50%, it was economically attractive at $37,190 per QALY gained with an 80% likelihood of cost-effectiveness at a $50,000 per QALY threshold. Conclusions Semaglutide might be a cost-effective option for the publicly funded health care system contingent on initial pricing. Considering the candidate population—patients who are overweight or obese with preexisting cardiovascular disease—policymakers should consider the budget effect of funding semaglutide and weigh it against other ways scarce health care dollars might be used.

Introduction and Objective: People experiencing homelessness face barriers to accessing and adhering to preventive care measures, leading to poorer diabetes outcomes, and a higher risk of diabetes-related complications compared to the general population. The objective of the study was to determine whether individuals with diabetes and a history of homelessness have higher rates of adverse kidney-related outcomes compared to those who had no history of homelessness in Ontario, Canada. Methods: We conducted a propensity score-matched cohort study using administrative health data (2006-2019), including patients with diabetes and at least one hospital encounter, excluding those with prior renal disease. The exposure variable was a history of homelessness documented during the hospital encounter, and outcomes included nephrologist visits, reduction in kidney function (eGFR), and acute care visits for kidney-related avoidable causes. Rate ratios were used to compare rates per person-year, and cause-specific hazard models were used to assess eGFR decline and renal replacement therapy initiation. Results: Of the 660,999 eligible individuals with diabetes, 3366 had a history of homelessness, of which 2650 were matched to controls without a history of homelessness. After matching, the two groups were similar with respect to their baseline characteristics (e.g., age, diabetes type, or diabetes duration). The rate of nephrologist visits did not differ between the two groups (RR 1.27, 95% CI: 0.82 - 1.97), but those with a history of homelessness had higher rates of hospitalization for CKD-related conditions (RR 2.26, 95% CI: 1.82 - 2.80). Compared to non-homeless controls, the hazard ratio for eGFR decline was 1.71 (95% CI: 1.56 - 1.88), and 1.65 (95% CI: 1.04 - 2.60) for requiring renal replacement therapy. Conclusion: A history of homelessness among patients with diabetes is associated with higher rates of CKD-related adverse events compared to those without a history of homelessness. T. Reed: None. K. Wiens: None. S. Tariq: None. L. Bai: None. P.E. Ronksley: None. S.W. Hwang: None. P. Austin: None. G.L. Booth: None. E. Spackman: None. D.J. Campbell: Research Support; Siemens Healthcare Diagnostics. Speaker's Bureau; Siemens Healthcare Diagnostics. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC).

Objectives This study aimed to evaluate the required test characteristics that a psoriatic arthritis (PsA) biomarker test would need to achieve to be considered cost-effective. Methods We adapted an existing Markov model to compare a hypothetical biomarker with current practice. The model followed a patient cohort aged 45 years with moderate psoriasis (PsO) in which PsA was prevalent but unrecognized over a 40-year time horizon. Patients were assumed to be routinely seen at a dermatology clinic. In the current practice arm, patients with PsA were clinically detected. In the biomarker arm, a hypothetical test was assumed to be administered at baseline. Patients who screened positive would accept a combination of conventional disease-modifying antirheumatic drugs and targeted treatment to slow disease progression. Progression was modeled as linear changes in Health Assessment Questionnaire (HAQ) scores. We varied the sensitivity, specificity, and biomarker price based on current development progress. Scenario analyses considered alternative patient cohorts with mild and severe PsO separately. Results The base case showed that a biomarker test with 70 percent sensitivity, 80 percent specificity, and a price of US$500 would be cost-effective (incremental cost-effectiveness ratio US$47,566 per quality-adjusted life-year [QALY]). Three-way analyses showed that a test with 80 percent specificity could be cost-effective at a US$50,000 per QALY threshold with a sensitivity as low as 66 percent at US$500. Only a near-perfect test would be cost-effective at a US$1,000 price point. Results were sensitive to HAQ progression under treatment, therapy costs, and the patient population. Conclusion This study supports the continued product development of candidate PsA biomarkers.

Sole ulcers, a common cause of lameness is the costliest non-infectious foot lesion in dairy cows and one of the most prevalent non-infectious foot lesions in freestall housing systems. Costs associated with sole ulcers are treatment costs, plus increased labor and decreased productivity and fertility. Routine hoof trimming is part of a strategy to manage sole ulcers. However, hoof trimming strategies differ among farms. The two most frequently applied strategies are: 1) partial herd hoof trimming with a 2-month interval between trims; and 2) whole herd hoof trimming at 6-month intervals. A Markov model was developed to investigate whether every 2 months partial herd hoof trimming or whole herd hoof trimming every 6 months was the most cost-effective strategy to avoid costs associated with sole ulcers. In this model, the net benefits for a 100-cow herd and the average productive life span of a dairy cow in intensive dairy systems of 3 years were evaluated. Partial herd hoof trimming was the most cost-effective strategy 100% of the time compared to whole herd hoof trimming, with a difference in 3-year net benefits of US$4,337 (95% CI: US$2,713—US$5,830). Based on sensitivity analyses, variables that were the sources of the biggest uncertainty in the model were herd size, the probability of being trimmed in a partial herd trim, and the prevalence of sole ulcers. To further investigate the impacts of herd size and of probability of being trimmed, various scenario analyses were conducted. With increasing herd size, the difference in net benefits in favor of partial herd hoof trimming increased even more. Scenario analyses about the probability of getting trimmed all indicated that targeted intervention increased the difference in net benefits in favor of partial herd hoof trimming. However, if the selection of cows to be trimmed in a partial herd trim was random, the whole herd hoof trimming strategy became cost-effective. Therefore, targeted selection and early intervention are necessary to decrease costs associated with sole ulcers.

Alberta has the highest proportion of preterm births in Canada, which is associated with increased health service utilization and costs. The aim was to evaluate the effect of Alberta Family Integrated Care (Alberta FICare (TM)) on health care costs compared to standard care. Data from a pragmatic cluster randomized controlled trial (cRCT) of Alberta FICare in Level II neonatal intensive care units (NICUs) were linked to administrative data on hospital admissions and emergency department (ED) visits to assess costs associated with birth admission and readmissions and ED visits within two months post-discharge - the total cost - per infant per group. Descriptive statistics were used to describe characteristics of the sample and unadjusted total costs. Predictive modeling compared the mean total costs between the groups, while accounting for potential confounding and stratification. A total of 718 infants from 10 NICUs were included. The mean (standard deviation) unadjusted total cost per infant was $39,649 ($19,741) and $42,195 ($20,955) in the Alberta FICare and standard care groups, respectively. Accounting for site geographic area and infant risk factors, the adjusted mean total cost per infant was lower in the Alberta FICare group ($39,434) compared to the standard care group ($41,740). The cRCT potentially lacked statistical power for this analysis, resulting in the non-statistically significant difference between the groups. Alberta FICare showed its potential to reduce the public health care system's costs. A pan-Canadian study would offer better insights in the intervention's effects on costs.

Objectives: This study aimed to assess whether recently proposed alternatives to the quality-adjusted life-year (QALY), intended to address concerns about discrimination, are suitable for informing resource allocation decisions. Methods: We consider 2 alternatives to the QALY: the health years in total (HYT), recently proposed by Basu et al, and the equal value of life-years gained (evLYG), currently used by the Institute for Clinical and Economic Review. For completeness we also consider unweighted life-years (LYs). Using a hypothetical example comparing 3 mutually exclusive treatment options, we consider how calculations are performed under each approach and whether the resulting rankings are logically consistent. We also explore some further challenges that arise from the unique properties of the HYT approach. Results: The HYT and evLYG approaches can result in logical inconsistencies that do not arise under the QALY or LY approaches. HYT can violate the independence of irrelevant alternatives axiom, whereas the evLYG can produce an unstable ranking of treatment options. HYT have additional issues, including an implausible assumption that the utilities associated with healthrelated quality of life and LYs are "separable," and a consideration of "counterfactual" health-related quality of life for patients who are dead. Conclusions: The HYT and evLYG approaches can result in logically inconsistent decisions. We recommend that decision makers avoid these approaches and that the logical consistency of any approaches proposed in future be thoroughly explored before considering their use in practice.

Objective: FoodRx is a 12-month healthy food prescription incentive program for people with type 2 diabetes (T2DM) and experiences of household food insecurity. In this study, we aimed to explore potential users’ prospective acceptability (acceptability prior to program use) of the design and delivery of the FoodRx incentive and identify factors influencing prospective acceptability. Design: We used a qualitative descriptive approach and purposive sampling to recruit individuals who were interested or uninterested in using the FoodRx incentive. Semi-structured interviews were guided by the theoretical framework of acceptability, and corresponding interview transcripts were analysed using differential qualitative analysis guided by the socioecological model. Setting: Individuals living in Alberta, Canada. Participants: In total, fifteen adults with T2DM and experiences of household food insecurity. Results: People who were interested in using the FoodRx incentive ( n 10) perceived it to be more acceptable than those who were uninterested ( n 5). We identified four themes that captured factors that influenced users’ prospective acceptability: (i) participants’ confidence, views and beliefs of FoodRx design and delivery and its future use (intrapersonal), (ii) the shopping routines and roles of individuals in participants’ social networks (interpersonal), (iii) access to and experience with food retail outlets (community), and (iv) income and food access support to cope with the cost of living (policy). Conclusion: Future healthy food prescription programs should consider how factors at all levels of the socioecological model influence program acceptability and use these data to inform program design and delivery.

Accumulation of amyloid-beta (Aβ) in the brain has been explored as a primary cause of Alzheimer’s Disease (AD). Better known as the amyloid hypothesis, it has been the main target of researchers vying to bring their therapeutic interventions to market despite several failed attempts by predecessors. In June 2021, Aduhelm (Aducanumab) became the first U.S. Food and Drug Administration (FDA) approved treatment for AD based on the amyloid hypothesis in which sparked controversy. This meta-analysis aims to investigate the efficacy of amyloid-beta targeting interventions at all stages of the disease including the prodromal or mild cognitive impairment (MCI) stage compared to placebo. All completed and terminated Phase III trials are assessed to provide a comprehensive overview of interventions targeting amyloid-beta to inform the legitimacy of the amyloid hypothesis.

Aims: To compare processes of diabetes care by homeless status. Methods: A population-based propensity matched cohort study was conducted in Ontario, Canada. People with diabetes were identified in administrative healthcare data between April 2006 and March 2019. Those with a documented history of homelessness were matched to non-homeless controls. Data on processes of care measures included glucose monitoring tests, screening for microvascular complications, and physician follow-up. Differences in processes of care were compared by homeless status using proportions, risk ratios, and rate ratios. Results: Of the 1,076,437 people with diabetes, 5219 matched pairs were identified. Homelessness was associated with fewer tests for glycated hemoglobin (RR = 0.63; 95 %CI: 0.60-0.67), LDL cholesterol (RR = 0.80; 95 %CI: 0.78-0.82), serum creatinine (RR = 0.94; 95 %CI: 0.92-0.97), urine protein quantification (RR = 0.62; 95 %CI: 0.59-0.66), and eye examinations (RR = 0.74; 95 %CI: 0.71-0.77). People with a history of homelessness were less likely to use primary care for diabetes management (RR = 0.62; 95 %CI: 0.59-0.66) or specialist care (RR = 0.87; 95 %CI: 0.83-0.91) compared to non-homeless controls. Conclusions: Disparities in diabetes care are evident for people with a history of homelessness and contribute to excess morbidity in this population. These data provide an impetus for investment in tailored interventions to improve healthcare equity and prevent long-term complications.

Background Management of suspected Clostridioides difficile infection (CDI) in the hospital setting typically results in patient isolation, laboratory testing, infection control, and presumptive treatment. We investigated whether implementation of rapid near-patient testing (NPT) reduced patient isolation time, hospital length of stay (LOS), antibiotic usage, and cost. Methods A 2-period pragmatic cluster randomized crossover trial was conducted. Thirty-nine wards were randomized into 2 study arms. The primary outcome measure was effect of NPT on patient isolation time using a mixed-effects generalized linear regression model. Secondary outcomes examined were hospital LOS and antibiotic therapy based on a negative binomial regression model. Natural experiment (NE), intention-to-treat (ITT), and per-protocol (PP) analyses were conducted. Results During the entire study period, a total of 656 patients received NPT for CDI and 1667 received standard-of-care testing. For the primary outcome, a significant decrease of patient isolation time with NPT was observed (NE, 9.4 hours [P < .01]; ITT, 2.3 hours [P < .05]; PP, 6.7 hours [P < .1]). A significant reduction in hospital LOS was observed with NPT for short stay (NE, 47.4% [P < .01]; ITT, 18.4% [P < .01]; PP, 34.2% [P < .01]). Each additional hour delay for a negative result increased metronidazole use (24 defined daily doses per 1000 patients; P < .05) and non-CDI-treating antibiotics by 70.13 mg (P < .01). NPT was found to save 25.48 US dollars per patient when including test cost to the laboratory and patient isolation in the hospital. Conclusions This pragmatic cluster randomized crossover trial demonstrated that implementation of CDI NPT can contribute to significant reductions in isolation time, hospital LOS, antibiotic usage, and healthcare cost. Clinical Trials Registration. NCT03857464.