Implementing digital health technologies in primary care is anticipated to improve patient experience. We examined the relationships between patient experience and digital health access in primary ...care settings in Ontario, Canada. We conducted a retrospective cross-sectional study using patient responses to the Health Care Experience Survey linked to health and administrative data between April 2019-February 2020. We measured patient experience by summarizing HCES questions. We used multivariable logistic regression stratified by the number of primary care visits to investigate associations between patient experience with digital health access and moderating variables. Our cohort included 2,692 Ontario adults, of which 63.0% accessed telehealth, 2.6% viewed medical records online, and 3.6% booked appointments online. Although patients reported overwhelmingly positive experiences, we found no consistent relationship with digital health access. Online appointment booking access was associated with lower odds of poor experience for patients with three or more primary care visits in the past 12 months (adjusted odds ratio 0.16, 95% CI 0.02-0.56). Younger age, tight financial circumstances, English as a second language, and knowing their primary care provider for fewer years had greater odds of poor patient experience. In 2019/2020, we found limited uptake of digital health in primary care and no clear association between real-world digital health adoption and patient experience in Ontario. Our findings provide an essential context for ensuing rapid shifts in digital health adoption during the COVID-19 pandemic, serving as a baseline to reexamine subsequent improvements in patient experience.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Kawasaki disease (KD) incidence is increasing in Ontario. Cardiovascular sequelae following KD are well-described. However, there are limited data on non-cardiovascular outcomes.
To determine the ...risk of hearing loss, anxiety, developmental disorders, intellectual disabilities and attention-deficit/hyperactivity disorder (ADHD) among KD survivors vs. non-exposed children.
We included all Ontario children (≤18 yr) surviving hospitalization with a KD diagnosis between 1995 and 2018, using population-based health administrative databases. We excluded children with prior KD diagnoses and non-residents. KD cases were matched with 100 non-exposed children by age, sex and year. Follow-up continued until death or March 2019. We calculated the prevalence, incidence and adjusted hazard ratios (aHR 95%CI) of outcomes between 0–1 yr, 1–5 yr, 5–10 yr and >10 yr follow-up.
Among 4597 KD survivors, 364 (7.9%) were diagnosed with hearing loss, 1213 (26.4%) anxiety disorders, 398 (8.7%) developmental disorders, 51 (1.1%) intellectual disability and 21 (0.5%) ADHD, during median 11 year follow-up. Compared to 459,700 non-exposed children, KD survivors were not at increased risk of hearing loss after adjustment for potential confounders. KD survivors were at increased risk of anxiety disorders between 0–1 yr (aHR 1.75 1.46–2.10), 1–5 yr (aHR 1.13 1.01–1.28), 5–10 yr (aHR 1.14 1.03–1.28) and >10 yr (aHR 1.11 1.02–1.22); developmental disorders between 0–1 yr (aHR 1.49 1.28–1.74) and 1–5 yr (aHR 1.19 1.02–1.40); intellectual disabilities >10 yr (aHR 2.36 1.36–4.10); and ADHD >10 yr (aHR 2.01 1.14–3.57).
KD survivors are at increased risk of being diagnosed with anxiety disorders sooner, being diagnosed with developmental disorders between 0 and 5 yr and being diagnosed with intellectual disabilities or ADHD >10 yr after KD diagnosis. This may justify enhanced developmental and audiological surveillance of KD survivors.
Survival has improved in patients diagnosed with multiple myeloma (MM) over the last two decades; however, there remains a paucity of data on the causes of death in MM patients and whether causes of ...death change during the disease trajectory. We conducted a retrospective population-based study to evaluate the rates of MM-specific vs non-MM cause of death and to identify factors associated with cause specific death in MM patients, stratified into autologous stem cell transplant (ASCT) and non-ASCT cohorts. A total of 6677 patients were included, 2576 in the ASCT group and 4010 in the non-ASCT group. Eight hundred and seventy-three (34%) ASCT patients and 2787 (68%) non-ASCT patients died during the follow-up period. MM was the most frequent cause of death, causing 74% of deaths in the ASCT group and 67% in the non-ASCT group. Other cancers were the second leading cause of death, followed by cardiac and infectious diseases. Multivariable analysis demonstrated that a more recent year of diagnosis and novel agent use within 1 year of diagnosis were associated with a decreased risk of MM-specific death, whereas a history of previous non-MM cancer, older age, and the presence of CRAB criteria at diagnosis increased the risk of non-MM death. Our data suggests that despite improvement in MM outcomes in recent years, MM remains the greatest threat to overall survival for patients. Further advances in the development of effective MM therapeutic agents in both ASCT and non-ASCT populations and patient access to them is needed to improve outcomes.
Kawasaki disease (KD) is a childhood vasculitis with conflicting reported North American trends in incidence and patient characteristics.
(1) determine KD incidence between 1995 and 2017; (2) compare ...patient characteristics by era and age group; (3) determine complication and cardiovascular follow-up rates.
We used population-based health administrative data to identify children (0-18 yr) hospitalized with KD in Ontario, Canada between 1995 and 2017. We excluded children with prior KD diagnosis or incomplete records. We determined the annualized incidence and follow-up trends.
KD was diagnosed in 4,346 children between 1995 and 2017. Annual KD incidence was 22.0 (<5 yr), 6.1 (5-9 yr), and 0.6 (10-18 yr) per 100,000 children. KD incidence increased significantly for all age groups, including from 18.4 to 25.0 cases per 100,000 children <5 yr. Ninety-day mortality occurred in ≤5 children (≤0.1%). Coronary artery aneurysm (CAA) occurred in 106 children (2.4%, 95% confidence interval 2.0-2.9) during admission and 151 (3.5%, 95% confidence interval 3.0-4.1) during 11-year median follow-up. Children 10-18 yr had longer hospitalizations (4.3 vs. 3.5 days, p = 0.003) and more CAA (7.4% vs. 3.4%, p = 0.007). By 1-year post-diagnosis, 3970 (91.3%) and 2576 (59.3%) children had echocardiography and cardiology follow-up, respectively.
KD incidence is increasing in Ontario, with greater healthcare utilization from hospitalizations and subsequent follow-up.
4346 children were hospitalized for Kawasaki disease over 22 years in Ontario, and Kawasaki disease incidence increased significantly for all age groups, males and females. Older children (10-18 years) had longer hospital length of stay, more PICU admissions and more frequent coronary artery aneurysms. Nearly all children with Kawasaki disease had follow-up echocardiography within 1 year.
Indices of aggressive or supportive end-of-life (EOL) care are used to evaluate health services quality. Disparities according to sex were previously described, with studies showing that male sex is ...associated with aggressive EOL care. This is a secondary analysis of 69,983 patients who died of a GI malignancy in Ontario between 2006 and 2018. Quality indices from the last 14-30 days of life and aggregate measures for aggressive and supportive EOL care were derived from administrative data. Hospitalizations, emergency department use, intensive care unit admissions, and receipt of chemotherapy were considered indices of aggressive care, while physician house call and palliative home care were considered indices of supportive care. Overall, a smaller proportion of females experienced aggressive care at EOL (14.3% vs. 19.0%, standardized difference = 0.13, where ≥0.1 is a meaningful difference). Over time, rates of aggressive care were stable, while rates of supportive care increased for both sexes. Logistic regression showed that younger females (ages 18-39) had increased odds of experiencing aggressive EOL care (OR 1.71, 95% CI 1.30-2.25), but there was no such association for males. Quality of EOL care varies according to sex, with a smaller proportion of females experiencing aggressive EOL care.
Population-based quality indicators of either aggressive or supportive care at end of life (EOL), especially when specific to a cancer type, help to inform quality improvement efforts. This is a ...population-based, retrospective cohort study of gastrointestinal (GI) cancer decedents in Ontario from 1 January 2006-31 December 2018, using administrative data. Quality indices included hospitalizations, emergency department (ED) use, intensive care unit admissions, receipt of chemotherapy, physician house call, and palliative home care in the last 14-30 days of life. Previously defined aggregate measures of both aggressive and supportive care at end of life were also used. In our population of 69,983 patients who died of a GI malignancy during the study period, the odds of experiencing aggressive care at EOL remained stable, while the odds of experiencing supportive care at EOL increased. Most of our population received palliative care in the last year of life (
= 65,076, 93.0%) and a palliative care home care service in the last 30 days of life (
= 45,327, 70.0%). A significant number of patients also experienced death in an acute care hospital bed (
= 28,721, 41.0%) or had a new hospitalisation in the last 30 days of life (
= 33,283, 51.4%). The majority of patients received palliative care in the last year of life, and a majority received a palliative care home service within the last 30 days of life. The odds of receiving supportive care at EOL have increased over time. Differences in care exist according to income, age, and rurality.
BackgroundThe shifting landscape of abortion care from a hospital-only to a distributed service including primary care has implications for how to identify abortion cohorts for research and ...surveillance. The objectives of this study were to 1) create an improved approach to define abortion cohorts using linked administrative data sets and 2) evaluate the performance of this approach for abortion surveillance compared with standard approaches.
MethodsWe applied four principles to identify induced abortion cohorts when some services are delivered beyond hospital settings; 1) exclude early pregnancy losses and postpartum procedures; 2) use multiple data sources; 3) define episodes of care; 4) apply a hierarchical algorithm to determine abortion date to a population-based cohort of all abortion events in Ontario (Canada) from January 1, 2018-March 15, 2020. We calculated risk differences (RD, with 95% confidence intervals) comparing the proportion of medication vs. surgical, first vs. second trimester, and complication incidence applying these principles vs. standard approaches.
ResultsHospital-only data (versus multiple data sources) underestimated the frequency of medication abortion (16.1% vs. 31.4%; RD -15.3% -14.3, -16.3) and first-trimester abortion (82.1% vs. 94.5%; RD -12.8 -11.4, 13.4) and overestimated incidence of abortion complication (2.9% vs. 0.69%; RD 2.2% 1.8, 2.7). An unlinked (versus linked) approach underestimated the frequency of abortion complications (0.19% vs 0.69%, -RD 0.50% -0.44 - -0.56). Including (versus excluding) abortions following early pregnancy loss or delivery events increased the estimated incidence of abortion complications (1.29% vs. 0.69%, RD 0.60% 0.51-0.69.
ConclusionNew methods are required to accurately identify abortion cohorts for surveillance or research. When legal or regulatory approaches to medication abortion evolve to enable abortion in primary care or office-based settings, hospital-based surveillance systems will become incomplete and biased; to continue valid and complete abortion surveillance, methods must be adjusted to ensure complete capture of procedures across all settings.
To evaluate the prognosis of 30-day survival post-cardiac arrest among patients receiving home care and nursing home residents.
We conducted a population-level retrospective cohort study of ...community-dwelling adults (≥18 years) who received cardiac arrest care at a hospital in Ontario, Canada, between 2006 to 2018. We linked population-based health datasets using the Home Care Dataset to identify patients receiving home care and the Continuing Care Reporting System to identify nursing home residents. We included both out-of-hospital and in-hospital cardiac arrests. We determined unadjusted and adjusted associations using logistic regression after adjusting for age and sex. We converted relative measures to absolute risks.
Our cohort contained 86,836 individuals. Most arrests (55.5 %) occurred out-of-hospital, with 9,316 patients enrolled in home care and 2,394 residing in a nursing home. When compared to those receiving no support services, the likelihood of survival to 30-days was lower for those receiving home care (RD = −6.5; 95 %CI = −7.5 – −5.0), with similar results found within sub-groups of out-of-hospital (RD = −6.7; 95 %CI = −7.6 – −5.7) and in-hospital arrests (RD = −8.7; 95 %CI = −10.6 – −7.3). The likelihood of 30-day survival was lower for nursing home residents (RD = −7.2; 95 %CI = −9.3 - −5.3) with similar results found within sub-groups of out-of-hospital (RD = −8.6; 95 %CI = −10.6 – −5.7) and in-hospital arrests (RD = −5.0; 95 %CI = −7.8 – −2.1).
Patients receiving home care and nursing home residents had worse overall prognoses of survival post-cardiac arrest compared to those receiving no pre-arrest support, highlighting two medically-complex groups likely to benefit from advance care planning.
ObjectivesThe objective of this study was to describe the receipt of potentially non-beneficial interventions in the last 100 days of life of cancer patients and to examine variations in these ...interventions according to patient characteristics and cancer site.
ApproachWe conducted a population-based retrospective cohort study of all adults age 18+ who died of cancer in Ontario, Canada between January 1, 2013 and December 31, 2017 using linked administrative health data held at ICES. Potentially non-beneficial interventions were captured via hospital discharge records and included chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy. We used bivariate analyses and multivariable Poisson regression to examine associations between the receipt of interventions and decedent age, sex, rurality, area-level income, and cancer site.
ResultsAmong the 125,755 decedents, the most common intervention was blood transfusion (18.1%) and major surgery (12.8%); 23.8% received no interventions, while 14% of decedents received 3+ interventions. Lower intervention rates were observed in older patients (adjusted rate ratio (RR) 0.46, 95% confidence interval (CI) 0.44-0.49 for age 95+ vs. 19-44), females (RR 0.93, 95% CI 0.92-0.94), and individuals living in higher income areas (RR 0.96, 95% CI 0.95-0.98 for highest vs. lowest income quintile). Higher intervention rates were observed in rural patients (RR 1.13, 95% CI 1.11-1.14). Patients with pancreatic cancer had the highest intervention rate (RR 1.13, 95% CI 1.10-1.16), while breast cancer patients had the lowest intervention rate (RR 0.86, 95% CI 0.84-0.89) compared to colorectal cancer patients.
ConclusionPotentially non-beneficial interventions were common in the last 100 days of life of patients with cancer. Variations in interventions across patient demographics and cancer site may reflect differences in healthcare access, end-of-life care preferences, patients’ prognostic awareness, and disease factors.
This study examined a 2-year period after diagnosis of an eating disorder to compare health care utilization in diagnostic subgroups including: anorexia nervosa (AN), bulimia nervosa (BN), ...binge-eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), and other specified eating disorders (Other).
We conducted a retrospective study of children diagnosed with AN (n = 674), BN (n = 230), BED (n = 59), ARFID (n = 171), and Other (n = 315). We used a general population cohort for comparison, matched 5:1 to the diagnostic subgroups on sex and birth date. We then conducted a separate analysis using the ARFID subgroup as a reference group compared to the other subgroups. Outcomes were determined using data linkage with health administrative databases and included hospitalizations, emergency department, general practitioner, psychiatry, and pediatrician visits. Odds ratios (dichotomous outcomes) and rate ratios (continuous outcome) were calculated.
Mental health care utilization was higher for all subgroups compared to the general population. When the subgroups were compared to the ARFID subgroup, those with ARFID appeared to have similar health care utilization to the other subgroups, except when compared to those with AN. The AN subgroup had higher odds of a mental health related hospitalization (OR 1.62, 95% CI 1.04-2.5) higher rates of mental health related pediatrician visits (RR 1.76, 95% CI 1.26-2.46) and psychiatry visits (RR 1.69, 95% CI 1.07-2.68).
Those with ARFID have similar utilization as other subtypes of eating disorders, except when compared to those with AN who have higher health care utilization.
Our study found that the health service needs of young people with all types of eating disorders are substantially higher than the general population, and it appears that Avoidant/Restrictive Food Intake Disorder (ARFID) has similar health care utilization to other eating disorders.
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