RESUMEN
INTRODUCTION: Genetic testing is used across medical disciplines leading to unprecedented demand for genetic services. This has resulted in excessive waitlists and unsustainable pressure on the standard model of genetic healthcare. Alternative models are needed; e-health tools represent scalable and evidence-based solution. We aim to evaluate the effectiveness of the Genetics Navigator, an interactive patient-centred digital platform that supports the collection of medical and family history, provision of pregenetic and postgenetic counselling and return of genetic testing results across paediatric and adult settings. METHODS AND ANALYSIS: We will evaluate the effectiveness of the Genetics Navigator combined with usual care by a genetics clinician (physician or counsellor) to usual care alone in a randomised controlled trial. One hundred and thirty participants (adults patients or parents of paediatric patients) eligible for genetic testing through standard of care will be recruited across Ontario genetics clinics. Participants randomised into the intervention arm will use the Genetics Navigator for pretest and post-test genetic counselling and results disclosure in conjunction with their clinician. Participants randomised into the control arm will receive usual care, that is, clinician-delivered pretest and post-test genetic counselling, and results disclosure. The primary outcome is participant distress 2 weeks after test results disclosure. Secondary outcomes include knowledge, decisional conflict, anxiety, empowerment, quality of life, satisfaction, acceptability, digital health literacy and health resource use. Quantitative data will be analysed using statistical hypothesis tests and regression models. A subset of participants will be interviewed to explore user experience; data will be analysed using interpretive description. A cost-effectiveness analysis will examine the incremental cost of the Navigator compared with usual care per unit reduction in distress or unit improvement in quality of life from public payer and societal perspectives. ETHICS AND DISSEMINATION: This study was approved by Clinical Trials Ontario. Results will be shared through stakeholder workshops, national and international conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT06455384.
Asunto(s)
Asesoramiento Genético , Humanos , Asesoramiento Genético/métodos , Adulto , Niño , Pruebas Genéticas/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Calidad de Vida , Ontario , Canadá , Navegación de PacientesRESUMEN
BACKGROUND: Timely diagnosis and treatment for ST-elevation myocardial infarction (STEMI) requires a coordinated response from multiple providers. Rapid intervention is key to reducing mortality and morbidity. Activation of the cardiac catheterization laboratory may occur through verbal communication and may also involve the secure sharing of electrocardiographic images between frontline health care providers and interventional cardiologists. To improve this response, we developed a quick, easy-to-use, privacy-compliant smartphone app, that is SMART AMI-ACS (Strategic Management of Acute Reperfusion and Therapies in Acute Myocardial Infarction Acute Coronary Syndromes), for real-time verbal communication and sharing of electrocardiographic images among health care providers in Ontario, Canada. The app further provides information about diagnosis, management, and risk calculators for patients presenting with acute coronary syndrome. OBJECTIVE: This study aims to integrate the app into workflow processes to improve communication for STEMI activation, resulting in decreased treatment times, improved patient outcomes, and reduced unnecessary catheterization laboratory activation and transfer. METHODS: Implementation of the app will be guided by the Reach, Effectiveness, Acceptability, Implementation, and Maintenance (RE-AIM) framework to measure impact. The study will use quantitative registry data already being collected through the SMART AMI project (STEMI registry), the use of the SMART AMI app, and quantitative and qualitative survey data from physicians. Survey questions will be based on the Consolidated Framework for Implementation Research. Descriptive quantitative analysis and thematic qualitative analysis of survey results will be conducted. Continuous variables will be described using either mean and SD or median and IQR values at pre- and postintervention periods by the study sites. Categorical variables, such as false activation, will be described as frequencies (percentages). For each outcome, an interrupted time series regression model will be fitted to evaluate the impact of the app. RESULTS: The primary outcomes of this study include the usability, acceptability, and functionality of the app for physicians. This will be measured using electronic surveys to identify barriers and facilitators to app use. Other key outcomes will measure the implementation of the app by reviewing the timing-of-care intervals, false "avoidable" catheterization laboratory activation rates, and uptake and use of the app by physicians. Prospective evaluation will be conducted between April 1, 2022, and March 31, 2023. However, for the timing- and accuracy-of-care outcomes, registry data will be compared from January 1, 2019, to March 31, 2023. Data analysis is expected to be completed in Fall 2024, with the completion of a paper for publication anticipated by the end of 2024. CONCLUSIONS: Smartphone technology is well integrated into clinical practice and widely accessible. The proposed solution being tested is secure and leverages the accessibility of smartphones. Emergency medicine physicians can use this app to quickly, securely, and accurately transmit information ensuring faster and more appropriate decision-making for STEMI activation. TRIAL REGISTRATION: ClinicalTrials.gov NCT05290389; https://clinicaltrials.gov/study/NCT05290389. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55506.
Asunto(s)
Electrocardiografía , Servicios Médicos de Urgencia , Aplicaciones Móviles , Infarto del Miocardio con Elevación del ST , Teléfono Inteligente , Humanos , Electrocardiografía/instrumentación , Electrocardiografía/métodos , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/fisiopatología , Servicios Médicos de Urgencia/métodos , OntarioRESUMEN
BACKGROUND: Multiple marker screening is offered to pregnant individuals in many jurisdictions to screen for trisomies 21 and 18. On occasion, the result is 'double-positive'-a screening result that is unexpectedly positive for both aneuploidies. Although this occurs rarely, the paucity of available evidence about the outcomes of these pregnancies hinders patient counselling. This study aimed to investigate the association of double-positive results with preterm birth and other adverse perinatal outcomes. METHODS: We conducted a population-based retrospective cohort study of pregnancies with an estimated date of delivery from September 1, 2016, to March 31, 2021, using province-wide perinatal registry data in Ontario, Canada. Pregnancies with double-positive screening results where trisomies 21 and 18 were ruled-out were compared to pregnancies with screen negative results for both aneuploidies. We used modified Poisson regression models with robust variance estimation to examine the association of double positive results with preterm birth and secondary outcomes. RESULTS: From 429 540 pregnancies with multiple marker screening, 863 (0.2%) had a double-positive result; trisomies 21 and 18 were ruled out in 374 pregnancies, 203 of which resulted in a live birth. Among the pregnancies in the double-positive group resulting in a live birth, the risk of preterm birth was increased compared to pregnancies with a screen negative result: adjusted risk ratio (aRR) 2.6 (95%CI 2.0-3.6), adjusted risk difference (aRD) 10.5% (95%CI 5.4-15.7). In a sensitivity analysis excluding all diagnosed chromosomal abnormalities, the risk of preterm birth remained elevated to a similar degree: aRR 2.6 (95%CI 1.9-3.7), aRD 10.0% (95%CI 4.8-15.3). The risk of other adverse perinatal outcomes was also higher, including the risk of chromosomal abnormalities other than trisomies 21 and 18: aRR 81.1 (95%CI 69.4-94.8), aRD 34.0% (95%CI 29.2-38.8). Pregnancies with double-positive results were also less likely to result in a live birth, even when excluding all diagnosed chromosomal abnormalities; and at increased risk of adverse perinatal outcomes for those resulting in a live birth. CONCLUSION: Although rare, double-positive multiple marker screening results are associated with an increased risk of preterm birth and other adverse perinatal outcomes, even when excluding all identified chromosomal abnormalities.
Asunto(s)
Síndrome de Down , Nacimiento Prematuro , Humanos , Femenino , Embarazo , Ontario/epidemiología , Síndrome de Down/diagnóstico , Adulto , Estudios Retrospectivos , Nacimiento Prematuro/epidemiología , Síndrome de la Trisomía 18/diagnóstico , Diagnóstico Prenatal/métodos , Diagnóstico Prenatal/estadística & datos numéricos , Resultado del Embarazo/epidemiología , Recién Nacido , Biomarcadores/sangre , Sistema de RegistrosRESUMEN
BACKGROUND: Lung cancer is one of the most common cancers and causes of cancer death in Canada. Some previous literature suggests that socioeconomic inequalities in lung cancer screening, treatment and survival may exist. The objective of this study was to compare overall survival for immigrants versus long-term residents of Ontario, Canada among patients diagnosed with lung cancer. METHODS: This population-based retrospective cohort study utilized linked health administrative databases and identified all individuals (immigrants and long-term residents) aged 40 + years diagnosed with incident lung cancer between April 1, 2012 and March 31, 2017. The primary outcome was 5-year overall survival with December 31, 2019 as the end of the follow-up period. We implemented adjusted Cox proportional hazards models stratified by age at diagnosis, sex, and cancer stage at diagnosis to examine survival. RESULTS: Thirty-eight thousand seven hundred eighty-eight individuals diagnosed with lung cancer were included in our cohort including 7% who were immigrants. Immigrants were younger at diagnosis and were more likely to reside in the lowest neighbourhood income quintile (30.6% versus 24.5%) than long-term residents. After adjusting for age at diagnosis, neighbourhood income quintile, comorbidities, visits to primary care in the 6 to 30 months before diagnosis, continuity of care, cancer type and cancer stage at diagnosis, immigrant status was associated with a lower hazard of dying 5-years post-diagnosis for both females (0.7; 95% CI 0.6-0.8) and males (0.7; 95% CI 0.6-0.7) in comparison to long-term residents. This trend held in adjusted models stratified by cancer stage at diagnosis. For example, female immigrants diagnosed with early stage lung cancer had a hazard ratio of 0.5 (95% CI 0.4-0.7) in comparison to long-term residents. CONCLUSION: Overall survival post diagnosis with lung cancer was better among Ontario immigrants versus long-term residents. Additional research, potentially on the protective effects of immigrant enclave and the intersection of immigrant status with racial/ethnic identity, is needed to further explore why better overall survival for immigrants remained.
Asunto(s)
Emigrantes e Inmigrantes , Neoplasias Pulmonares , Humanos , Femenino , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/etnología , Emigrantes e Inmigrantes/estadística & datos numéricos , Masculino , Ontario/epidemiología , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Adulto , Anciano de 80 o más Años , Factores Socioeconómicos , Modelos de Riesgos ProporcionalesRESUMEN
Older adults with cognitive impairment often experience low mobility and functional decline in hospital, transfer to facility-based transitional care programs, and have poorer outcomes compared to those without cognitive impairment. This protocol paper describes a study which aims to determine the feasibility of, satisfaction with, and efficacy of a nurse-led mobility intervention (OASIS Walking Intervention) for older adults with cognitive impairment in facility-based transitional care programs in Ontario, Canada. A quasi-experimental one-group time series feasibility study will be conducted. A sample size of 26 participants will be recruited from two transitional care programs in Ontario, Canada. Participants will receive the OASIS Walking Intervention for up to 45 minutes per session, 5 sessions per week, for 6 weeks. The intervention consists of: 1) a patient-centered communication care plan; 2) sit to stand activity; and 3) a walking program. Feasibility will be determined by: a) recruitment rate; b) retention rate; and c) adherence. Efficacy of the intervention will be determined by the change over time in older adults' lower extremity muscle strength, mobility, and functional status and by their discharge destination (home vs. nursing home). Satisfaction will be measured using the Client Satisfaction Questionnaire. Efficacy outcomes will be measured before the start of the intervention, after 3 weeks of the intervention, and immediately after 6-week intervention. Descriptive statistics will be used for measures of feasibility, satisfaction, and discharge destination. Repeated measures analysis of variance (RM-ANOVA) will be used to analyze efficacy. Ethics approval has been received for this study. Findings from the study will be used to refine the intervention for use in a definitive pilot trial. Results will be disseminated via peer-reviewed publications, international conferences, through group presentations at the study sites, and through the study site networks. Trial registration: The trial has been registered on Clinicaltrials.gov (NCT06150339).
Asunto(s)
Disfunción Cognitiva , Estudios de Factibilidad , Cuidado de Transición , Caminata , Humanos , Anciano , Disfunción Cognitiva/terapia , Femenino , Masculino , Ontario , Anciano de 80 o más Años , Satisfacción del PacienteRESUMEN
BACKGROUND AND OBJECTIVES: Administrative data are invaluable for assessing outcomes at the population level. However, there are few validated patient-centered outcome measures that capture morbidity following traumatic brain injury (TBI) using these data. We sought to characterize and validate days at home (DAH) as a measure to quantify population-level outcomes after moderate to severe TBI. We additionally assessed the earliest feasible outcome assessment period for patients with TBI using this outcome measure. METHODS: This multicenter retrospective cohort study used linked health administrative data sources to identify adults with moderate to severe TBI presenting to trauma centers in Ontario, Canada, between 2009 and 2021. DAH at 180 days (DAH180 days) reflects the total number of days spent alive and at home excluding the days spent institutionalized across care settings. Construct validity was determined using hierarchical quantile regression to assess the associations between clinical and injury covariates with DAH180 days. Predictive validity was assessed using Spearman rank correlation. We estimated minimally important difference (MID) in DAH180 days to aid with outcome measure interpretability. RESULTS: There were 6,340 patients who met inclusion criteria. Median DAH180 days was 70 days (interquartile range 0-144). Mortality occurred in 2,162 (34.1%) patients within 90 days following injury. Patients in the lower DAH180 days group were more commonly older (absolute standardized difference [ASD] = 0.68) with higher preinjury health resource utilization (ASD = 0.36) and greater injury severity (ASD = 0.81). Increased baseline health resource utilization (-10.1 days, 95% CI -17.4 to -2.8, p = 0.0041), older age (-4.6 days, 95% CI -5.7 to -3.4, p < 0.001), higher cranial injury severity (-84.6 days, 95% CI -98.3 to -71.0, p < 0.001), and major extracranial injuries (-14.2 days, 95% CI -19.5 to -8.93, p < 0.001) were significantly associated with fewer DAH180 days. DAH180 days was positively correlated with DAH at up to 3 years (r = 0.91, 95% CI 0.90-0.92) and negatively correlated with direct health care expenditure (rs = -0.89, 95% CI -0.88 to -0.90). The average MID estimated from anchor-based and distribution-based methods was 18 days. DISCUSSION: We validate DAH180 days as a potentially useful outcome measure with construct, predictive, and face validity in a population with moderate to severe TBI. Given the intensity of acute care requirements for patients with TBI, our work highlights DAH180 days as a feasible and sufficiently responsive outcome measure.
Asunto(s)
Lesiones Traumáticas del Encéfalo , Humanos , Lesiones Traumáticas del Encéfalo/mortalidad , Lesiones Traumáticas del Encéfalo/terapia , Masculino , Femenino , Persona de Mediana Edad , Adulto , Estudios Retrospectivos , Ontario/epidemiología , Anciano , Evaluación de Resultado en la Atención de Salud , Adulto Joven , Estudios de Cohortes , Atención Dirigida al PacienteRESUMEN
Side effects are a common concern of current and potential HIV pre-exposure prophylaxis (PrEP) users, potentially leading to missed doses. We examined the relationship between reported side effects and adherence in the Ontario PrEP Cohort Study (ON-PrEP). In total, 600 predominantly gay (87.3%), White (65.8%), and male (95.0%) participants completed questionnaires assessing the presence and severity of five side effect categories (nausea, diarrhea, headache, abdominal pain, and "other") as well as their adherence to daily PrEP (any missed doses in the previous 4 days). In total, 175 participants (29%) ever reported experiencing side effects: most commonly diarrhea (7.5% of study visits), and most were of mild severity. Lower incomes (p = 0.01), identifying as bisexual (p = 0.04), and baseline concern about side effects (p < 0.001) were associated with ever reporting side effects. The odds of reporting any side effects decreased by a factor of 0.44 (95% confidence interval 0.25-0.80) with each additional year of PrEP use, however 1 in 10 participants still reported side effects after 1 year of use. The odds of reporting optimal adherence were 0.48 (0.28-0.83) times lower for participants reporting any side effects, 0.67 (0.51-0.89) times lower per additional side effect category reported, and 0.78 (0.65-0.97) times lower per incremental increase in side effect severity ratings. We found some evidence of interaction between side effect measures and duration of PrEP use, suggesting that these relationships were stronger for participants taking PrEP for longer. Clinicians should make efforts to ascertain patients' experience of side effects and consider risk counseling and alternative PrEP regimens to promote adherence.
Asunto(s)
Fármacos Anti-VIH , Infecciones por VIH , Cumplimiento de la Medicación , Profilaxis Pre-Exposición , Humanos , Profilaxis Pre-Exposición/estadística & datos numéricos , Masculino , Infecciones por VIH/prevención & control , Ontario/epidemiología , Adulto , Fármacos Anti-VIH/administración & dosificación , Fármacos Anti-VIH/efectos adversos , Femenino , Cumplimiento de la Medicación/estadística & datos numéricos , Estudios de Cohortes , Persona de Mediana Edad , Encuestas y Cuestionarios , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/epidemiologíaRESUMEN
OBJECTIVE: To estimate the real world effectiveness of modified vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine against mpox infection. DESIGN: Emulation of a target trial. SETTING: Linked databases in Ontario, Canada. PARTICIPANTS: 9803 men aged ≥18 years with a history of being tested for syphilis and a laboratory confirmed bacterial sexually transmitted infection (STI) in the previous year, or who filled a prescription for HIV pre-exposure prophylaxis in the previous year. On each day between 12 June 2022 and 27 October 2022, those who had been vaccinated 15 days previously were matched 1:1 with unvaccinated men by age, geographical region, past HIV diagnosis, number of bacterial STI diagnoses in the previous three years, and receipt of any non-MVA-BN vaccine in the previous year. MAIN OUTCOME MEASURE: The main outcome measure was vaccine effectiveness ((1-hazard ratio)×100) of one dose of subcutaneously administered MVA-BN against laboratory confirmed mpox infection. A Cox proportional hazards model was used to estimate hazard ratios to compare the rate of laboratory confirmed mpox between the two groups. RESULTS: 3204 men who received the vaccine were matched to 3204 unvaccinated controls. A total of 71 mpox infections were diagnosed, with 0.09 per 1000 person days (95% confidence interval (CI) 0.05 to 0.13) in the vaccinated group and 0.20 per 1000 person days (0.15 to 0.27) in the unvaccinated group over the study period of 153 days. Estimated vaccine effectiveness of one dose of MVA-BN against mpox infection was 58% (95% CI 31% to 75%). CONCLUSION: The findings of this study, conducted in the context of a targeted vaccination programme and evolving outbreak of mpox, suggest that one dose of MVA-BN is moderately effective in preventing mpox infection.
Asunto(s)
Eficacia de las Vacunas , Humanos , Masculino , Adulto , Ontario/epidemiología , Persona de Mediana Edad , Adulto Joven , Adolescente , Modelos de Riesgos Proporcionales , Vacuna contra Viruela/administración & dosificaciónRESUMEN
Health Information Seeking Behavior (HISB) refers to the behavior and strategies used to attain, clarify, or confirm health information. The uptake of health information depends on system-level and individual-level factors. The purpose of the present study is to understand the sources from which Punjabi elders obtain COVID-19 vaccine-related information and their information seeking behavior. A cross-sectional survey was conducted among 391 Punjabi elders aged 50+ years in the Greater Toronto Area (GTA), Ontario. The survey questions included the need for COVID-19 vaccine information, the type of information sought, sources of information, and barriers to seeking information. Descriptive analysis was conducted using frequencies and percentages, and logistic regression was performed to understand the associations between participants' sociodemographic characteristics and HISB. The results suggested that Punjabi elders are more likely to use informal sources and less likely to seek information from health professionals and government health and wellness websites. The results also suggested that most participants do not cross-check their information with other sources and are more likely to cross-check the information with family/friends, compared to credible care providers, across all demographics. Ultimately, there may be a need for stakeholders to collaborate to regulate the accuracy and type of health-information that is disseminated through media, and to tailor health communication to the health information seeking behavior of this population.
Asunto(s)
COVID-19 , Conducta en la Búsqueda de Información , Humanos , COVID-19/epidemiología , Masculino , Persona de Mediana Edad , Femenino , Estudios Transversales , Anciano , Ontario/epidemiología , Vacunas contra la COVID-19/administración & dosificación , Anciano de 80 o más Años , Información de Salud al Consumidor , SARS-CoV-2 , Encuestas y Cuestionarios , PandemiasRESUMEN
INTRODUCTION: Geese harvesting is a longstanding cultural tradition deeply ingrained among the Omushkego Cree in Fort Albany First Nation, embodying a holistic approach to health that integrates Indigenous knowledge, community wellbeing, and resilience. Despite historical disruptions stemming from colonization and assimilation policies, women have played a pivotal role in preserving and passing down traditional practices. The significance of goose harvesting extends beyond providing a nutrient-rich and cost-effective food source; it serves as a vehicle for cultural preservation and education, particularly fostering language acquisition among children. Nevertheless, concerns persist regarding the potential decline in the transmission of Indigenous knowledge. The interruption of intergenerational knowledge transfer not only poses implications for overall wellbeing but also worsens historical trauma within the community. In response to these challenges, the Niska (goose) harvesting program was developed with an aim to revitalize community harvesting practices, with a specific focus on incorporating the perspectives of women, especially in the preparatory and smoking phases of the geese. METHODS: Omushkego Cree women were approached to participate. The study was conducted during the spring of 2018, and employed photovoice and semi-structured interviews that explored the impact of geese preparatory activities on the health and wellbeing of Indigenous women. RESULTS: Major themes from the qualitative data included the importance of knowledge sharing, cultural continuity, healing, and the profound connection to the land. Women emphasized the value of sharing acquired knowledge, passing on traditions, and maintaining a connection to their cultural identity. Cultural continuity, depicted through intergenerational teachings and experiences, emerged as crucial for overall wellbeing. Participants spoke of the healing dynamics derived from engaging in traditional activities, highlighting the positive impact on physical, mental, emotional, and spiritual wellbeing. The land was identified as a central element in this healing process, representing more than just a physical space but an extension of home, contributing to a sense of peace and tranquility. The land became a medium for transmitting cultural teachings, shaping identity, and sustaining a subsistence lifestyle. CONCLUSION: The study emphasizes the importance of future research including more female youth participants to uncover specific challenges and strengths within this demographic. Overall, the Niska program demonstrates a comprehensive approach that intertwines cultural revitalization, community engagement, and holistic wellbeing, emphasizing the need for interventions that go beyond immediate challenges to create enduring positive impacts on Indigenous communities.
Asunto(s)
Gansos , Salud de la Mujer , Humanos , Femenino , Ontario , Animales , Adulto , Promoción de la Salud/métodos , Promoción de la Salud/organización & administración , Indígena CanadienseRESUMEN
BACKGROUND: Increased length of stay after surgery is associated with increased healthcare utilization and adverse patient outcomes. While enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay after colorectal surgery in trial settings, their effectiveness in real-world settings is more uncertain. The aim of this study was to assess the impact of ERAS protocol implementation on length of stay after colorectal surgery, using real-world data. METHODS: In 2012, ERAS protocols were introduced at 15 Ontario hospitals as part of the iERAS study. A cohort of patients undergoing colorectal surgery treated at these hospitals between 2008 and 2019 was created using health administrative data. Mean length of stay was computed for the intervals before and after ERAS implementation. Interrupted time series analyses were performed for predefined subgroups, namely all colorectal surgery, colorectal surgery without complications, right-sided colorectal surgery, and left-sided colorectal surgery. Sensitivity analyses were then conducted using adjusted length of stay, accounting for length of stay predictors, including: patient age, sex, marginalization, co-morbidities, and diagnosis; surgeon volume of cases, years in practice, and colorectal surgery expertise; hospital volume; and other contextual factors, including procedure type and timing, surgical approach, and in-hospital complications. RESULTS: A total of 32 612 patients underwent colorectal surgery during the study interval. ERAS implementation led to a decrease in length of stay of 1.05 days (13.7%). Larger decreases in length of stay were seen with more complex surgeries, with a level change of 1.17 days (15.6%) noted for the subgroup of patients undergoing left-sided colorectal surgery. The observed decreases in length of stay were durable for the length of the study interval in all analyses. When adjusting for predictors of length of stay, the effect of ERAS implementation on length of stay was larger (reduction of 1.46 days). CONCLUSION: Introducing formal ERAS protocols reduces length of stay after colorectal surgery significantly, independent of temporal trends toward decreasing length of stay. These effects are durable, demonstrating that ERAS protocol implementation is an effective hospital-level intervention to reduce length of stay after colorectal surgery.
Asunto(s)
Recuperación Mejorada Después de la Cirugía , Tiempo de Internación , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Ontario , Cirugía Colorrectal , Análisis de Series de Tiempo Interrumpido , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Protocolos Clínicos , Recto/cirugíaRESUMEN
In this study, the fluxes of microplastics (mp) were quantified during a 12-month period for three rural headwater lake catchments in Muskoka-Haliburton, south-central Ontario, Canada. A novel catchment particle balance approach was used, incorporating inputs from atmospheric deposition and stream inflows against lake outflow and sedimentation. This approach provides the first reported observation-based estimates of microplastic residence time in freshwater lakes. Atmospheric deposition had the highest daily microplastic flux (3.95-8.09 mp/m2/day), compared to the inflow streams (2.21-2.34 mp/m2/day), suggesting that it is the dominant source of microplastics to rural regions. Approximately 44-71% of the deposited microplastics were retained in the terrestrial catchments and 30-49% of the microplastics in the stream inflows were retained in the study lakes. Given that output fluxes ranged from 0.72-3.76 mp/m2/day in the sediment and 1.18-1.66 mp/m2/day in the lake outflows, the microplastic residence time was estimated to be between 3 and 12 years, suggesting that lakes are an important reservoir for microplastics. Fibers were the dominant shape in atmospheric deposition, streamwater, and lake water; however, in lake sediment, there was a higher proportion of fragments. Across all media, poly(ethylene terephthalate) was the dominant polymer identified (23%).
Asunto(s)
Lagos , Microplásticos , Contaminantes Químicos del Agua , Microplásticos/análisis , Contaminantes Químicos del Agua/análisis , Ontario , Monitoreo del AmbienteRESUMEN
OBJECTIVE: To identify FPs with additional training and focused practice activities relevant to the needs of older patients within health administrative data and to describe their medical practices and service provision in community-based primary care settings. DESIGN: Retrospective cohort study. SETTING: Ontario. PARTICIPANTS: Family physicians with Certificates of Added Competence in care of the elderly from the College of Family Physicians of Canada or focused practice billing designations in care of the elderly. MAIN OUTCOME MEASURES: Evidence of additional training or certification in care of the elderly or practice activities relevant to the care of older adults. RESULTS: Of 14,123 FPs, 242 had evidence of additional scope to better support older adults. These FPs mainly practised in team-based care models, tended to provide comprehensive care, and billed for core primary care services. In an unadjusted analysis, factors statistically significantly associated with greater likelihood of having additional training or focused practices relevant to the care of older patients included physician demographic characteristics (eg, female sex, having completed medical school in Canada, residential instability at the community level), primary care practice model (ie, focused practice type), primary care activities (eg, more likely to provide consultations, practise in long-term care, refer patients to psychiatry and geriatrics, bill for complex house call assessments, bill for home care applications, and bill for long-term care health report forms), and patient characteristics (ie, older average age of patients). CONCLUSION: The FP workforce with additional training or focused practices in caring for older patients represents a small but specialized group of providers who contribute a portion of the total primary care activities for older adults. Health human resource planning should consider the contributions of all FPs who care for older adults, and enhancing geriatric competence across the family medicine workforce should be emphasized.
Asunto(s)
Médicos de Familia , Atención Primaria de Salud , Humanos , Estudios Retrospectivos , Femenino , Masculino , Ontario , Anciano , Médicos de Familia/educación , Médicos de Familia/estadística & datos numéricos , Medicina Familiar y Comunitaria/educación , Persona de Mediana Edad , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Servicios de Salud para Ancianos , Competencia ClínicaRESUMEN
PURPOSE: Understanding the experiences of people with developmental disabilities during the initial period of COVID-19 pandemic. METHODS: Individuals with developmental disabilities and their caregivers completed baseline and up to five follow-up online surveys using the CRISIS-AFAR measures, between July 2020 and September 2021. We used qualitative (thematic analysis) and quantitative (MANOVA) analytic methods. RESULTS: One hundred and eighteen participants (64 caregivers on individuals 6-62 years, 54 self-reporting individuals aged 17-55 years) completed baseline survey; 46 participants (23 caregivers, 23 self-reporting adults) completed ≥1 follow-up. Qualitative themes included uncertainty, and negative and positive influences on behaviours and routines, daily life and mental wellness. Those experiencing positive impacts did not stably perceive so longitudinally. CONCLUSIONS: Despite both negative and positive influences on individuals with developmental disabilities and their families, the prolonged pandemic had wide-ranging repercussions. Emergency preparedness planning should consider the disruptive effects of public health measures on routine and support for this vulnerable population.
Asunto(s)
COVID-19 , Discapacidades del Desarrollo , Humanos , Discapacidades del Desarrollo/epidemiología , Adulto , COVID-19/epidemiología , COVID-19/psicología , Adolescente , Femenino , Masculino , Persona de Mediana Edad , Adulto Joven , Ontario/epidemiología , Niño , Cuidadores/psicología , Encuestas y Cuestionarios , Investigación Cualitativa , Pueblos de América del NorteRESUMEN
BACKGROUND AND PURPOSE: Total hip arthroplasty (THA) can be performed through various surgical approaches, including direct anterior (DAA). DAA-THA may offer faster recovery but carries a higher risk of complications, which may be mitigated by surgeon volume and experience. We examined the association of surgeons' annual surgical volume with major complications after DAA-THA in a population-based sample. METHODS: A population-based retrospective cohort study was carried out on primary DAA-THA patients in Ontario between April 2016 and March 2021. We used restricted cubic splines to visually define the association between annual DAA surgeon volume and the risk of major surgical complications (fractures, dislocations, infections, and revisions) within 1 year of surgery. We further compared the complication rates amongst different DAA volume categories (< 30, 30-60, and > 60 cases/year). RESULTS: The study encompassed 9,672 DAA-THA patients (52% female, median age 67 years). We showed a sharp decline in the probability of complications as the surgical volume of DAA-THA increased within the lower range of 0-30 cases/year; the probability slightly increased after the surgical volume exceeded 60 cases/year. The overall complication rates were 3.09%, 2.24%, and 2.18% for the surgical experience group of < 30 cases/year, 30-60 cases/year, and > 60 cases/year, respectively. CONCLUSION: There was an inverse relationship between surgical volume and complication rates in DAA-THA within the lower volume ranges. Maintaining a surgical volume of at least 30 DAA-THA cases/year can minimize complications, emphasizing the importance of surgical volume in this approach.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Complicaciones Posoperatorias , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Persona de Mediana Edad , Ontario/epidemiología , Competencia Clínica , Cirujanos/estadística & datos numéricos , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Understanding the factors contributing to mental well-being in youth is a public health priority. Self-reported enthusiasm for the future may be a useful indicator of well-being and has been shown to forecast social and educational success. Typically, cross-domain measures of ecological and health-related factors with relevance to public policy and programming are analyzed either in isolation or in targeted models assessing bivariate interactions. Here, we capitalize on a large provincial data set and machine learning to identify the sociodemographic, experiential, behavioral, and other health-related factors most strongly associated with levels of subjective enthusiasm for the future in a large sample of elementary and secondary school students. OBJECTIVE: The aim of this study was to identify the sociodemographic, experiential, behavioral, and other health-related factors associated with enthusiasm for the future in elementary and secondary school students using machine learning. METHODS: We analyzed data from 13,661 participants in the 2019 Ontario Student Drug Use and Health Survey (OSDUHS) (grades 7-12) with complete data for our primary outcome: self-reported levels of enthusiasm for the future. We used 50 variables as model predictors, including demographics, perception of school experience (i.e., school connectedness and academic performance), physical activity and quantity of sleep, substance use, and physical and mental health indicators. Models were built using a nonlinear decision tree-based machine learning algorithm called extreme gradient boosting to classify students as indicating either high or low levels of enthusiasm. Shapley additive explanations (SHAP) values were used to interpret the generated models, providing a ranking of feature importance and revealing any nonlinear or interactive effects of the input variables. RESULTS: The top 3 contributors to higher self-rated enthusiasm for the future were higher self-rated physical health (SHAP value=0.62), feeling that one is able to discuss problems or feelings with their parents (SHAP value=0.49), and school belonging (SHAP value=0.32). Additionally, subjective social status at school was a top feature and showed nonlinear effects, with benefits to predicted enthusiasm present in the mid-to-high range of values. CONCLUSIONS: Using machine learning, we identified key factors related to self-reported enthusiasm for the future in a large sample of young students: perceived physical health, subjective school social status and connectedness, and quality of relationship with parents. A focus on perceptions of physical health and school connectedness should be considered central to improving the well-being of youth at the population level.
Asunto(s)
Aprendizaje Automático , Estudiantes , Humanos , Adolescente , Masculino , Estudios Transversales , Femenino , Estudiantes/psicología , Estudiantes/estadística & datos numéricos , Niño , Ontario , Instituciones Académicas , AutoinformeRESUMEN
INTRODUCTION: Integrated youth services (IYS) presents a unique opportunity to adopt social prescribing (SP) strategies within the IYS service model by developing and leveraging a highly connected multidisciplinary network of clinical and community-based service providers to tackle health inequities and enhance service access and outcomes for youth. This paper outlines a case study of Youth Wellness Hubs Ontario (YWHO), Canada, a collective of youth-serving organizations integrated and networked, and operating as a learning health system implementing SP services. The main study objective was to document how YWHO hubs engage in social prescribing through service provision. METHODS: We adopted an embedded case study approach. Data were collected from youth (n = 6361) aged between 12 and 25 years who were seeking services at a YWHO hub. Descriptive analyses, including frequencies across categories, were generated from service data, including reason for visit, needs addressed and service provided. RESULTS: A comparative analysis of services requested and provided found that youth across visits to YWHO hubs were engaging with multiple services and service providers, with a wide range of health, mental health and social support needs being addressed. CONCLUSION: YWHO implements SP services that aim to improve mental health resilience by supporting the vocational, educational and socialization needs of young people accessing IYS through YWHO hubs.
Asunto(s)
Apoyo Social , Humanos , Ontario , Adolescente , Masculino , Niño , Femenino , Adulto Joven , Adulto , Promoción de la Salud/métodos , Promoción de la Salud/organización & administración , Servicios de Salud del Adolescente/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Salud Mental , Estudios de Casos OrganizacionalesRESUMEN
BACKGROUND: Unnecessary antibiotic prescriptions in primary care are common and contribute to antimicrobial resistance in the population. Audit and feedback (A&F) on antibiotic prescribing to primary care can improve the appropriateness of antibiotic prescribing, but the optimal approach is uncertain. We performed two pragmatic randomized controlled trials of different approaches to audit and feedback. The trial results showed that A&F was associated with significantly reducing antibiotic prescribing. Still, the effect size was small, and the modifications to the A&F interventions tested in the trials were not associated with any change. Herein, we report a theory-informed qualitative process evaluation to explore potential mechanisms underlying the observed effects. METHODS: Ontario family physicians in the intervention arms of both trials who were sent A&F letters were invited for one-on-one interviews. Purposive sampling was used to seek variation across interested participants in personal and practice characteristics. Qualitative analysis utilized inductive and deductive techniques informed by the Clinical Performance Feedback Intervention Theory. RESULTS: Modifications to the intervention design tested in the trial did not alter prescribing patterns beyond the changes made in response to the A&F overall for various reasons. Change in antibiotic prescribing in response to A&F depended on whether it led to the formation of specific intentions and whether those intentions translated to particular behaviours. Those without intentions to change tended to feel that their unique clinical context was not represented in the A&F. Those with intentions but without specific actions taken tended to express a lack of self-efficacy for avoiding a prescription in contexts with time constraints and/or without an ongoing patient relationship. Many participants noted that compared to overall prescribing, A&F on antibiotic prescription duration was perceived as new information and easily actionable. CONCLUSION: Our findings indicate that contextual factors, including the types of patients and the setting where they are seen, affect how clinicians react to audit and feedback. These results suggest a need to test tailored feedback reports that reflect the context of how, where, and why physicians prescribe antibiotics so that they might be perceived as more personal and more actionable. TRIAL REGISTRATION: Clinical Trial registration IDs: NCT04594200, NCT05044052.
Asunto(s)
Antibacterianos , Pautas de la Práctica en Medicina , Humanos , Antibacterianos/uso terapéutico , Antibacterianos/administración & dosificación , Pautas de la Práctica en Medicina/estadística & datos numéricos , Ontario , Médicos de Familia , Retroalimentación , Femenino , Masculino , Prescripción Inadecuada/prevención & control , Prescripción Inadecuada/estadística & datos numéricos , Atención Primaria de Salud , Investigación Cualitativa , Auditoría MédicaRESUMEN
OBJECTIVE: The COVID-19 pandemic resulted in decreased prostate specific antigen (PSA) testing for prostate cancer screening and its impact remains uncharacterized. Our objective was to compare incident PSA testing rates, PSA levels, and prostate cancer treatment rates before and during the pandemic after the state of emergency (SoE) was declared. MATERIALS AND METHODS: This was a population-based, retrospective cohort study among men 50-80 years of age in Ontario, Canada undergoing incident PSA testing from November 23, 2018 to July 9, 2021. Working backwards and forwards from the date of the province-wide SoE (March 17, 2020), 30-day time periods were constructed during which incident PSA testing rates were measured. Our primary outcome was the rate of incident PSA testing. Secondary endpoints included comparison of incident PSA levels and prostate cancer treatment rates. RESULTS: We identified 835,402 men who underwent incident PSA testing. There was a 20% decrease in PSA testing after the SoE (RR = 0.80,95% CI: 0.800.81, P < .001). There was a higher proportion of extreme PSA levels after the SoE with a higher proportion of patients with a PSA >20 ng/mL (rate ratio = 1.63,95% CI: 1.54-1.73, P < .0001) and >100 ng/mL (rate ratio = 1.98,95% CI: 1.77-2.20, P < .0001). This effect was highest for those aged 50-59 years. More patients required active treatment (5,201,59.5% prior to the pandemic vs. 5,072,64.2%, P < .001 after the SoE declaration). CONCLUSIONS: The COVID-19 SoE resulted in patients experiencing a 2-fold increase in the risk of having an extreme PSA level and higher odds of treatment. Future studies are needed to assess the impact on the rates of advanced prostate cancer and cancer-specific mortality.
Asunto(s)
COVID-19 , Antígeno Prostático Específico , Neoplasias de la Próstata , Humanos , Masculino , COVID-19/epidemiología , COVID-19/sangre , Antígeno Prostático Específico/sangre , Anciano , Persona de Mediana Edad , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/epidemiología , Neoplasias de la Próstata/diagnóstico , Estudios Retrospectivos , Ontario/epidemiología , Incidencia , Anciano de 80 o más Años , Detección Precoz del Cáncer/estadística & datos numéricos , Detección Precoz del Cáncer/métodos , SARS-CoV-2RESUMEN
The COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.