Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study

Background:Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability.Methods:We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1, 2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤ 64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity.Results:Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [CI] 1.19–1.56) and greater risk of readmission (relative risk 1.77, 95% CI 1.14–2.75). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability.Interpretation:Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.

A successful public health response to the COVID-19 pandemic requires accurate and timely identification of, and support for, high-risk groups. There is increasing recognition that marginalized groups, including congregate care residents, racial and ethnic minorities, and people experiencing poverty, have elevated incidence of COVID-19.^1,2 Older age and comorbidities such as diabetes are also risk factors for severe COVID-19 outcomes.^3,4 One potential high-risk group that has received relatively little attention is people with disabilities.The World Health Organization estimates there are 1 billion people with disabilities globally.⁵ In North America, the prevalence of disability is 20%, with one-third of people older than 65 years having a disability.⁶ Disabilities include physical disabilities, hearing and vision impairments, traumatic brain injury and intellectual or developmental disabilities.^5,6 Although activity limitations experienced by people with disabilities are heterogeneous,^5,6 people with disabilities share high rates of risk factors for acquiring COVID-19, including poverty, residence in congregate care and being members of racialized communities.^7–9 People with disabilities may be more reliant on close contact with others to meet their daily needs, and some people with disabilities, especially intellectual developmental disabilities, may have difficulty following public health rules. Once they acquire SARS-CoV-2 infection, people with disabilities may be at risk for severe outcomes because they have elevated rates of comorbidities.¹⁰ Some disabilities (e.g., spinal cord injuries and neurologic disabilities) result in physiologic changes that increase vulnerability to respiratory diseases and may mask symptoms of acute respiratory disease, which may delay diagnosis.^11–13 There have also been reports of barriers to high-quality hospital care for patients with disabilities who have COVID-19, including communication issues caused by the use of masks and restricted access to support persons.^14–17Some studies have suggested that patients with disabilities and COVID-19 are at elevated risk for severe disease and death, with most evaluating intellectual or developmental disability.^13,18–26 Yet, consideration of disability-related needs has largely been absent from the COVID-19 response, with vaccine eligibility driven primarily by age and medical comorbidity, limited accommodations made for patients with disabilities who are in hospital, and disability data often not being captured in surveillance programs.^14–17 To inform equitable pandemic supports, there is a need for data on patients with a broad range of disabilities who have COVID-19. We sought to evaluate standard clinical outcomes in patients admitted to hospital with COVID-19²⁷ (i.e., in-hospital death, intensive care unit [ICU] admission, hospital length of stay and unplanned 30-d readmission) for patients with and without a disability, overall and stratified by age. We hypothesized that patients with a disability would have worse outcomes because of a greater prevalence of comorbidities,¹⁰ physiologic characteristics that increase morbidity risk^11–13 and barriers to high-quality hospital care.^14–17     

Association between long-term exposure to ambient air pollution and COVID-19 severity: a prospective cohort study

Background:The tremendous global health burden related to COVID-19 means that identifying determinants of COVID-19 severity is important for prevention and intervention. We aimed to explore long-term exposure to ambient air pollution as a potential contributor to COVID-19 severity, given its known impact on the respiratory system.Methods:We used a cohort of all people with confirmed SARS-CoV-2 infection, aged 20 years and older and not residing in a long-term care facility in Ontario, Canada, during 2020. We evaluated the association between long-term exposure to fine particulate matter (PM_2.5), nitrogen dioxide (NO₂) and ground-level ozone (O₃), and risk of COVID-19-related hospital admission, intensive care unit (ICU) admission and death. We ascertained individuals’ long-term exposures to each air pollutant based on their residence from 2015 to 2019. We used logistic regression and adjusted for confounders and selection bias using various individual and contextual covariates obtained through data linkage.Results:Among the 151 105 people with confirmed SARS-CoV-2 infection in Ontario in 2020, we observed 8630 hospital admissions, 1912 ICU admissions and 2137 deaths related to COVID-19. For each interquartile range increase in exposure to PM_2.5 (1.70 μg/m³), we estimated odds ratios of 1.06 (95% confidence interval [CI] 1.01–1.12), 1.09 (95% CI 0.98–1.21) and 1.00 (95% CI 0.90–1.11) for hospital admission, ICU admission and death, respectively. Estimates were smaller for NO₂. We also estimated odds ratios of 1.15 (95% CI 1.06–1.23), 1.30 (95% CI 1.12–1.50) and 1.18 (95% CI 1.02–1.36) per interquartile range increase of 5.14 ppb in O₃ for hospital admission, ICU admission and death, respectively.Interpretation:Chronic exposure to air pollution may contribute to severe outcomes after SARS-CoV-2 infection, particularly exposure to O₃.

By November 2021, COVID-19 had caused more than 5 million deaths globally¹ and more than 29 400 in Canada.² The clinical manifestations of SARS-CoV-2 infection range from being asymptomatic to multiple organ failure and death. Identifying risk factors for COVID-19 severity is important to better understand etiological mechanisms and identify populations to prioritize for screening, vaccination and medical treatment. Risk factors for severity of COVID-19 include male sex, older age, pre-existing medical conditions and being from racialized communities.^3–5 More recently, ambient air pollution has been implicated as a potential driver of COVID-19 severity.^6–10Long-term exposure to ambient air pollution, a major contributor to global disease burden,¹¹ could increase the risk of severe COVID-19 outcomes by several mechanisms. Air pollutants can reduce individuals’ pulmonary immune responses and antimicrobial activities, boosting viral loads.⁸ Air pollution can also induce chronic inflammation and overexpression of the alveolar angiotensin-converting enzyme 2 (ACE) receptor,⁷ the key receptor that facilitates SARS-CoV-2 entry into cells.^12,13 Exposure to air pollution contributes to chronic conditions, such as cardiovascular disease, that are associated with unfavourable COVID-19 prognosis, possibly owing to persistent immune activation and excessive amplification of cytokine development.¹⁰ Thus, greater exposure to long-term air pollution may lead to severe COVID-19 outcomes.Reports exist of positive associations between long-term exposure to particulate matter with diameters equal to or smaller than 2.5 or 10 μm (PM_2.5 and PM₁₀), ground-level ozone (O₃) and nitrogen dioxide (NO₂), and metrics of COVID-19 severity (e.g., mortality and case fatality rate).^8–10 However, most studies to date have used ecological and cross-sectional designs, owing to limited access to individual data, which leads to ambiguity in interpreting the results, thus hindering their influence on policy. ^6,14 Ecological designs do not allow for disentangling the relative impacts of air pollution on individual susceptibility to infection and disease severity.¹⁴ Residual confounding by factors such as population mobility and social interactions is also problematic. Therefore, a cohort study with data on individuals with SARS-CoV-2 is a more appropriate design.^6,14 Studies that have used individual data were conducted in specific subpopulations^15,16 or populations with few severe cases,¹⁷ or had limited data on individual exposure to air pollutants.¹⁸ In Canada, 1 ecological study found a positive association between long-term exposure to PM_2.5 and COVID-19 incidence,¹⁹ but no published study has explored the association between air pollution and COVID-19 severity.We aimed to examine the associations between long-term exposure to 3 common air pollutants (PM_2.5, NO₂ and O₃) and key indicators of COVID-19 severity, including hospital admission, intensive care unit (ICU) admission and death, using a large prospective cohort of people with confirmed SARS-CoV-2 infection in Ontario, Canada, in 2020. The air contaminants PM_2.5, NO₂ and O₃ are regularly monitored by the Canadian government, and are key pollutants that are considered when setting air-quality policies. They originate from varying sources (NO₂ is primarily emitted during combustion of fuel, O₃ is primarily formed in air by chemical reactions of nitrogen oxides and volatile organic compounds, and PM_2.5 can be emitted during combustion or formed by reactions of chemicals like sulphur dioxide and nitrogen oxides in air) and they may affect human health differently.^20,21,22     

Geographic concentration of SARS-CoV-2 cases by social determinants of health in metropolitan areas in Canada: a cross-sectional study

Background:Understanding inequalities in SARS-CoV-2 transmission associated with the social determinants of health could help the development of effective mitigation strategies that are responsive to local transmission dynamics. This study aims to quantify social determinants of geographic concentration of SARS-CoV-2 cases across 16 census metropolitan areas (hereafter, cities) in 4 Canadian provinces, British Columbia, Manitoba, Ontario and Quebec.Methods:We used surveillance data on confirmed SARS-CoV-2 cases and census data for social determinants at the level of the dissemination area (DA). We calculated Gini coefficients to determine the overall geographic heterogeneity of confirmed cases of SARS-CoV-2 in each city, and calculated Gini covariance coefficients to determine each city’s heterogeneity by each social determinant (income, education, housing density and proportions of visible minorities, recent immigrants and essential workers). We visualized heterogeneity using Lorenz (concentration) curves.Results:We observed geographic concentration of SARS-CoV-2 cases in cities, as half of the cumulative cases were concentrated in DAs containing 21%–35% of their population, with the greatest geographic heterogeneity in Ontario cities (Gini coefficients 0.32–0.47), followed by British Columbia (0.23–0.36), Manitoba (0.32) and Quebec (0.28–0.37). Cases were disproportionately concentrated in areas with lower income and educational attainment, and in areas with a higher proportion of visible minorities, recent immigrants, high-density housing and essential workers. Although a consistent feature across cities was concentration by the proportion of visible minorities, the magnitude of concentration by social determinant varied across cities.Interpretation:Geographic concentration of SARS-CoV-2 cases was observed in all of the included cities, but the pattern by social determinants varied. Geographically prioritized allocation of resources and services should be tailored to the local drivers of inequalities in transmission in response to the resurgence of SARS-CoV-2.

The COVID-19 epidemic in Canada has varied in size and trajectory across provinces and large cities.^1,2 At the national level³ and within regions,^4,5 the burden of confirmed SARS-CoV-2 cases and severe COVID-19 outcomes has fallen disproportionately on socially and economically marginalized communities. ⁶ Social determinants of health refer to nonmedical factors influencing health outcomes, and structural determinants encompass cultural norms, policies and institutions that generate social stratification and determine socioeconomic position.^7,8 In Canada and elsewhere, data have consistently highlighted the importance of determinants such as household size and density, work in essential services and structural racism (measured by proxy) in the relative risk of COVID-19.^9–17Understanding the factors associated with geographic patterns of transmission within cities can help identify the populations and, specifically, the contexts with the greatest risks. Geographic analyses can enable better allocation of resources, tailoring of policies and implementation of context-specific strategies to more effectively and efficiently curb local transmission. ¹⁸ Although respiratory virus transmission is often geographically clustered within a city,¹⁹ the early public health response to SARS-CoV-2 transmission in Canada did little to take within-city clustering into account.^20,21 Similarly, few studies have quantified and compared the geographic concentration of SARS-CoV-2 cases by social determinants across Canada, and the extent to which the magnitude of inequalities might vary among cities and provinces.^19,22 We therefore sought to quantify and compare the magnitude of geographic concentration of SARS-CoV-2 cases by area-level social determinants of health across metropolitan areas in British Columbia, Manitoba, Ontario and Quebec, Canada.     

Suicidality among sexual minority and transgender adolescents: a nationally representative population-based study of youth in Canada

Background:Very little research has described risk of suicidal ideation and suicide attempt among transgender youth using high-quality, nationally representative data. We aimed to assess risk of suicidality among transgender and sexual minority adolescents in Canada.Methods:We analyzed a subsample of adolescents aged 15–17 years from the 2019 Canadian Health Survey on Children and Youth, a nationally representative, cross-sectional survey. We defined participants’ transgender identity (self-reported gender different from sex assigned at birth) and sexual minority status (self-reported attraction to people of the same gender) as exposures, and their self-reported previous-year suicidal ideation and lifetime suicide attempt as outcomes.Results:We included 6800 adolescents aged 15–17 years, including 1130 (16.5%) who indicated some degree of same-gender attraction, 265 (4.3%) who were unsure of their attraction and 50 (0.6%) who reported a transgender identity. Compared with cisgender, heterosexual adolescents, transgender adolescents showed 5 times the risk of suicidal ideation (95% confidence interval [CI] 3.63 to 6.75; 58% v. 10%) and 7.6 times the risk of suicide attempt (95% CI 4.76 to 12.10; 40% v. 5%). Among cisgender adolescents, girls attracted to girls had 3.6 times the risk of previous-year suicidal ideation (95% CI 2.59 to 5.08) and 3.3 times the risk of having ever attempted suicide (95% CI 1.81 to 6.06), compared with their heterosexual peers. Adolescents attracted to multiple genders had 2.5 times the risk of suicidal ideation (95% CI 2.12 to 2.98) and 2.8 times the risk of suicide attempt (95% CI 2.18 to 3.68). Youth questioning their sexual orientation had twice the risk of having attempted suicide in their lifetime (95% CI 1.23 to 3.36).Interpretation:We observed that transgender and sexual minority adolescents were at increased risk of suicidal ideation and attempt compared with their cisgender and heterosexual peers. These findings highlight the need for inclusive prevention approaches to address suicidality among Canada’s diverse youth population.

Suicide is the second leading cause of death among adolescents and young adults aged 15–24 years in Canada.^1,2 Suicidal ideation and suicide attempt are common among adolescents³ and are risk factors for death by suicide.⁴ Sexual minority youth (i.e., youth who are attracted to the same gender or multiple genders, or who identify as lesbian, gay, bisexual or queer)⁵ are known to be at increased risk of poor mental health,^6–8 including suicidal ideation and attempt.^5–10 Over the previous 2 decades, stigma around identifying as a sexual minority has reduced;⁷ however, the risk of poor mental health and of suicidality remains high among sexual minority youth.^7,11 This population is still more likely to experience bullying and peer victimization,^9,12,13 which is associated with suicidality among sexual minority adolescents.⁵Transgender youth are those whose gender identity does not match their sex assigned at birth.¹⁴ Among other terms, gender-nonconforming, nonbinary, genderqueer and genderfluid are used to describe the gender identity of a subset of young people who identify outside the gender binary (i.e., as neither male nor female) or who experience fluidity between genders.⁹ Suicidality among transgender and gender-nonconforming adolescents is not as well studied. In a Canadian survey of transgender and gender-nonconforming youth aged 14–25 years, 64% of participants reported that they had seriously considered suicide in the previous 12 months.¹⁵ Transgender and gender-nonconforming youth seem to have a higher probability of many risk factors for suicidality, including peer victimization,^8,16 family dysfunction^7,17 and barriers to accessing mental health care.¹⁸ However, the epidemiology of suicidality among transgender and gender-nonconforming youth remains understudied in population-based samples; most research on the mental health of transgender youth comes from small community samples of help-seeking youth or targeted surveys of transgender adolescents.^5,19,20 Two population-based studies from California²¹ and New Zealand²² suggested that transgender youth are at increased risk of suicidal ideation and suicide attempt. However, only the New Zealand study²² used the gold-standard measure of gender identity, contrasting adolescents’ sex assigned at birth with their self-identified gender.²³Further epidemiological research employing large, representative samples and adequate measures of gender identity is needed to understand the burden of suicidality among lesbian, gay, bisexual, transgender and queer youth. We sought to build on existing evidence to assess risk of suicidal ideation and attempt among transgender and sexual minority adolescents in Canada, as compared with their cisgender and heterosexual peers, as well as to explore the relation between suicidality and experience of bullying.     

Changes in ischemic stroke presentations,management and outcomes during the first year of the COVID-19 pandemic in Alberta: a population study

Background:Pandemics may promote hospital avoidance, and added precautions may exacerbate treatment delays for medical emergencies such as stroke. We sought to evaluate ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic.Methods:We conducted a population-based study, using linked administrative and stroke registry data from Alberta to identify all patients presenting with stroke before the pandemic (Jan. 1, 2016 to Feb. 27, 2020) and in 5 periods over the first pandemic year (Feb. 28, 2020 to Mar. 31, 2021), reflecting changes in case numbers and restrictions. We evaluated changes in hospital admissions, emergency department presentations, thrombolysis, endovascular therapy, workflow times and outcomes.Results:The study included 19 531 patients in the prepandemic period and 4900 patients across the 5 pandemic periods. Presentations for ischemic stroke dropped in the first pandemic wave (weekly adjusted incidence rate ratio [IRR] 0.54, 95% confidence interval [CI] 0.50 to 0.59). Population-level incidence of thrombolysis (adjusted IRR 0.50, 95% CI 0.41 to 0.62) and endovascular therapy (adjusted IRR 0.63, 95% CI 0.47 to 0.84) also decreased during the first wave, but proportions of patients presenting with stroke who received acute therapies did not decline. Rates of patients presenting with stroke did not return to prepandemic levels, even during a lull in COVID-19 cases between the first 2 waves of the pandemic, and fell further in subsequent waves. In-hospital delays in thrombolysis or endovascular therapy occurred in several pandemic periods. The likelihood of in-hospital death increased in Wave 2 (adjusted odds ratio [OR] 1.48, 95% CI 1.25 to 1.74) and Wave 3 (adjusted OR 1.46, 95% CI 1.07 to 2.00). Out-of-hospital deaths, as a proportion of stroke-related deaths, rose during 4 of 5 pandemic periods.Interpretation:The first year of the COVID-19 pandemic saw persistently reduced rates of patients presenting with ischemic stroke, recurrent treatment delays and higher risk of in-hospital death in later waves. These findings support public health messaging that encourages care-seeking for medical emergencies during pandemic periods, and stroke systems should re-evaluate protocols to mitigate inefficiencies.

In response to the COVID-19 pandemic, affected countries implemented various public health measures to decrease viral transmission. An unintended consequence of these measures could be hospital avoidance by patients with medical emergencies, as observed during other outbreaks in the 2000s.^1,2 Some public health messaging specifically warned groups at high cardiovascular risk, such as older people or those with heart disease, that they were at elevated risk of severe COVID-19.³ Physical distancing may also result in loss of services and support networks, impairing patients’ ability to seek medical assistance.⁴ Furthermore, pandemics generate new challenges of managing personal protective equipment and cleaning protocols,⁵ and additional information bottlenecks, which could result in workflow delays for emergencies like stroke.⁶Previous studies have reported declines in patients presenting to hospital with stroke or acute coronary syndrome during the pandemic.^7,8 A World Stroke Organization survey of members in several countries indicated a sharp reduction in stroke admissions by 50%–80% in the first weeks of the pandemic.⁹ A cross-sectional study reported a global decline in hospital admissions for stroke.¹⁰ Patients who present to hospital seem to be doing so later than usual, perhaps waiting until their condition becomes more severe.^11–14 However, studies have not been at a population level, consequently suffering from selection bias, and have generally focused only on the first wave of the pandemic. As the associations between the pandemic and the incidence, treatment, workflow and outcomes of stroke are likely to be modified by several events — including changing COVID-19 case counts, public health restrictions and health system strains — it is important to explore population data from pandemic periods beyond the first wave to better understand these phenomena.Verifying and quantifying the pandemic’s effect on stroke presentations and workflow can help tailor public health messaging to continue emphasizing the time-critical nature of emergencies like stroke. Such data may also help optimize pandemic stroke workflow protocols. We sought to explore patterns of hospital admissions, treatment rates, workflow delays and outcomes for ischemic stroke during the first year of the COVID-19 pandemic in Alberta, Canada.     

Impact of population mixing between vaccinated and unvaccinated subpopulations on infectious disease dynamics: implications for SARS-CoV-2 transmission

Background:The speed of vaccine development has been a singular achievement during the COVID-19 pandemic, although uptake has not been universal. Vaccine opponents often frame their opposition in terms of the rights of the unvaccinated. We sought to explore the impact of mixing of vaccinated and unvaccinated populations on risk of SARS-CoV-2 infection among vaccinated people.Methods:We constructed a simple susceptible–infectious–recovered compartmental model of a respiratory infectious disease with 2 connected subpopulations: people who were vaccinated and those who were unvaccinated. We simulated a spectrum of patterns of mixing between vaccinated and unvaccinated groups that ranged from random mixing to complete like-with-like mixing (complete assortativity), in which people have contact exclusively with others with the same vaccination status. We evaluated the dynamics of an epidemic within each subgroup and in the population as a whole.Results:We found that the risk of infection was markedly higher among unvaccinated people than among vaccinated people under all mixing assumptions. The contact-adjusted contribution of unvaccinated people to infection risk was disproportionate, with unvaccinated people contributing to infections among those who were vaccinated at a rate higher than would have been expected based on contact numbers alone. We found that as like-with-like mixing increased, attack rates among vaccinated people decreased from 15% to 10% (and increased from 62% to 79% among unvaccinated people), but the contact-adjusted contribution to risk among vaccinated people derived from contact with unvaccinated people increased.Interpretation:Although risk associated with avoiding vaccination during a virulent pandemic accrues chiefly to people who are unvaccinated, their choices affect risk of viral infection among those who are vaccinated in a manner that is disproportionate to the portion of unvaccinated people in the population.

The remarkable speed of vaccine development, production and administration during the COVID-19 pandemic is a singular human achievement.¹ While the ability to vaccinate to herd immunity has been held back by the increasing transmissibility of novel SARS-CoV-2 variants of concern (e.g., Delta and Omicron variants),^2,3 and global distribution of vaccines is inequitable,⁴ the effectiveness of SARS-CoV-2 vaccines in reducing severity of disease and disrupting onward transmission even when breakthrough infections occur is likely to have saved many lives. The emergence of the immune-evasive Omicron variant may undermine some of these gains, although provision of booster vaccine doses may restore vaccination to a high level of potency, and vaccines developed specifically to enhance immunity to the Omicron variant may emerge in 2022.^3,5–7However, antivaccine sentiment, fuelled in part by organized disinformation efforts, has resulted in suboptimal uptake of readily available vaccines in many countries, with adverse health and economic consequences.^8–10 Although the decision not to receive vaccination is often framed in terms of the rights of individuals to opt out,^11,12 such arguments neglect the potential harms to the wider community that derive from poor vaccine uptake. Nonvaccination is expected to result in amplification of disease transmission in unvaccinated subpopulations, but the communicable nature of infectious diseases means that this also heightens risk for vaccinated populations, when vaccines confer imperfect immunity. Although assortative (like-with-like) mixing¹³ is characteristic of many communicable disease systems and may be expected to limit interaction between vaccinated and unvaccinated subpopulations to some degree, the normal functioning of society means that complete like-with-like mixing is not observed in reality. Furthermore, the airborne spread of SARS-CoV-2^14–20 means that close-range physical mixing of people from vaccinated and unvaccinated groups is not necessary for between-group disease transmission.Historically, behaviours that create health risks for the community as well as individuals have been the subject of public health regulation. This is true of communicable infectious diseases but also applies to public health statutes that limit indoor cigarette smoking²¹ and legal restrictions on driving under the influence of alcohol and other intoxicants.^22,23Simple mathematical models can often provide important insights into the behaviour of complex communicable diseases systems.^13,24,25 To better understand the implications of the interplay between vaccinated and unvaccinated populations under different assumptions about population mixing, we constructed a simple susceptible–infectious–recovered model to reproduce the dynamics of interactions between vaccinated and unvaccinated subpopulations in a predominantly vaccinated population. We sought to contrast contribution to epidemic size and risk estimates by subpopulation, and to understand the impact of mixing between vaccinated and unvaccinated groups on expected disease dynamics.     

Patient–physician language concordance and quality and safety outcomes among frail home care recipients admitted to hospital in Ontario,Canada

Background:When patients and physicians speak the same language, it may improve the quality and safety of care delivered. We sought to determine whether patient–physician language concordance is associated with in-hospital and postdischarge outcomes among home care recipients who were admitted to hospital.Methods:We conducted a population-based study of a retrospective cohort of 189 690 home care recipients who were admitted to hospital in Ontario, Canada, between 2010 and 2018. We defined patient language (obtained from home care assessments) as English (Anglophone), French (Francophone) or other (allophone). We obtained physician language from the College of Physicians and Surgeons of Ontario. We defined hospital admissions as language concordant when patients received more than 50% of their care from physicians who spoke the patients’ primary language. We identified in-hospital (adverse events, length of stay, death) and post-discharge outcomes (emergency department visits, readmissions, death within 30 days of discharge). We used regression analyses to estimate the adjusted rate of mean and the adjusted odds ratio (OR) of each outcome, stratified by patient language, to assess the impact of language-concordant care within each linguistic group.Results:Allophone patients who received language-concordant care had lower risk of adverse events (adjusted OR 0.25, 95% confidence interval [CI] 0.15–0.43) and in-hospital death (adjusted OR 0.44, 95% CI 0.29–0.66), as well as shorter stays in hospital (adjusted rate of mean 0.74, 95% CI 0.66–0.83) than allophone patients who received language-discordant care. Results were similar for Francophone patients, although the magnitude of the effect was smaller than for allophone patients. Language concordance or discordance of the hospital admission was not associated with significant differences in postdischarge outcomes.Interpretation:Patients who received most of their care from physicians who spoke the patients’ primary language had better in-hospital outcomes, suggesting that disparities across linguistic groups could be mitigated by providing patients with language-concordant care.

A growing number of people in Canada (more than 6.1 million in 2016) are faced with the challenge of living in a situation in which their primary language is not spoken by most of the population and is not recognized as an official provincial or territorial language. ^1,2 We refer to this as a minority language situation, and such people include Francophones living outside of Quebec, Anglophones living in Quebec, and all residents of Canada whose primary language is a language other than English or French (allophones). Numerous studies have shown that people in North America with limited English proficiency generally have poorer access to health care and receive health care services of lower quality and safety, resulting in higher risk of adverse events and increased health resource use.^3–8 Despite these findings, few authors have considered the impact of patient–provider language concordance, whereby patients and providers have proficiency in a shared language.⁹ Studies in the United States have shown that patients with asthma who receive language-concordant primary care are less likely to omit medications, miss appointments or visit the emergency department.¹⁰ Patients with diabetes who receive language-concordant care have improved glycemic and low-density-lipoprotein control,^11,12 as well as increased participation in diabetic foot care programs.¹³ Although patient language is generally considered to be a nonmodifiable risk factor, language discordance represents a potentially modifiable variable, which could be the target of interventions (e.g., by referring patients to providers who have proficiency in their primary language).Frail patients are more likely to have communication problems and poor health outcomes than the general population; thus, language concordance may be particularly important in this patient population.^14,15 The risk of harm for frail, older patients has been attributed to medical complexity and multi-morbidity; ^16–18 however, since communication barriers also increase with age, older patients may also be more likely to experience harm because of poor patient–provider communication. ¹⁹ Most studies of language concordance have been limited to the primary care setting. We are aware of 2 studies conducted in the acute care setting, with 1 showing that Francophones residing in Ontario were less likely to experience harm when they were treated in hospitals that were required by law to provide services French. ^20,21We sought to compare the risk of adverse, hospital-related outcomes among frail patients living in Ontario, Canada, after stratifying by patient language and patient–physician language concordance or discordance. We hypothesized that patients receiving language-concordant care would have better outcomes than those receiving language-discordant care.     

Impact of cancer surgery slowdowns on patient survival during the COVID-19 pandemic: a microsimulation modelling study

Background:With the declaration of the global pandemic, surgical slowdowns were instituted to conserve health care resources for anticipated surges in patients with COVID-19. The long-term implications on survival of these slowdowns for patients with cancer in Canada is unknown.Methods:We constructed a microsimulation model based on real-world population data on cancer care from Ontario, Canada, from 2019 and 2020. Our model estimated wait times for cancer surgery over a 6-month period during the pandemic by simulating a slowdown in operating room capacity (60% operating room resources in month 1, 70% in month 2, 85% in months 3–6), as compared with simulated prepandemic conditions with 100% resources. We used incremental differences in simulated wait times to model survival using per-day hazard ratios for risk of death. Primary outcomes included life-years lost per patient and per cancer population. We conducted scenario analyses to evaluate alternative, hypothetical scenarios of different levels of surgical slowdowns on risk of death.Results:The simulated model population comprised 22 799 patients waiting for cancer surgery before the pandemic and 20 177 patients during the pandemic. Mean wait time to surgery prepandemic was 25 days and during the pandemic was 32 days. Excess wait time led to 0.01–0.07 life-years lost per patient across cancer sites, translating to 843 (95% credible interval 646–950) life-years lost among patients with cancer in Ontario.Interpretation:Pandemic-related slowdowns of cancer surgeries were projected to result in decreased long-term survival for many patients with cancer. Measures to preserve surgical resources and health care capacity for affected patients are critical to mitigate unintended consequences.

Declaration of the global COVID-19 pandemic led to the implementation of several clinical and policy-related measures to mitigate risk to vulnerable populations and conserve health care resources. Literature from early waves of the pandemic characterized patients with cancer as a vulnerable population.^1,2 Moreover, cancer surgery can be highly resource intensive, which could strain the health care system’s ability to respond to the pandemic. Accordingly, in March 2020, the Ontario government recommended reducing the number of cancer surgeries, along with other elective surgeries performed in the province. These measures were aimed at reducing both patient morbidity and use of health care resources, primarily by decreasing routine postoperative admissions to wards and intensive care units, in anticipation of a potential surge of patients with COVID-19.³Although necessary, this initial strategy resulted in a backlog of cancer surgeries, and some patients faced longer wait times to surgical treatment.⁴ Given clear evidence showing that longer surgical wait times can increase cancer-related risk of death, there is concern for the unintended consequences of the surgical slowdowns during the COVID-19 pandemic.^5–8 International data have projected the negative impact on long-term survival associated with potential delays to cancer diagnosis or surgery across various cancer types.^9–11 Recognizing the global differences in level of infection, response to the COVID-19 pandemic and cancer survival rates, country-specific data are required to understand local consequences and better guide future responses to times of resource constraint. As such, the objective of the current study was to evaluate the long-term implications of pandemic–related cancer surgery slowdowns on cancer survival in Ontario, Canada.     

Diversity among health care leaders in Canada: a cross-sectional study of perceived gender and race

Background:Diverse health care leadership teams may improve health care experiences and outcomes for patients. We sought to explore the race and gender of hospital and health ministry executives in Canada and compare their diversity with that of the populations they serve.Methods:This cross-sectional study included leaders of Canada’s largest hospitals and all provincial and territorial health ministries. We included individuals listed on institutional websites as part of the leadership team if a name and photo were available. Six reviewers coded and analyzed the perceived race and gender of leaders, in duplicate. We compared the proportion of racialized health care leaders with the race demographics of the general population from the 2016 Canadian Census.Results:We included 3056 leaders from 135 institutions, with reviewer concordance on gender for 3022 leaders and on race for 2946 leaders. Reviewers perceived 37 (47.4%) of 78 health ministry leaders as women, and fewer than 5 (< 7%) of 80 as racialized. In Alberta, Saskatchewan, Prince Edward Island and Nova Scotia, provinces with a centralized hospital executive team, reviewers coded 36 (50.0%) of 72 leaders as women and 5 (7.1%) of 70 as racialized. In British Columbia, New Brunswick and Newfoundland and Labrador, provinces with hospital leadership by region, reviewers perceived 120 (56.1%) of 214 leaders as women and 24 (11.5%) of 209 as racialized. In Manitoba, Ontario and Quebec, where leadership teams exist at each hospital, reviewers perceived 1326 (49.9%) of 2658 leaders as women and 243 (9.2%) of 2633 as racialized. We calculated the representation gap between racialized executives and the racialized population as 14.5% for British Columbia, 27.5% for Manitoba, 20.7% for Ontario, 12.4% for Quebec, 7.6% for New Brunswick, 7.3% for Prince Edward Island and 11.6% for Newfoundland and Labrador.Interpretation:In a study of more than 3000 health care leaders in Canada, gender parity was present, but racialized executives were substantially under-represented. This work should prompt health care institutions to increase racial diversity in leadership.

Race and gender-based disparities in health care leadership^1–4 may negatively affect the health of marginalized patients.^5,6 Diverse leadership is an integral step in establishing equitable health care institutions that serve the needs of all community members.⁷ Many barriers prevent racialized people, women and gender nonbinary individuals from attaining leadership positions, including reduced access to networking opportunities, ^8–10 discrimination from patients and colleagues^2,11–13 and an institutional culture that views white, male leaders as most effective. ^14,15 The intersectional effects of discrimination may intensify these barriers for racialized women and nonbinary people.^16,17 Fundamentally, diversity and inclusion in our institutions is important on the basis of basic human rights for all people.¹⁸Health care leadership in Europe and the United States is thought to lack gender and racial diversity.^19–22 The degree to which these imbalances exist across Canadian health care institutions is not clear. Despite past evidence that men hold a disproportionate number of health care leadership positions in Canada,^23,24 a recent study noted gender parity among leaders of provincial and territorial ministries of health.²⁵ Among university faculty^26,27 and administration, ²⁸ racialized individuals appear to be under-represented, suggesting that a similar trend may exist in health care leadership.Race and gender can be studied in many ways.²⁹ Perceived race is a measure of “the race that others believe you to be,” and these assessments “influence how people are treated and form the basis of racial discrimination including nondeliberate actions that nonetheless lead to socioeconomic inequities.”²⁹ Similarly, perceived gender refers to an observer’s assumptions about a person’s gender, which can lead to differential and unfair treatment. ³⁰ Assessing perceived race and gender provides crucial insights into the ways in which social inequalities are informed and produced.²⁹ In this study, we sought to identify the perceived race and gender of hospital executive leaders in Canada and of nonelected leaders of the provincial and territorial health ministries. Furthermore, we wanted to analyze how the perceived racial composition of health care leadership compares with the racial composition of the population in the geographic areas that these leaders serve.     

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study

Background:Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults.Methods:We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits.Results:We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14).Interpretation:Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

In the continuum of care services and settings for older adults lies home care at one end and long-term care at the other.¹ Home care services may include, but are not limited to, nursing care, personal care, homemaking services, and physiotherapy and occupational therapy for older adults who live independently in their community. Home care services are publicly funded under the Ontario Health Insurance Plan (OHIP).^2,3 Long-term care homes provide access to 24-hour nursing and personal care and operate at full capacity in Ontario, with waiting lists of 6 months or longer before an older adult in the community could receive an offer for a bed.^2,4 Retirement homes are thought to fit between home care and long-term care in this continuum.¹Retirement homes are referred to as assisted-living facilities in other North American jurisdictions, and they are private, congregate living environments that deliver supportive care to adults who are 65 years of age and older.^3,5,6 These homes are often marketed to provide a lifestyle and community, and they provide a range of assisted-living care services (e.g., meals, nursing services, etc.).^5,7 Retirement homes predominately operate on a private, for-profit business model, and the room, board and services are purchased by residents.^3,5 In Ontario, retirement homes are regulated through an independent, not-for-profit regulator (i.e., Retirement Homes Regulatory Authority [RHRA]).⁵ There are more than 700 licensed retirement homes in Ontario with over 70 000 available beds occupied by over 55 000 residents, which is comparable to the number of available beds in the long-term care sector.^3,5,6,8 Retirement homes are legislated differently from long-term care homes and primarily cater to adults who do not require 24-hour nursing care.^1,5,9 Unlike long-term care homes, no standardized reporting system is available to identify and describe residents of retirement homes.¹⁰ These residents are conceptualized as having fewer needs for care because they reside in a congregate care home to support independent living; however, this has been difficult to verify given there are no population-level data.A body of literature from the United States has described residents of assisted-living facilities and the sector,^11–17 but Canadian literature is comparatively nascent. Canadian studies have investigated transitions to a long-term care home, risk of hospital admission among those who live with dementia, and life events and health conditions associated with the transition to a congregate care setting.^7,9,18–20 At present, a Canadian population-level cohort of residents of retirement homes that describes the individual-level characteristics and use of health services of the older adults who reside in these homes appears to be lacking. Therefore, it is difficult to position this sector in the gradient of services and housing options for older adults in Canada.We created a population-level cohort of residents in retirement homes and sought to evaluate their rates of health services utilization relative to residents of long-term care homes and other populations of older adults (i.e., home care recipients and community-dwelling older adults) in Ontario.     

Illuminating and mitigating the evolving impacts of COVID-19 on ethnocultural communities: a participatory action mixed-methods study

BACKGROUND:The COVID-19 pandemic has exacerbated disparities in poverty and illness for people in vulnerable circumstances in ethnocultural communities. We sought to understand the evolving impacts of COVID-19 on ethnocultural communities to inform intersectoral advocacy and community action.METHODS:The Illuminate Project used participatory action research, with cultural health brokers as peer researchers, from Sept. 21 to Dec. 31, 2020, in Edmonton, Alberta. Twenty-one peer researchers collected narratives from members of ethnocultural communities and self-interpreted them as they entered the narratives into the SenseMaker platform, a mixed-method data collection tool. The entire research team analyzed real-time, aggregate, quantitative and qualitative data to identify emerging thematic domains, then visualized these domains with social network analysis.RESULTS:Brokers serving diverse communities collected 773 narratives. Identified domains illuminate the evolving and entangled impacts of COVID-19 including the following: COVID-19 prevention and management; care of acute, chronic and serious illnesses other than COVID-19; maternal care; mental health and triggers of past trauma; financial insecurity; impact on children and youth and seniors; and legal concerns. We identified that community social capital and cultural brokering are key assets that facilitate access to formal health and social system supports.INTERPRETATION:The Illuminate Project has illustrated the entangled, systemic issues that result in poor health among vulnerable members of ethnocultural communities, and the exacerbating effects of COVID-19, which also increased barriers to mitigation. Cultural brokering and community social capital are key supports for people during the COVID-19 pandemic. These findings can inform policy to reduce harm and support community resiliency.

Mahatma Gandhi observed that “the true measure of any society can be found in how it treats its most vulnerable members.” Ethnocultural communities, defined by their unique shared characteristics (e.g., cultural traditions, language, country of origin),¹ face greater challenges and have higher rates of poverty and illness than the general Canadian population. Migration results in conditions that affect all social determinants of health and disproportionally affect health outcomes, herein referred to as vulnerable circumstances.^2,3 The emergence of major outbreaks of SARS-CoV-2 infections in ethnocultural communities highlights both the vulnerable circumstances of these communities and the disparities they face in accessing high-quality, culturally appropriate information and support.^4–7 Studies have shown substantial variation in deaths attributed to COVID-19 based on factors such as age, sex, ethnicity, length of time in Canada, income and education.^8–11 However, given the well-known gap in reporting comprehensive COVID-19 data in relation to race and ethnicity, efforts to measure its impact are hampered.^8–12 There is an urgent need to understand the evolving challenges of COVID-19 to inform action and public policy that can mitigate these challenges.To understand evolving situations of complexity and crisis, sensemaking, defined as “a continuous process to establish situational awareness,”¹³ is a crucial undertaking.¹⁴ Using participatory action research,^15–18 we sought to understand the evolving impacts of COVID-19 on ethnocultural communities to inform broader national efforts to migitate the impacts of COVID-19. Particularly, we sought to understand how the challenges of COVID-19 are entangled with contextual factors at multiple levels, how families and communities are leveraging strengths and social capital to adapt, and the role of cultural brokers in managing the crisis.     

Inappropriate use of clinical practices in Canada: a systematic review

Background:Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.Methods:We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.Results:We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).Interpretation:We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

As health care systems struggle with sustainability, there is increased recognition that a substantial percentage of the health care received is inappropriate.¹ Inappropriate health care occurs when effective clinical practices are underused, ineffective clinical practices are overused or other practices are misused. It can lead to negative patient experiences,² poor health outcomes^3,4 and inefficient use of scarce health care resources.⁵ In response, there is widespread professional and policy interest in reducing inappropriate health care in Canada and abroad. For example, in 2014, Choosing Wisely Canada,⁶ a physician-led campaign in partnership with the Canadian Medical Association, was established. This initiative encourages conversations between clinicians and patients about low-value or overused care in efforts to reduce inappropriate care. Choosing Wisely Canada is endorsed across Canada by all provincial and territorial medical associations (https://choosingwiselycanada.org/about/).Although reducing inappropriate health care is a high priority for health care professionals, agencies and governments in Canada, designing effective initiatives for quality improvement has been a difficult goal to achieve without knowledge of which clinical practices are inappropriately used. This is further challenged because Canada does not have a mandatory and comprehensive national tracking system for quality. The Canadian Institute for Health Information (CIHI) houses multiple Canadian health databases, but it does not collect information on all clinical practices. Therefore, a systematic synthesis is necessary to provide an overview of inappropriate health care in Canada.⁷ Summaries of inappropriately used clinical practices exist for several countries: United States,^8,9 United Kingdom¹⁰ and Australia.¹¹ Each of these syntheses found high levels (50% on average) of inappropriately used practices and laid the foundation for several quality improvement initiatives in these countries. We aimed to conduct a systematic review to estimate the nature and amount of inappropriately used clinical practices in Canada.     

SARS-CoV-2 seroprevalence in health care workers from 10 hospitals in Quebec,Canada: a cross-sectional study

Background:The COVID-19 pandemic has disproportionately affected health care workers. We sought to estimate SARS-CoV-2 seroprevalence among hospital health care workers in Quebec, Canada, after the first wave of the pandemic and to explore factors associated with SARS-CoV-2 seropositivity.Methods:Between July 6 and Sept. 24, 2020, we enrolled health care workers from 10 hospitals, including 8 from a region with a high incidence of COVID-19 (the Montréal area) and 2 from low-incidence regions of Quebec. Eligible health care workers were physicians, nurses, orderlies and cleaning staff working in 4 types of care units (emergency department, intensive care unit, COVID-19 inpatient unit and non-COVID-19 inpatient unit). Participants completed a questionnaire and underwent SARS-CoV-2 serology testing. We identified factors independently associated with higher seroprevalence.Results:Among 2056 enrolled health care workers, 241 (11.7%) had positive SARS-CoV-2 serology. Of these, 171 (71.0%) had been previously diagnosed with COVID-19. Seroprevalence varied among hospitals, from 2.4% to 3.7% in low-incidence regions to 17.9% to 32.0% in hospitals with outbreaks involving 5 or more health care workers. Higher seroprevalence was associated with working in a hospital where outbreaks occurred (adjusted prevalence ratio 4.16, 95% confidence interval [CI] 2.63–6.57), being a nurse or nursing assistant (adjusted prevalence ratio 1.34, 95% CI 1.03–1.74) or an orderly (adjusted prevalence ratio 1.49, 95% CI 1.12–1.97), and Black or Hispanic ethnicity (adjusted prevalence ratio 1.41, 95% CI 1.13–1.76). Lower seroprevalence was associated with working in the intensive care unit (adjusted prevalence ratio 0.47, 95% CI 0.30–0.71) or the emergency department (adjusted prevalence ratio 0.61, 95% CI 0.39–0.98).Interpretation:Health care workers in Quebec hospitals were at high risk of SARS-CoV-2 infection, particularly in outbreak settings. More work is needed to better understand SARS-CoV-2 transmission dynamics in health care settings.

The COVID-19 pandemic has disproportionately affected health care workers. In France, Spain, Italy, Germany and the United States, at least 10% of cases reported in spring 2020 were in health care workers.¹ In Quebec, 25% (14 177 of 56 565) of all cases declared during the first wave of the pandemic, from March to July 2020, were in health care workers,² about one-third of whom were working in acute care hospitals.¹ The Montréal area was the most affected region in Quebec and Canada during the first wave, reaching a COVID-19 incidence rate of 1336 per 100 000 population.²The number of COVID-19 cases reported among health care workers underestimated the number of those infected with SARS-CoV-2 during that period, given limited testing leading to undiagnosed asymptomatic or paucisymptomatic infections.³ Seroprevalence studies are an important tool to determine the proportion of people infected with SARS-CoV-2, both in the general population and among health care workers.⁴ After the first wave in Quebec, SARS-CoV-2 seroprevalence in adults aged 18–69 years was found to be low (3.1% in Montréal and 1.3% in less affected regions), but this proportion could be much higher among health care workers who had to work despite the general shutdown of social and economic activities, especially if they were exposed to major outbreaks.⁵Only 2 other Canadian studies provide SARS-CoV-2 seroprevalence estimates among health care workers, and both studies were from a single centre.^6,7 Outside Canada, most seroprevalence studies among health care workers include a single site and do not provide a representative estimate for a defined region.⁸ Several studies have reported a higher seroprevalence among health care workers from units treating patients with COVID-19 (COVID-19 units) compared with other units (non–COVID-19 units), emergency departments or intensive care units.^9,10 Other studies have not identified such associations.^11,12 In this study, we aimed to assess the seroprevalence of SARS-CoV-2 antibody among hospital health care workers from a variety of settings after the first pandemic wave in Quebec, and to explore factors associated with SARS-CoV-2 seropositivity.     

The link between medical conditions and fatal drownings in Canada: a 10-year cross-sectional analysis

Background:Drowning accounts for hundreds of preventable deaths in Canada every year, but the impact of preexisting medical conditions on the likelihood of death from drowning is not known. We aimed to describe the prevalence of pre-existing medical conditions among people who fatally drowned in Canada and evaluate the risk of fatal drowning among people with common pre-existing medical conditions.Methods:We reviewed all Canadian unintentional fatal drownings (2007–2016) in the Drowning Prevention Research Centre Canada’s database. For each fatal drowning we established whether the person had pre-existing medical conditions and whether those conditions contributed to the drowning. We calculated relative risk (RR) of fatal drowning stratified by age and sex for each pre-existing medical condition using data from the Canadian Chronic Disease Surveillance System.Results:During 2007–2016, 4288 people fatally drowned unintentially in Canada, of whom one-third had a pre-existing medical condition. A pre-existing medical condition contributed to drowning in 43.6% (n = 616) of cases. Fatal drowning occurred more frequently in people with ischemic heart disease (RR 2.7, 95% confidence interval [CI] 2.5–3.0) and seizure disorders (RR 6.3, 95% CI 5.4–7.3) but less frequently in people with respiratory disease (RR 0.12, 95% CI 0.10–0.15). Females aged 20–34 years with a seizure disorder had a 23 times greater risk than their age- and sex-matched cohort (RR 23, 95% CI 14–39). In general, fatal drowning occurred more often while people were bathing (RR 5.9, 95% CI 4.8–7.0) or alone (RR 1.99, 95% CI 1.32–2.97) and less often in males (RR 0.92, 95% CI 0.88–0.95) or in those who had used alcohol (RR 0.72, 95% CI 0.65–0.80), among those with pre-existing medical conditions.Interpretation:The risk of fatal drowning is increased in the presence of some preexisting medical conditions. Tailored interventions aimed at preventing drowning based on pre-existing medical conditions and age are needed. Initial prevention strategies should focus on seizure disorders and bathtub drownings.

Drowning is an important cause of death in Canada and some aspects of its epidemiology have been characterized.^1,2 Identifying and addressing risk factors for fatal drowning can save lives. For example, after research showed a considerable proportion of child drownings occurred in unsecured household pools and the effectiveness of pool fencing at reducing these deaths, legislative changes were introduced in Quebec.^3–5Although studies evaluating risk factors frequently focus on modifiable environmental or behavioural factors (e.g., infant bath seats, supervision status or alcohol and drug use),^6–11 limited research has evaluated the relation between pre-existing medical conditions and the risk of drowning.Studies that have evaluated the association between pre-existing medical conditions and drowning are limited by small sample sizes and narrow focus on certain conditions (e.g., autism spectrum disorder, epilepsy), or are age-specific (e.g., children).^12–17 The association between various pre-existing medical conditions and drowning in different age groups is not well understood. This information could assist with the development of targeted drowning prevention strategies and prioritizing of resources spent on prevention.Forty-four percent of Canadian adults have at least 1 chronic disease, which suggests that millions of Canadians with conditions that potentially impair their heart, lungs or brain participate in water activities.¹⁸ Furthermore, swimming and aquatic fitness is often encouraged for those with chronic illness to promote health.^19,20 However, the public and physicians should be aware of pre-existing medical conditions that might place people at a higher risk of drowning, so that appropriate precautions can be taken to ensure safety while participating in aquatic activities.We sought to describe pre-existing medical conditions by age group among people who fatally drowned in Canada and to evaluate the risk of fatal drowning among people with common conditions to inform future public health interventions.     

Remdesivir for the treatment of patients in hospital with COVID-19 in Canada: a randomized controlled trial

Background:The role of remdesivir in the treatment of patients in hospital with COVID-19 remains ill defined in a global context. The World Health Organization Solidarity randomized controlled trial (RCT) evaluated remdesivir in patients across many countries, with Canada enrolling patients using an expanded data collection format in the Canadian Treatments for COVID-19 (CATCO) trial. We report on the Canadian findings, with additional demographics, characteristics and clinical outcomes, to explore the potential for differential effects across different health care systems.Methods:We performed an open-label, pragmatic RCT in Canadian hospitals, in conjunction with the Solidarity trial. We randomized patients to 10 days of remdesivir (200 mg intravenously [IV] on day 0, followed by 100 mg IV daily), plus standard care, or standard care alone. The primary outcome was in-hospital mortality. Secondary outcomes included changes in clinical severity, oxygen- and ventilator-free days (at 28 d), incidence of new oxygen or mechanical ventilation use, duration of hospital stay, and adverse event rates. We performed a priori subgroup analyses according to duration of symptoms before enrolment, age, sex and severity of symptoms on presentation.Results:Across 52 Canadian hospitals, we randomized 1282 patients between Aug. 14, 2020, and Apr. 1, 2021, to remdesivir (n = 634) or standard of care (n = 648). Of these, 15 withdrew consent or were still in hospital, for a total sample of 1267 patients. Among patients assigned to receive remdesivir, in-hospital mortality was 18.7%, compared with 22.6% in the standard-of-care arm (relative risk [RR] 0.83 (95% confidence interval [CI] 0.67 to 1.03), and 60-day mortality was 24.8% and 28.2%, respectively (95% CI 0.72 to 1.07). For patients not mechanically ventilated at baseline, the need for mechanical ventilation was 8.0% in those assigned remdesivir, and 15.0% in those receiving standard of care (RR 0.53, 95% CI 0.38 to 0.75). Mean oxygen-free and ventilator-free days at day 28 were 15.9 (± standard deviation [SD] 10.5) and 21.4 (± SD 11.3) in those receiving remdesivir and 14.2 (± SD 11) and 19.5 (± SD 12.3) in those receiving standard of care (p = 0.006 and 0.007, respectively). There was no difference in safety events of new dialysis, change in creatinine, or new hepatic dysfunction between the 2 groups.Interpretation:Remdesivir, when compared with standard of care, has a modest but significant effect on outcomes important to patients and health systems, such as the need for mechanical ventilation. Trial registration: ClinicalTrials.gov, no. {"type":"clinical-trial","attrs":{"text":"NCT04330690","term_id":"NCT04330690"}}NCT04330690.

The role of remdesivir in treating patients in hospital with COVID-19 remains ill defined.¹ Remdesivir, a repurposed antiviral medication, has full or emergency approval from a number of regulators — including Health Canada — for the treatment of COVID-19, based on clinical trial data documenting a benefit on improving time to recovery.² An interim report of the larger World Health Organization (WHO) Solidarity trial showed no difference regarding mortality or need for mechanical ventilation, with a number of smaller trials being inconclusive on these important outcomes.^3–6 Recommendations of clinical guidelines are mixed, with some recommending remdesivir as standard of care, and others weakly recommending against.^7,8 Its impact on other clinical outcomes, including resource utilization and post–hospital stay outcomes, has not been fully defined, and there remains a possibility of an important treatment effect, particularly in certain groups of patients.⁹Solidarity is a global pragmatic clinical trial examining the effects of various therapeutics in patients with COVID-19.^3,10 Canadian Treatments for COVID-19 (CATCO) is a substudy of Solidarity, funded by the Canadian Institutes of Health Research (CIHR), in which added data elements are collected to better understand the effects of specific agents. We aimed to estimate the effect of treatment with remdesivir compared with standard care, for patients in hospital with COVID-19 in Canada; global data, which include Canadian patients randomized before Jan. 29, 2021, will also be available in a separate publication.     

Factors associated with consent for organ donation: a retrospective population-based study

Background:Optimizing the approach to and consent of potential organ donors maximizes patient autonomy and the availability of organs for transplants. We set out to identify modifiable factors associated with donation consent.Methods:We conducted a retrospective cohort study of consecutive adults (≥ 18 yr) referred for organ donation in Ontario between April 2013 and June 2019. We analyzed patient clinical data and demographics, data on substitute decision-makers and characteristics of the donation consent approach. Study outcomes were consent for organ donation and approach rate. We evaluated independent associations between consent and approach-and system-level factors.Results:We identified 34 837 referrals for organ donation, of which 6548 (18.8%) substitute decision-makers were approached for consent. Of these, 3927 (60.0% of approaches) consented for organ donation and 1883 (48.0% of consents) patients proceeded to be organ donors. The most common reason substitute decision-makers were not approached for consent in a case with donation potential was a late referral by the health care team (45.2%). Modifiable factors independently associated with consent included a telephone approach for consent (adjusted odds ratio [OR] 0.46, 95% confidence interval [CI] 0.35–0.58) and a collaborative approach by a physician and donation coordinator (adjusted OR 1.26, 95% CI 1.01–1.59).Interpretation:Consent for organ donation was associated with several modifiable factors. Organizations should target interventions to ensure timely referrals to organ donation organizations, increase in-person consent approaches and increase physician participation in the approach process.

Many people die on transplant waiting lists because the demand for organs outstrips supply. Almost 4500 people are on organ transplant waiting lists in Canada. Despite public support for organ donation across Canada,¹ donation rates vary between 8.8 and 21.2 donors per million population, ² and a substantial pool of potential donors is not being realized. ^2,3 The identification, referral and approach of potential donors can be facilitated by policy, legislation and best practices, ^3,4 although the efficacy of interventions is variable across jurisdictions.^5,6 Some comprehensive interventions to increase donor numbers have not changed consent rates,⁷ suggesting that the consent approach process may be a target for improvement.Substitute decision-makers play an important role in the organ donation process, even in jurisdictions with donation consent registries or opt-out consent systems. Substitute decision-makers are almost always asked permission for organ donation, even when there is a registered donation consent,⁸ and their consent rates vary widely.⁹ Substitute decision-makers faced with consent decisions often do so in emotionally charged circumstances, and many do not know the explicit wishes of the patient.¹⁰ Given this context, the process of obtaining consent and the supports provided may have a substantial impact on the decision. Practices have been identified that improve consent rates from substitute decision-makers,¹¹ and these are routinely performed by large, high-performing organ donation organizations. Several epidemiological studies have identified nonmodifiable factors associated with donation consent (e.g., race, age, socioeconomic status and education).^12–15 The persistent variability in consent rates suggests that other modifiable factors may influence a substitute decision-maker’s decision to consent.We aimed to identify modifiable approach-and system-level factors that were associated with positive consent for organ donation in Ontario, Canada.