Preterm birth and stillbirth rates during the COVID-19 pandemic: a population-based cohort study

BACKGROUND:Conflicting reports have emerged for rates of preterm births and stillbirths during the COVID-19 pandemic. Most of these reports did not account for natural variation in these rates. We aimed to evaluate variations in preterm birth and stillbirth rates before and during the COVID-19 pandemic in Ontario, Canada.METHODS:We conducted a retrospective cohort study using linked population health administrative databases of pregnant people giving birth in any hospital in Ontario between July 2002 and December 2020. We calculated preterm birth and stillbirth rates. We assessed preterm birth at 22–28, 29–32 and 33–36 weeks’ gestation, and stillbirths at term and preterm gestation. We used Laney control P′ charts for the 18-year study period (6-mo observation periods) and interrupted time-series analyses for monthly rates for the most recent 4 years.RESULTS:We evaluated 2 465 387 pregnancies, including 13 781 that resulted in stillbirth. The mean preterm birth rate for our cohort was 7.96% (range 7.32%–8.59%). From January to December 2020, we determined that the preterm birth rate in Ontario was 7.87%, with no special cause variation. The mean stillbirth rate for the cohort was 0.56% (range 0.48%–0.70%). From January to December 2020, the stillbirth rate was 0.53%, with no special cause variation. We did not find any special cause variation for preterm birth or stillbirth subgroups. We found no changes in slope or gap between prepandemic and pandemic periods using interrupted time-series analyses.INTERPRETATION:In Ontario, Canada, we found no special cause variation (unusual change) in preterm birth or stillbirth rates, overall or by subgroups, during the first 12 months of the COVID-19 pandemic compared with the previous 17.5 years.

Preterm birth (birth before 37 weeks’ gestation) is a leading cause of mortality and morbidities in the neonatal period,¹ childhood and adulthood.² Stillbirth has devastating consequences for families.³ The causes of both preterm birth and stillbirth are multifactorial. During the pandemic, reports described reductions in preterm birth rates in Denmark,⁴ the Netherlands,⁵ Ireland⁶ and the United States.⁷ At the same time, increases in stillbirth rates were reported from the United Kingdom,⁸ Italy,⁹ Nepal¹⁰ and India,¹¹ with or without changes in rates of preterm births. Meta-analyses have emerged with differing conclusions.^12,13 Some speculated reasons for reductions in preterm births included reductions in physical activity during pregnancy, reduced stress related to work–life balance, less exposure to infection, fewer medical interventions, reduced travel and pollution,¹⁴ and improved hygiene and rest. Proposed reasons for increases in preterm birth rates include higher stress due to worry about the pandemic, employment or financial challenges, home schooling and reduced maternity services.¹⁵ Less stringent fetal surveillance from reduced attendance at medical appointments for fear of infection, cancellation of face-to-face appointments and reduced staffing for maternity services are possible reasons for increased rates of stillbirths. Thus, it is important to evaluate preterm births and stillbirths simultaneously to understand the true impact.¹⁶Some previous reports compared preterm birth and stillbirth rates during the pandemic to similar time periods in the past few years. However, within a jurisdiction, these rates are known to fluctuate between epochs¹⁷ and, thus, it is preferable to evaluate rates over longer periods to establish whether observed variations are usual (common cause variation) or unusual (special cause variation). Our objective was to evaluate whether the COVID-19 pandemic affected preterm birth or stillbirth rates in Ontario by comparing rates for the early COVID-19 pandemic time period with rates from the previous 17.5 years to identify patterns of variation.     

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.     

Incidence and mortality rates of keratinocyte carcinoma from 1998–2017: a population-based study of sex differences in Ontario,Canada

Background:Keratinocyte carcinoma is the most common malignant disease, but it is not captured in major registries. We aimed to describe differences by sex in the incidence and mortality rates of keratinocyte carcinoma in Ontario, Canada.Methods:We conducted a population-based retrospective study of adults residing in Ontario between Jan. 1, 1998, and Dec. 31, 2017, using linked health administrative databases. We identified the first diagnosis of keratinocyte carcinoma using a validated algorithm of health insurance claims, and deaths related to keratinocyte carcinoma from death certificates. We calculated the incidence and mortality rates of keratinocyte carcinoma, stratified by sex, age and income quintile. We evaluated trends using the average annual percentage change (AAPC) based on joinpoint regression.Results:After decreasing from 1998 to 2003, the incidence rate of keratinocyte carcinoma increased by 30% to 369 per 100 000 males and 345 per 100 000 females in 2017 (AAPC 1.9%, 95% confidence interval [CI] 1.7 to 2.1 from 2003 to 2017). The incidence rate was higher in females younger than 55 years, but higher in males aged 55 years or older. Between 2008 and 2017, the incidence rate rose faster in females than males aged 45–54 years (AAPC 1.2% v. 0.5%, p = 0.01) and 55–64 years (1.2% v. 0.1%, p < 0.01). The incidence was higher in males than females in the higher income quintiles. Between 1998 and 2017, the mortality rate of keratinocyte carcinoma was 1.8 times higher in males than females, on average, and rose 4.8-fold overall (AAPC 8.9%, 95% CI 6.4 to 11.4 in males; 8.0%, 95% CI 5.3–10.8 in females).Interpretation:The population burden of keratinocyte carcinoma is growing, and the incidence and mortality rates rose disproportionately among certain sex- and age-specific groups. This warrants further investigation into causal factors and renewed preventive public health measures.

Keratinocyte carcinoma comprises basal and squamous cell carcinomas, and is the most common malignant disease in Canada and the United States.^1–5 Although keratinocyte carcinoma has a low mortality rate, it is associated with substantial morbidity and impaired quality of life.^2,6,7 Among cancers, it also ranks fifth in health care costs in the US.⁸Epidemiological studies of keratinocyte carcinoma in North America are limited by its exclusion from most cancer registries. ⁹ Previous studies found that higher overall incidence of keratinocyte carcinoma is associated with male sex,^10–14 older age^15–17 and higher socioeconomic status.^18–21 However, differences in the incidence and mortality rates of keratinocyte carcinoma by sex in relation to age and socioeconomic status have not been well characterized.A better understanding of the epidemiology of keratinocyte carcinoma in Canada and differences by sex would inform public health initiatives, health services policy and patient education strategies. This is particularly relevant now, given the recent regulatory approval of systemic immunotherapies for locally advanced or metastatic squamous and basal cell carcinoma.^22–25 Our objective was to identify the population-based incidence and mortality trends of keratinocyte carcinoma in Ontario, Canada over 2 decades and to evaluate sex differences.     

Maternal cardiovascular disease after twin pregnancies complicated by hypertensive disorders of pregnancy: a population-based cohort study

Background:People whose singleton pregnancy is affected by hypertensive disorders of pregnancy (HDP) are at risk of future cardiovascular disease. It is unclear, however, whether this association can be extrapolated to twin pregnancies. We aimed to compare the association between HDP and future cardiovascular disease after twin and singleton pregnancies.Methods:We conducted a population-based retrospective cohort study that included nulliparous people in Ontario, Canada, 1992–2017. We compared the future risk of cardiovascular disease among pregnant people from the following 4 groups: those who delivered a singleton without HDP (referent) and with HDP, and those who delivered twins either with or without HDP.Results:The populations of the 4 groups were as follows: 1 431 651 pregnant people in the singleton birth without HDP group; 98 631 singleton birth with HDP; 21 046 twin birth without HDP; and 4283 twin birth with HDP. The median duration of follow-up was 13 (interquartile range 7–20) years. The incidence rate of cardiovascular disease was lowest among those with a singleton or twin birth without HDP (0.72 and 0.74 per 1000 person-years, respectively). Compared with people with a singleton birth without HDP, the risk of cardiovascular disease was highest among those with a singleton birth and HDP (1.47 per 1000 person-years; adjusted hazard ratio [HR] 1.81 [95% confidence interval (CI) 1.72–1.90]), followed by people with a twin pregnancy and HDP (1.07 per 1000 person-years; adjusted HR 1.36 [95% CI 1.04–1.77]). The risk of the primary outcome after a twin pregnancy with HDP was lower than that after a singleton pregnancy with HDP (adjusted HR 0.74 [95% CI 0.57–0.97]), when compared directly.Interpretation:In a twin pregnancy, HDP are weaker risk factors for postpartum cardiovascular disease than in a singleton pregnancy.

Cardiovascular disease has been shown to be the leading cause of death among women.^1–3 Classic risk factors for cardiovascular disease include obesity, diabetes mellitus, hypertension and family history of cardiovascular disease. ³ More recently, an association has been established between a history of hypertensive disorders of pregnancy (HDP) — gestational hypertension and pre-eclampsia — and future risk of cardiovascular disease.^1,4–11 Consequently, some recommend using a history of HDP for cardiovascular disease risk stratification in women.^3,12The leading hypothesis for the pathogenesis of HDP is that it results from abnormal placentation due to impaired trophoblast invasion,^13–16 resulting in reduced placental perfusion.^17–19 This, in turn, leads to abnormal secretion of the angiogenic factors soluble FMS-like tyrosine kinase 1 (sFlt1) and soluble endoglin (sEng),²⁰ which induce endothelial dysfunction and the clinical manifestations of HDP.^19,21–24 The mechanisms underlying the association between HDP and future cardiovascular disease are under debate.²⁵ One hypothesis is that HDP are merely a marker of underlying subclinical or clinical vascular risk factors that predispose a person to both HDP and future cardiovascular disease.A person who is pregnant with twins is at about 3–4 times higher risk of HDP than a person with a singleton pregnancy,^26–33 with rates of 14% and 5%, respectively.³⁴ The higher risk of HDP in twin pregnancies may be due to higher circulating sFlt1 and sEng owing to greater placental mass in twin pregnancies, ^35–37 and less related to the classic vascular risk factors for HDP in a singleton pregnancy. Therefore, a logical question is whether the established higher risk of future cardiovascular disease after singleton pregnancies with HDP also occurs in twin pregnancies with HDP. Limited data are available to answer this question.³⁸ In the current study, we aimed to test the hypothesis that the association between HDP and future cardiovascular disease is less pronounced in twin versus singleton pregnancies.     

Reasons for cannabis use during pregnancy and lactation: a qualitative study

Background:Cannabis use among pregnant and lactating people is increasing, despite clinical evidence showing that cannabis use may be associated with low birth weight and childhood developmental deficits. Our objective was to understand why pregnant and lactating people use cannabis and how these motivations change across perinatal stages.Methods:Using qualitative, constructivist grounded theory methodology, we conducted telephone and virtual interviews with 52 individuals from across Canada. We selected participants using maximum variation and theoretical sampling. They were eligible if they had been pregnant or lactating within the past year and had decided to continue, cease or decrease their cannabis use during the perinatal period.Results:We identified 3 categories of reasons that people use cannabis during pregnancy and lactation: sensation-seeking for fun and enjoyment; symptom management of chronic conditions and conditions related to pregnancy; and coping with the unpleasant, but nonpathologized, experiences of life. Before pregnancy, participants endorsed reasons for using cannabis in these 3 categories in similar proportions, with many offering multiple reasons for use. During pregnancy, reasons for use shifted primarily to symptom management. During lactation, reasons returned to resemble those expressed before pregnancy.Interpretation:In this study, we showed that pregnant and lactating people use cannabis for many reasons, particularly for symptom management. Reasons for cannabis use changed across reproductive stages. The dynamic nature of the reasons for use across stages speaks to participant perception of benefits and risks, and perhaps a desire to cast cannabis use during pregnancy as therapeutic because of perceived stigma.

Cannabis use by pregnant and lactating people is increasing, though it is difficult to establish the prevalence of cannabis use in pregnancy. Reported prevalence varies from 2% to 36%, depending on the methodology used to detect use, the population studied and the definition of use.^1–12 Pregnant people have reported using cannabis to manage pregnancy-related conditions (e.g., nausea, weight gain, sleep difficulty)^13–19 and pre-existing conditions (e.g., mental health, insomnia, chronic pain),^13,14,18 as well as to improve mood, mental, physical and spiritual well-being,^16,18 provide pleasure and manage stress.^13–16 Recent systematic reviews have not found empirical data on reasons for cannabis use during lactation.^20,21Evidence is still emerging about clinical outcomes related to cannabis use during pregnancy and lactation, and well-controlled studies are lacking.^22–24 The available evidence is limited by reliance on self-reported data about dose, composition and timing of exposure, the changing nature of tetrahydrocannabinol levels in cannabis over time, and a lack of studies that control for known confounders such as polysubstance and tobacco use.^25–31 The available evidence does suggest that cannabis use during pregnancy may be associated with complications such as low birth weight, childhood neurodevelopmental outcomes and preterm birth.^{22–24,32,33} Very few studies have analyzed the outcomes associated with cannabis exposure through breastmilk, with 1 study suggesting decreased infant motor development and another showing no effects on developmental outcomes.^34–36 Given the potential harms identified, and in the absence of high-quality evidence available to guide practice, most clinical guidelines recommend abstinence from cannabis during pregnancy and lactation.^37–39People who perceive benefits from cannabis may wish to or may be motivated to continue using it through pregnancy and lactation, however. Counselling that explores the reasons patients are considering cannabis use and suggests related alternatives or harm reduction strategies has been identified as a helpful strategy to minimize potential harm.^13,40,41,42 Such an approach requires that clinicians understand the motivations to use cannabis before pregnancy, during pregnancy and during lactation. We sought to explore why people use cannabis during pregnancy and lactation.     

Effect of influenza vaccination in patients with asthma

BACKGROUND:Although annual influenza vaccination is recommended for persons with asthma, its effectiveness in this patient population is not well described. We evaluated the effect of influenza vaccination in the current and previous seasons in preventing influenza among people with asthma.METHODS:Using population health data from the Navarre region of Spain for the 2015/16 to 2019/20 influenza seasons, we conducted a test-negative case–control study to assess the effect of influenza vaccination in the current and 5 previous seasons. From patients presenting to hospitals and primary health care centres with influenza-like illness who underwent testing for influenza, we estimated the effects of influenza vaccination among patients with asthma overall and between those presenting as inpatients or outpatients, as well as between patients with and without asthma.RESULTS:Of 1032 patients who had asthma and were tested, we confirmed that 421 had influenza and the remaining 611 were test-negative controls. We found that the average effect of influenza vaccination was 43% (adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.40 to 0.80) for current-season vaccination regardless of previous doses, and 38% (adjusted OR 0.62, 95% CI 0.39 to 0.96) for vaccination in previous seasons only. Effects were similar for outpatients and inpatients. Among patients with asthma and confirmed influenza, current-season vaccination did not reduce the odds of hospital admission (adjusted OR 1.05, 95% CI 0.51 to 2.18). Influenza vaccination effects were similar for patients with and without asthma.INTERPRETATION:We estimated that, on average, current or previous influenza vaccination of people with asthma prevented almost half of influenza cases. These results support recommendations that people with asthma receive influenza vaccination.

Influenza can lead to serious complications in people with risk factors, and the main preventive measure is vaccination. ¹ Influenza infection can exacerbate symptoms of asthma. Because people with asthma have an increased risk of severe complications and hospital admission when infected with influenza virus,^2–5 annual influenza vaccination is recommended worldwide for people with asthma.^1,5–8People who are targeted for influenza vaccination frequently accumulate several doses over successive years,⁹ and adherence to influenza vaccination has been found to be higher in those with asthma.¹⁰ Patients with asthma frequently receive long-term corticosteroid treatment (inhaled or oral), therefore, their systemic immunity may have a reduced response to vaccines.^5,11,12Effectiveness of influenza vaccines in preventing primary health care consultations or hospital admissions in people with asthma has been evaluated in observational studies,^13–15 but we are unaware of any studies that compared the effect in preventing outpatient and inpatient cases or assessed the effect of vaccination in previous seasons.^13,16 The test-negative design is the suggested method to evaluate effectiveness of influenza vaccines in preventing laboratory-confirmed influenza, because it achieves good comparability and control of bias.^17–19 Only 1 study used this method for people with asthma over several seasons.¹³ The pooled analysis of several seasons, the inclusion of inpatients and outpatients, and consideration of vaccination history would provide a complete view of the effect of influenza vaccination in people with asthma.Our objective was to assess the average effect of influenza vaccination status in the current and previous seasons on preventing laboratory-confirmed influenza among people with asthma. We also aimed to compare these estimates with those of the target population for influenza vaccination.     

Evaluation of the relative virulence of novel SARS-CoV-2 variants: a retrospective cohort study in Ontario,Canada

Background:Between February and June 2021, the initial wild-type strains of SARS-CoV-2 were supplanted in Ontario, Canada, by new variants of concern (VOCs), first those with the N501Y mutation (i.e., Alpha/B1.1.17, Beta/B.1.351 and Gamma/P.1 variants) and then the Delta/B.1.617 variant. The increased transmissibility of these VOCs has been documented, but knowledge about their virulence is limited. We used Ontario’s COVID-19 case data to evaluate the virulence of these VOCs compared with non-VOC SARS-CoV-2 strains, as measured by risk of hospitalization, intensive care unit (ICU) admission and death.Methods:We created a retrospective cohort of people in Ontario who tested positive for SARS-CoV-2 and were screened for VOCs, with dates of test report between Feb. 7 and June 27, 2021. We constructed mixed-effect logistic regression models with hospitalization, ICU admission and death as outcome variables. We adjusted models for age, sex, time, vaccination status, comorbidities and pregnancy status. We included health units as random intercepts.Results:Our cohort included 212 326 people. Compared with non-VOC SARS-CoV-2 strains, the adjusted elevation in risk associated with N501Y-positive variants was 52% (95% confidence interval [CI] 42%–63%) for hospitalization, 89% (95% CI 67%–117%) for ICU admission and 51% (95% CI 30%–78%) for death. Increased risk with the Delta variant was more pronounced at 108% (95% CI 78%–140%) for hospitalization, 235% (95% CI 160%–331%) for ICU admission and 133% (95% CI 54%–231%) for death.Interpretation:The increasing virulence of SARS-CoV-2 VOCs will lead to a considerably larger, and more deadly, pandemic than would have occurred in the absence of the emergence of VOCs.

Novel SARS-CoV-2 variants of concern (VOCs), including viral lineages carrying the N501Y (Alpha/B.1.1.7) or both the N501Y and E484K mutations (Beta/B.1.351 and Gamma/P.1), were first identified in Ontario, Canada, in December 2020.¹ Although initially uncommon in Ontario, these VOCs outcompeted earlier SARS-CoV-2 lineages and, as of late April 2021, were responsible for almost all new infections in Ontario, with Alpha the most prevalent lineage.¹ In April 2021, the B.1.617.2 variant, now known as Delta under the revised nomenclature from the World Health Organization, emerged in the province, outcompeted earlier VOCs and, by July 2021, represented most infections in the province.^2,3This serial replacement by emerging variants reflects progressively higher effective reproduction numbers that allow novel variants to outcompete previously dominant strains in the face of identical measures to control spread of infection.^4–6 However, VOCs are also concerning because emerging evidence points to increased virulence, with increased risk of hospitalization, intensive care unit (ICU) admission and death, after adjustment for age and other predictive factors among patients with VOC infections.^7–10 Although the increased virulence of strains with the N501Y mutation relative to strains that lack this mutation has been described,^7–9 only limited information is available on the virulence of infection with the Delta variant, relative to earlier N501Y-positive VOCs (i.e., Alpha, Beta and Gamma).^10–12 Our objectives were to evaluate the virulence of N501Y-positive variants relative to earlier SARS-CoV-2 lineages and to evaluate the virulence of the Delta variant of SARS-CoV-2 relative to N501Y-positive VOCs using Ontario’s COVID-19 case data.     

Recent cannabis use and myocardial infarction in young adults: a cross-sectional study

Background:Cannabis use is increasing among young adults, but its effects on cardiovascular health are poorly understood. We aimed to assess the association between recent cannabis use and history of myocardial infarction (MI) in young adults (aged 18–44 yr).Methods:We performed a cross-sectional study using pooled data from the 2017 and 2018 cohorts of the American Behavioral Risk Factor Surveillance System survey of US adults. We analyzed the association between any recent cannabis use and history of MI using a weighted logistic regression model that adjusted for demographic factors, socioeconomic factors, health-related behaviours, concomitant substance use and other comorbidities. We also assessed this association after stratifying by frequency of use and by primary method of consumption.Results:Among 33 173 young adults (18.5 million weighted), 4610 respondents (3.2 million weighted) reported recent cannabis use (17.5%, 95% confidence interval [CI] 16.8%–18.2%). A history of MI was more frequent among recent cannabis users (n = 61 of 4610, 1.3%) relative to nonusers (n = 240 of 28 563 [0.8%], adjusted odds ratio [OR] 2.07, 95% CI 1.12–3.82). A history of MI was associated with cannabis use of more than 4 times per month (adjusted OR 2.31, 95% CI 1.18–4.50), and with smoking as a primary method of consumption (adjusted OR 2.01, 95% CI 1.02–3.98).Interpretation:Our study provides evidence supporting an association between recent cannabis use and history of MI in young adults. Increasing cannabis use in an at-risk population could have negative implications for cardiovascular health.

Cannabis is one of the most commonly used recreational drugs.¹ Recent legalization of cannabis in Canada,² and decriminalization in multiple jurisdictions in the United States,³ has contributed to its increased availability and social acceptance. Cannabis use is also increasing, particularly among young adults (aged 18 to 44 yr).^4,5 Furthermore, when comparing prevalence rates before and after legalization in Canada, use among young adults increased by a larger amount relative to other age groups.⁶ Despite the widespread use of cannabis, its effects on health remain poorly understood.The American Heart Association recently issued a recommendation not to smoke or vapourize any product containing cannabis because of its potential harm on cardiovascular health, and called for more research on the epidemiology and trends in cannabis use among youth and high-risk populations.⁷ The association between recent cannabis use and stroke has been assessed;⁸ however, its effect on other cardiovascular outcomes remains incompletely characterized. Although heavy cannabis use has been reported to trigger acute myocardial infarction (MI), the current evidence is limited to case–control studies that are prone to bias and studies relying solely on administrative data.^9–14 It is also limited in its definition of exposure, as these studies assess patients with heavy cannabis use (cannabis abuse or cannabis use disorder).^9–14 Very few studies have assessed the prevalence of recent cannabis use (any use within past 30 days) and its association with MI.^7,9,15 Prevalence estimates of the primary method of cannabis consumption and the frequency of cannabis use are incompletely characterized, and the potential impact of these factors on the risk of MI remains undefined.We aimed to assess the prevalence of recent cannabis use and its association with history of MI in young adults (aged 18 to 44 yr) in the US, using national health survey data.     

Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada

BACKGROUND:For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada.METHODS:We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006–2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more.RESULTS:We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52–8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07–33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37–2.91).INTERPRETATION:Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.

Access to birth close to home, surrounded by loved ones, is taken for granted by most Canadians. The societal importance of family support during birthing has been highlighted during the severe acute respiratory syndrome and COVID-19 pandemics, despite the known and potentially fatal risks to hospital visitors, because people in labour have been one of the few patient groups exempt from visitor restrictions.^1,2 For residents living in rural areas of Canada, long-distance travel for birth is a reality that is becoming increasingly common in some regions because of closures of obstetrical services in smaller community hospitals.³ This is only partially mitigated by the revitalization of rural midwifery practice.^4,5Emerging evidence shows that the frequency of adverse medical events during labour and delivery for rural populations is similar for births that take place close to home and births for which people travel because of an absence of services close to home.^3,4,6 Less is known about the impacts of travel for birth on breastfeeding rates, maternal mental health and family functioning. Several studies have documented the negative impacts of birthing away from home with respect to maternal satisfaction and birth experience.^7–10 This evidence is particularly compelling for Indigenous populations for whom birthing on or near traditional territories in the presence of family and community is a long-standing practice of foundational cultural and social importance that contributes to well-being, cultural continuity and kinship.^7–12The striking isolation, family disruption and racism experienced by Indigenous people who are forced to travel alone for birth as a result of externally imposed federal “evacuation for birth” policies¹¹ has been met with a series of policy initiatives to support return of birth to rural and remote Indigenous communities. ^13–15 In April 2017, then federal Minister of Health Dr. Jane Philpott, committed to “a path to be able to return the cries of birth” to Indigenous communities and funding to support travel for a companion when Indigenous people living in rural and remote areas needed to travel away from home for birth.¹⁶ Before 2017, Indigenous pregnant people often travelled and birthed away from home alone without family or community support, because escorts were not deemed medically necessary. Although these initiatives have improved access to Indigenous perinatal programming and Indigenous birth attendant support in some local areas, over the past decade there has not been any substantial expansion of Indigenous birthing facilities outside of urban centres in Canada and at least 1 remote Indigenous birthing facility has closed.¹⁷Given this dynamic policy context, the national scope and Indigenous identifiers in the Canadian Maternity Experiences Survey (MES) provides a unique opportunity to quantify how often Indigenous and non-Indigenous people are travelling away from home for birth and to evaluate the association between Indigenous and non-Indigenous identity and distance travelled for birth in Canada.     

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.     

Predicting death in home care users: derivation and validation of the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT)

BACKGROUND:Prognostication tools that report personalized mortality risk and survival could improve discussions about end-of-life and advance care planning. We sought to develop and validate a mortality risk model for older adults with diverse care needs in home care using self-reportable information — the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT).METHODS:Using a derivation cohort that comprised adults living in Ontario, Canada, aged 50 years and older with at least 1 Resident Assessment Instrument for Home Care (RAI-HC) record between Jan. 1, 2007, and Dec. 31, 2012, we developed a mortality risk model. The primary outcome was mortality 6 months after a RAI-HC assessment. We used proportional hazards regression with robust standard errors to account for clustering by the individual. We validated this algorithm for a second cohort of users of home care who were assessed between Jan. 1 and Dec. 31, 2013. We used Kaplan–Meier survival curves to estimate the observed risk of death at 6 months for assessment of calibration and median survival. We constructed 61 risk groups based on incremental increases in the estimated median survival of about 3 weeks among adults at high risk and 3 months among adults at lower risk.RESULTS:The derivation and validation cohorts included 435 009 and 139 388 adults, respectively. We identified a total of 122 823 deaths within 6 months of a RAI-HC assessment in the derivation cohort. The mean predicted 6-month mortality risk was 10.8% (95% confidence interval [CI] 10.7%–10.8%) and ranged from 1.54% (95% CI 1.53%–1.54%) in the lowest to 98.1% (95% CI 98.1%–98.2%) in the highest risk group. Estimated median survival spanned from 28 days (11 to 84 d at the 25th and 75th percentiles) in the highest risk group to over 8 years (1925 to 3420 d) in the lowest risk group. The algorithm had a c-statistic of 0.753 (95% CI 0.750–0.756) in our validation cohort.INTERPRETATION:The RESPECT mortality risk prediction tool that makes use of readily available information can improve the identification of palliative and end-of-life care needs in a diverse older adult population receiving home care.

Most people in high-income countries die of causes with progressive, predictable trajectories of decline.^1–4 Since 2000, the 3 leading causes of death in Canada — accounting for 55% of all deaths — have been cancer, heart disease and stroke.¹ Other leading causes of death, such as dementia and chronic lower respiratory diseases, also share signs and symptoms of senescence that are common across chronic diseases, including deterioration of physical and cognitive function, as well as an increased need for assistance.Despite the predictable nature of most deaths, many Canadian residents who are at the end of life do not receive adequate home-based supports.⁵ In Ontario — the largest province in Canada with more than 14 million residents and the setting of this study — only 40% of decedents receive formal home care, and less than 20% receive a physician home visit in their last year of life.^6,7 Even among those who had received palliative and end-of-life care, the start of service was often too close to death and failed to have a positive impact on the quality of life in those last months.⁸ The lack of available and accurate prognostic information is a key challenge. There are few existing tools that can be used to inform palliative care planning for the general population of older adults who live in the community and in people without cancer.⁹ Other barriers to accurate prognostic estimates include clinicians’ reluctance or lack of time and existing prognostication tools’ reliance on complex or specialized inputs, such as laboratory data and previous health care use. As a result, many older and frail adults do not receive timely palliative care and do not have an advance care plan.^6,10–13Our primary objective was to develop and validate a model for predicting mortality risk among the general population of community-dwelling adults with and without cancer that spans an actionable period for end-of-life planning (5 yr to imminent death). The variables included in our prognostication model — the Risk Evaluation for Support: Predictions for Elder-life in the Community Tool (RESPECT) — were prespecified to include exposures that could be self-reported by patients and their caregivers, including family members.     

Changes in health indicator gaps between First Nations and other residents of Manitoba

Background:The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades.Methods:We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods.Results:Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI −36% to −30%) for ambulatory primary care visits, by 22% (95% CI −27% to −16%) for mammography and by 27% (95% CI −40% to −23%) for injury hospitalizations.Interpretation:Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations.

Comprehensive data on the health of First Nations people in Canada are urgently needed.^1,2 This is a priority identified by the Truth and Reconciliation Commission of Canada, which highlights the striking health disparities between Indigenous and non-Indigenous populations in Canada and recognizes the disparities in their Calls to Action as “a direct result of previous Canadian government policies.”³ These health disparities are understood to be part of the continuing impact of colonization and genocidal policies aimed specifically at Indigenous people.^4,5The underlying causes of the health gap between Indigenous and non-Indigenous people, resulting from attempts by European settlers to assimilate Indigenous people into their own societies, have been detailed elsewhere.⁶ The collective trauma that Indigenous populations have experienced through colonial policies and practices include, among others, racism and marginalization in virtually every aspect of their lives; major disruptions of families and communities through forced attendance at residential schools and by the child welfare system; trauma from physical, emotional and sexual abuse, carried over into future generations; and damage to their Indigenous identity through loss of culture, language, traditions and teachings.^6,7 Other social determinants (e.g., poverty, social exclusion and poor access to clean water, quality housing, education and heath services) and the governments’ failure to address these issues also influence the health of First Nations people.^8,9A previous population-based study of First Nations’ health and health care use in Canada, published in 2002, focused on the Manitoba population, which has the highest proportion of First Nations residents among Canadian provinces.¹⁰ It identified substantial gaps in the health of First Nations and their access to health services compared with other Manitobans. Others have since reported on health disparities between Indigenous peoples and other Canadians;^11–14 however, the Manitoba data provide a unique opportunity to compare changes in health-related outcomes over nearly 2 decades. In the present study, we sought to compare indicators of health and health care use between First Nations people and other residents of Manitoba, to determine whether the gap between the 2 groups has changed over the past 18 years and establish whether any progress has been made in improving First Nations’ health.     

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.     

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.     

Use of standardized brief geriatric evaluation compared with routine care in general practice for preventing functional decline: a pragmatic cluster-randomized trial

Background:Although assessment of geriatric syndromes is increasingly encouraged in older adults, little evidence exists to support its systematic use by general practitioners (GPs). The aim of this study was to determine whether a systematic geriatric evaluation performed by GPs can prevent functional decline.Methods:We conducted a controlled, open-label, pragmatic cluster-randomized trial in 42 general practices in Switzerland. Participating GPs were expected to enrol an average of 10 community-dwelling adults (aged ≥ 75 yr) who understood French, and had visited their GP at least twice in the previous year. The intervention consisted of yearly assessment by the GP of 8 geriatric syndromes with an associated tailored management plan according to assessment results, compared with routine care. Our primary outcomes were the proportion of patients who lost at least 1 instrumental activity of daily living (ADL) and the proportion who lost at least 1 basic ADL, over 2 years. Our secondary outcomes were quality-of-life scores, measured using the older adult module of the World Health Organization Quality of Life Instrument, and health care use.Results:Forty-two GPs recruited 429 participants (63% women) with a mean age of 82.5 years (standard deviation 4.8 yr) at time of recruitment. Of these, we randomly assigned 217 participants to the intervention and 212 to the control arm. The proportion of patients who lost at least 1 instrumental ADL in the intervention and control arms during the course of the study was 43.6% and 47.6%, respectively (risk difference −4.0%, 95% confidence interval [CI] −14.9% to 6.7%, p = 0.5). The proportion of patients who lost at least 1 basic ADL was 12.4% in the intervention arm and 16.9% in the control arm (risk difference −5.1%, 95% CI −14.3% to 4.1%, p = 0.3).Interpretation:A yearly geriatric evaluation with an associated management plan, conducted systematically in GP practices, does not significantly lessen functional decline among community-dwelling, older adult patients, compared with routine care.Trial registration:ClinicalTrials.gov, {"type":"clinical-trial","attrs":{"text":"NCT02618291","term_id":"NCT02618291"}}NCT02618291.

The World Health Organization has defined healthy aging as the process of developing and maintaining functional ability that enables well-being in older age.¹ Functional ability is often measured by an individual’s ability to perform activities of daily living (ADLs) without assistance. Geriatric syndromes, corresponding to multifactorial, chronic conditions, can impair physical and mental capacities,^2–4 and are directly associated with functional decline.⁵ If recognized early, adapted preventive measures and management strategies can be started to limit functional decline.^6–8 Interventions that have been shown to delay functional decline include comprehensive geriatric assessment, regular home visits and physical therapy.^6,8,9 Comprehensive geriatric assessment consists of a “multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional capabilities of older adults to develop a coordinated plan to maximize overall health with ageing.”¹⁰ These assessments are usually performed by specialized geriatric teams for patients who have already been identified as frail or in the context of rehabilitation. However, most older patients see only their general practitioner (GP) and are not provided a comprehensive geriatric assessment, considering that this is a lengthy process that is often beyond the scope of a usual primary care consultation. A recent systematic review of comprehensive geriatric assessment in primary care found only 4 studies conducted in this setting,¹¹ showing mixed effects on clinical outcomes. Only 1 study assessed functional ability, and it showed no impact in this context.¹²In primary care, it may be more beneficial to use shorter screening tools.^13–19 Previous studies using shorter tools adapted for primary care have failed to show a difference for patients compared with routine care.^17,18 These interventions usually targeted patients who were already identified as frail or with a predefined number of problems.^17,18,20In contrast, our Active Geriatric Evaluation (AGE) tool targets all patients aged 75 and older. This clinical tool can be easily integrated to clinical encounters in GP practices, without the need for additional organizational changes. For this study, we aimed to determine whether the AGE tool, specifically designed for GPs and consisting of a brief assessment of the most relevant geriatric syndromes combined with management plans, could slow functional decline in older patients.     

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.