Evidence from an Applied Health Research Question (AHRQ): Health care utilization of publicly funded rehab services for patients post COVID-19 diagnosis.

Objectives The Rehabilitative Care Alliance issued an Applied Health Research Question request to collect information regarding healthcare and rehabilitation use among COVID-19 positive individuals. The objective of this project is to determine the association between length of stay (LOS) in acute care and the number of rehabilitation services used post COVID-19 diagnosis. Approach Hospital and rehabilitation service use was identified among individuals diagnosed with COVID-19, using administrative health data. Admission into acute care within 30 days post COVID-19 diagnosis was recorded. Use of inpatient, physiatry and home-care rehabilitative services were collected until March 31st 2021. Outpatient rehabilitation reporting is not mandatory and was not included. Marginalization was evaluated using the Ontario Marginalization Index factor scores. The association between LOS in acute care and number of rehabilitation categories used was assessed using a negative binomial model, stratified by with or without a stay in the ICU and controlling for age, sex, comorbidities and long-term care residence. Results Of 181,139 individuals diagnosed with COVID-19 prior to December 31st 2020, 5% were hospitalized. Of those hospitalized 2.3% then entered rehabilitation compared to 0.06% who were not hospitalized post COVID-19 infection. Rehabilitation users had higher residential instability (mean=0.45 vs -0.01 in the overall cohort), dependency (mean=-0.02 vs -0.27) and material deprivation (mean=0.37 vs 0.19) but similar ethnic diversity (mean=0.87 vs 0.90) compared to the full cohort. LOS in acute care was associated with a 3.3% increased risk of using additional rehabilitation services for individuals without a stay in the ICU (RR 1.033, 95% CI: 1.011 to 1.055; p=0.0036), and a 3.7% increased risk for individuals with a stay in the ICU (RR 1.037, 95% CI: 1.025 to 1.048; p<.0001). Conclusions Post COVID-19 diagnosis, a larger proportion of rehabilitation service users were hospitalized compared to all COVID-19+ individuals. Additionally, LOS in acute care was associated with the use of more rehabilitation care categories following a COVID-19 diagnosis, and the association was stronger for more severe cases requiring an ICU stay

Sex differences among children, adolescents and young adults for mental health service use within inpatient and outpatient settings, before and during the COVID-19 pandemic: a population-based study in Ontario, Canada

Objectives The pandemic and public health response to contain the virus had impacts on many aspects of young people’s lives including disruptions to daily routines, opportunities for social, academic, recreational engagement and early employment. Consequently, children, adolescents and young adults may have experienced mental health challenges that required use of mental health services. This study compared rates of use for inpatient and outpatient mental health services during the pandemic to pre-pandemic rates. Design Population-based repeated cross-sectional study. Setting Publicly delivered mental healthcare in primary and secondary settings within the province of Ontario, Canada. Participants All children 6–12 years of age (n=2 043 977), adolescents 13–17 years (n=1 708 754) and young adults 18–24 years (n=2 286 544), living in Ontario and eligible for provincial health insurance between March 2016 and November 2021. Primary outcome measures Outpatient mental health visits to family physicians and psychiatrists for: mood and anxiety disorders, alcohol and substance abuse disorders, other non-psychotic mental health disorders and social problems. Inpatient mental health visits to emergency departments and hospitalisations for: substance-related and addictive disorders, anxiety disorders, assault-related injuries, deliberate self-harm and eating disorders. All outcomes were analysed by cohort and sex. Results During the pandemic, observed outpatient visit rates were higher among young adults by 19.01% (95% CI: 15.56% to 22.37%; 209 vs 175 per 1000) and adolescent women 24.17% (95% CI: 18.93% to 29.15%; 131 vs 105 per 1000) for mood and anxiety disorders and remained higher than expected. Female adolescents had higher than expected usage of inpatient care for deliberate self-harm, eating disorders and assault-related injuries. Conclusions Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns

Evidence from an Applied Research Health Question (AHRQ): Healthcare utilization of HIV patients before and after admission to Casey House, a specialized HIV hospital

Introduction The Applied Health Research Question (AHRQ) portfolio is an initiative funded by the Ontario Ministry of Health and Long-Term Care, leveraging the linked data and the scientific expertise at ICES to answer questions from Knowledge Users that have a direct impact on healthcare policy, planning or practice. Objectives and Approach A request from Casey House, a specialty HIV hospital located in Toronto, ON, was reviewed and approved by the ICES AHRQ Team to evaluate patient healthcare utilization and costs. The purpose was to support the design of programs and services, improve transitions from healthcare settings to community services, and inform continuous quality improvement initiatives. Using inpatient records, hospital admissions to Casey House were identified in fiscal years 2009-2014. Inpatient, emergency, outpatient and home care visits were characterized before and after admission. Using the Ontario Drug Benefit Claims, antiretroviral (ARV) prescription fills were examined 7 days post discharge. Results Between April 1, 2009 and March 31, 2015, 268 HIV patients had one or more hospital admissions to Casey House. The majority of Casey House patients had an Aggregated Diagnosis Group (ADG) ≥ 10 (79%) or Resource Utilization Band (RUB) = 5 (78%), indicating a high co-morbidity burden. Rate of emergency department usage declined from 4.61 to 2.46 per person-year, before and after Casey House admission (p < 0.0001). Conversely, home care visits increased from 24.29 to 35.63 per person-year and family physician visits increased from 18.33 to 22.59 per person-year before and after Casey House admission (both p < 0.0001). Interestingly, 89% did not fill an ARV prescription within 7 days of Casey House discharge, however 76% followed up with an outpatient HIV visit within 30 days. Conclusion/Implications Healthcare utilization differed before and after admission to Casey House. Follow-up post-discharge warrants further examination to increase ARV prescription fills. Data from this AHRQ has facilitated future policy and programming changes. Results have been disseminated throughout the Toronto HIV research community to generate discussion on quality improvement in this population

Evaluation of low acuity patients discharged from a virtual emergency department at a major urban academic health sciences centre in Toronto, Canada.

Objective In response to the COVID-19 pandemic, Sunnybrook Health Sciences Centre launched the first virtual emergency department (VED) in Toronto, Ontario. The objective of this pilot project was to leverage linked administrative data to describe the healthcare utilization of VED patients compared to matched patients who attended an ED in person. Approach Evaluation of the VED program was supported by the ICES Applied Health Research Question Program, which is funded by the Ontario Ministry of Health to answer questions directly related to Ontario healthcare policy, planning, or practice. VED visit records from December 2020 to May 2021 were linked with Ontario administrative data. VED patients with low acuity complaints were matched 1:1 with in-person ED comparators according to visit date, presenting complaint, and a propensity score that incorporated age, sex, comorbidities, and other important potential confounders. The primary outcomes were healthcare utilization within 7 days and all-cause mortality within 30 days. Results Of the 609 eligible patients discharged from the VED, 600 (98.5%) were successfully matched to a comparator. Mean (SD) age was 43.0 (21.1) and 64.1% were female. In-person ED revisits and hospitalizations were similar for VED and comparator patients at 72 hours (ED: 12.1% vs. 11.3%; Δ 0.8%, 95%: -2.8, 4.5%; hospitalization:  1.2% vs. 1.5%; Δ 0.3%, 95%: -0.7, 1.4%,) and 7 days (ED: 16.1% vs. 14.4%; Δ 1.7, 95%: -2.4, 5.7%; hospitalization: 1.7% vs. 1.8%; Δ 0.2%, 95%: -0.1, 1.4%) following the index visit. The number of patients visiting a primary care provider within 7 days was also similar between groups (36.7% vs. 32.4%; Δ 4.3, 95%: -1.1, 9.8%). No patients died within 30 days. Conclusion/Implications VED patients and their matched comparators had similar healthcare utilization in the 7 days following their index ED visit. Methodology from this study will inform a province-wide evaluation of VED programs across Ontario

Supporting policy and practice in Ontario through ICES’ Applied Health Research Question (AHRQ) Program

ICES upholds a strong reputation for generating high-quality evidence to inform policy and practice through its collaborations with a broad range of health system stakeholders including government policymakers and healthcare providers including clinicians. Supported by the Ontario Ministry of Health and Ministry of Long-Term Care, the ICES Applied Health Research Question (AHRQ) Program leverages the data holdings and, scientific and clinical expertise to generate evidence tailored to the information needs of requestors. This paper outlines the approach, process, strengths, challenges and the resulting influence and impact to the healthcare landscape in Ontario

Maternal One-carbon Nutrients Status and Effects on DNA Methylation and Hydroxymethylation in Newborn Infants

DNA methylation is an important epigenetic determinant in gene expression, aberrancies of which are mechanistically related to the development of several diseases. During embryogenesis, a new DNA methylation pattern of the fetus is established, rendering this period highly susceptible to environmental modifiers. Maternal dietary intake and status of one-carbon nutrients (folate, vitamins B6, B12, choline, and betaine) have the potential to modulate DNA methylation via the provision of S-adenosylmethionine. The primary objective of this study was to determine the effects of maternal one-carbon nutrient status on DNA methylation and hydroxymethylation in umbilical cord blood mononuclear cells. This study also characterized folate and pyridoxal 5â phosphate (vitamin B6) concentrations in Canadian pregnant women and in umbilical cord blood. Demographic and dietary information was assessed in 368 pregnant women. Maternal blood samples were collected in early pregnancy and at the time of delivery when an umbilical cord blood sample was also collected. Blood concentrations of one-carbon nutrients including serum and RBC folate, serum vitamin B12, plasma pyridoxal 5â phosphate, plasma choline and betaine were measured. Mononuclear cells from umbilical cord blood were extracted and total global DNA 5-methylcytosine and 5-hydroxymethylcytosine content was calculated. Folate concentrations in maternal and cord blood were high, while pyridoxal 5â phosphate concentrations were adequate. There were no strong associations between one-carbon nutrient concentrations and DNA methylation or hydroxymethylation, although maternal concentrations measured in early pregnancy seemed to have more association than later time point measurements. Further studies are warranted to elucidate the potential impact of maternal one-carbon nutrient status on DNA methylation and hydroxymethylation in the developing fetus, which has the potential to modulate disease risk, including cancer, osteoporosis, metabolic and cardiovascular diseases, in the offspring later in life.Ph.D.2017-07-08 00:00:0

Clinical and economic impact of a community-based, hybrid model of in-person and virtual care in a Canadian rural setting: a cross-sectional population-based comparative study

Objectives To determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented with neighbouring jurisdictions without such a model and the broader regional health system.Design A cross-sectional comparative study.Setting Ontario, Canada, with a focus on three largely rural public health units from 1 April 2018 until 31 March 2021.Participants All residents of Ontario, Canada under the age of 105 eligible for the Ontario Health Insurance Plan during the study period.Interventions An innovative, community-based, hybrid model of in-person and virtual care, the Virtual Triage and Assessment Centre (VTAC), was implemented in Renfrew County, Ontario on 27 March 2020.Main outcome measures Primary outcome was a change in emergency department (ED) visits anywhere in Ontario, secondary outcomes included changes in hospitalisations and health-system costs, using per cent changes in mean monthly values of linked health-system administrative data for 2 years preimplementation and 1 year postimplementation.Results Renfrew County saw larger declines in ED visits (−34.4%, 95% CI −41.9% to −26.0%) and hospitalisations (−11.1%, 95% CI −19.7% to −1.5%) and slower growth in health-system costs than other rural regions studied. VTAC patients’ low-acuity ED visits decreased by −32.9%, high-acuity visits increased by 8.2%, and hospitalisations increased by 30.0%.Conclusion After implementing VTAC, Renfrew County saw reduced ED visits and hospitalisations and slower health-system cost growth compared with neighbouring rural jurisdictions. VTAC patients experienced reduced unnecessary ED visits and increased appropriate care. Community-based, hybrid models of in-person and virtual care may reduce the burden on emergency and hospital services in rural, remote and underserved regions. Further study is required to evaluate potential for scale and spread

Severe Obesity, Obesity, and Cardiometabolic Risk in Children 0 to 6 Years of Age

Background: The prevalence of obesity in children has been shown to be plateauing or decreasing in some countries. However the burden of severe obesity is often not assessed. Children with severe obesity may be at increased risk for cardiovascular disease and diabetes. The objective is to determine the prevalence of severe obesity in young children and to examine the association with cardiometabolic risk factors. Methods: A longitudinal study was conducted through The Applied Research Group for Kids! (TARGet Kids!), a practice-based research network in Toronto, Canada. Healthy children from birth to 6 years of age were recruited and followed through middle childhood. The main outcomes of the study were; total cholesterol, HDL, LDL, and non-HDL cholesterol, triglycerides, glucose, systolic blood pressure (SBP) and diastolic blood pressure (DBP). BMI was age and sex-standardized based on the WHO growth standards. A BMI z score > 3 was used to define obesity for children under 5 years of age, and severe obesity for children ≥5 years of age. Results: Among 5738 children less than 5 years, 0.8% had a zBMI>3. In 626 children 5 and 6 years, 2.1% has a zBMI>3. In the multivariable analysis adjusted for age, sex, maternal ethnicity, and family history, using repeated measures, children with a zBMI>3 had significantly higher odds of having abnormal SBP (OR 6.4, 95% CI 1.5-27.9; p=0.01) and DBP (OR, 3.6 95% CI 1.2-10.6; p=0.02), respectively, as compared to healthy weight children. Trends demonstrating an association between zBMI>3 and abnormal lipid levels were also identified. Conclusion: Young children with zBMI greater than 3 have significantly higher blood pressure measures and trends towards worse lipid profiles than children at lower zBMIs

Severe Obesity, Obesity, and Cardiometabolic Risk in Children 0 to 6 Years of Age

Background: The prevalence of obesity in children has been shown to be plateauing or decreasing in some countries. However the burden of severe obesity is often not assessed. Children with severe obesity may be at increased risk for cardiovascular disease and diabetes. The objective is to determine the prevalence of severe obesity in young children and to examine the association with cardiometabolic risk factors. Methods: A longitudinal study was conducted through The Applied Research Group for Kids! (TARGet Kids!), a practice-based research network in Toronto, Canada. Healthy children from birth to 6 years of age were recruited and followed through middle childhood. The main outcomes of the study were; total cholesterol, HDL, LDL, and non-HDL cholesterol, triglycerides, glucose, systolic blood pressure (SBP) and diastolic blood pressure (DBP). BMI was age and sex-standardized based on the WHO growth standards. A BMI z score > 3 was used to define obesity for children under 5 years of age, and severe obesity for children ≥5 years of age. Results: Among 5738 children less than 5 years, 0.8% had a zBMI>3. In 626 children 5 and 6 years, 2.1% has a zBMI>3. In the multivariable analysis adjusted for age, sex, maternal ethnicity, and family history, using repeated measures, children with a zBMI>3 had significantly higher odds of having abnormal SBP (OR 6.4, 95% CI 1.5-27.9; p=0.01) and DBP (OR, 3.6 95% CI 1.2-10.6; p=0.02), respectively, as compared to healthy weight children. Trends demonstrating an association between zBMI>3 and abnormal lipid levels were also identified. Conclusion: Young children with zBMI greater than 3 have significantly higher blood pressure measures and trends towards worse lipid profiles than children at lower zBMIs

Cost Evaluation of the Ontario Virtual Urgent Care Pilot Program: Population-Based, Matched Cohort Study

BackgroundIn 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns. ObjectiveThis study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective. MethodsUsing administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD $1=US$0.76 is applicable). ResultsWe matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral ($2805 vs$2299; difference of $506, 95$139-$885) and significantly lower for the VUC cohort of patients who did not require ED referral ($907 vs $1270; difference of$362, 95% CI 284-$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were$18.9 million (ie, $6.0 million +$12.9 million) versus $22.9 million ($4.9 million + $18.0 million) for the 2 in-person ED cohorts. ConclusionsThis costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions