CMAJ open最新文献

Background: Equitable access to surgical care has clinical and policy implications. We assess the association between social disadvantage and wait times for elective surgical procedures in Ontario.

Methods: We conducted a cross-sectional analysis using administrative data sets of adults receiving nonurgent inguinal hernia repair, cholecystectomy, hip arthroplasty, knee arthroplasty, arthroscopy, benign uterine surgery and cataract surgery from April 2013 to December 2019. We assessed the relation between exceeding target wait times and the highest versus lowest quintile of marginalization dimensions by use of generalized estimating equations logistic regression.

Results: Of the 1 385 673 procedures included, 174 633 (12.6%) exceeded the target wait time. Adjusted analysis for cataract surgery found significantly increased odds of exceeding wait times for residential instability (adjusted odd ratio [OR] 1.16, 95% confidence interval [CI] 1.11-1.21) and recent immigration (adjusted OR 1.12, 95% CI 1.07-1.18). The highest deprivation quintile was associated with 18% (adjusted OR 1.18, 95% CI 1.12-1.24) and 20% (adjusted OR 1.20, 95% CI 1.12-1.28) increased odds of exceeding wait times for knee and hip arthroplasty, respectively. Residence in areas where higher proportions of residents self-identify as being part of a visible minority group was independently associated with reduced odds of exceeding target wait times for hip arthroplasty (adjusted OR 0.82, 95% CI 0.75-0.91), cholecystectomy (adjusted OR 0.68, 95% CI 0.59-0.79) and hernia repair (adjusted OR 0.65, 95% CI 0.56-0.77) with an opposite effect in benign uterine surgery (adjusted OR 1.28, 95% CI 1.17-1.40).

Interpretation: Social disadvantage had a small and inconsistent impact on receiving care within wait time targets. Future research should consider these differences as they relate to resource distribution and the organization of clinical service delivery.

Background: In 2018, hospitals were mandated to record homelessness using International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA code Z59.0). We sought to answer whether the coding mandate affected the volume of patients identified as experiencing homelessness in acute inpatient hospitalizations and if there was any geographic variation.

Methods: We conducted a serial cross-sectional study describing 6 fiscal years (2015/16 to 2020/21) of hospital administrative data from the Hospital Morbidity Database. We reported frequencies and percentages of hospitalizations with a Z59.0 diagnostic code and disaggregated by several types of Canadian geographies. Controlling for fiscal quarter (coded Q1 to Q4) and province or territory, adjusted logistic regression models quantified the odds of Z59.0 being coded during hospital stays.

Results: The frequency and percentage of people experiencing homelessness in hospitalization records across Canada increased from 6934 (0.12%) in 2015/16 to 21 529 (0.41%) in 2020/21. Trends varied by province and territory. Recording of the Z59.0 code increased following the mandate (adjusted odds ratio 2.29, 95% confidence interval 2.25-2.32), relative to the pre-mandate period.

Interpretation: The 2018 coding mandate coincided with an increase in the use of the Z59.0 code to document homelessness in health care administrative data; however, trends varied by jurisdiction. The ICD-10-CA code Z59.0 presents a promising opportunity for standardized and routinely collected data to identify people experiencing homelessness in hospital administrative data.

Background: Canadian immunization programs for rotavirus started in 2011. We sought to determine their effect on the burden of community-acquired admissions and hospital-acquired rotavirus at pediatric hospitals.

Methods: The Canadian Immunization Monitoring Program Active (IMPACT) network conducted active surveillance for rotavirus-positive hospital admissions between 2005 and 2020 at 12 pediatric hospitals. We used yearly rates of community-acquired rotavirus per 10 000 admissions and hospital-acquired rotavirus infections per 1000 patient-days to determine changes in the pre- and post-vaccine program periods.

Results: During the 15-year study period, 5691 rotavirus hospital admissions and hospital-acquired infections were detected, including 4323 (76%) community-acquired infections and 1368 (24%) hospital-acquired infections. The average community-acquired rate in the pre-vaccine period was 60.3 (95% confidence interval [CI] 53.7-68.3) per 10 000 admissions, with a decline to 11.0 (95% CI 7.5-15.1) per 10 000 admissions in the post-vaccine period, resulting in an average reduction of 81.7% (95% CI 74.4%-87.8%). The rate of hospital-acquired rotavirus declined from 0.35 (95% CI 0.29-0.41) per 1000 patient-days in the pre-vaccine period to 0.05 (95% CI 0.03-0.07) per 1000 patient-days in the post-vaccine period, resulting in an 85.3% (95% CI 77.7%-91.9%) average decline. Herd protection was present among children aged 2-16 years.

Interpretation: Although start dates of rotavirus vaccine programs across provinces varied, there was around an 80% average decrease in both community-acquired and hospital-acquired rotavirus infections at pediatric hospitals in Canada in the 1- to 9-year interval after implementation of rotavirus vaccine programs. Herd protection is an important aspect of rotavirus vaccines for other children who are not vaccine eligible, and rotavirus vaccines continue to provide important benefits both for children and health care systems.

Background: Endovascular thrombectomy (EVT) has revolutionized ischemic stroke care. We aimed to assess whether neighbourhood socioeconomic status is predictive of access to EVT after receipt of alteplase for ischemic stroke among patients living in Alberta, Canada, and whether this relation is mediated by the distance a person lives to the nearest comprehensive stroke centre (CSC).

Methods: We performed a retrospective study including all people older than 18 years living in Alberta who were admitted to hospital with an ischemic stroke and who received intravenous alteplase treatment between Jan. 1, 2017, and Dec. 31, 2019. Data were obtained through administrative data sets. The primary outcome was treatment with EVT. We assigned neighbourhood deprivation quintile based on the Material and Social Deprivation Index. We used logistic regression modelling to assess for a relation between deprivation and treatment with EVT. We adjusted for age, sex, stroke severity and distance to the nearest CSC. We calculated the average causal mediation effect of distance to the nearest CSC on the relation between neighbourhood deprivation level and treatment with EVT.

Results: The study cohort consisted of 1335 patients, of whom 181 (13.6%) had missing data and were excluded from the main regression analysis. Endovascular thrombectomy was performed or attempted in 314 patients (23.5%). In the primary model, patients from the most deprived neighbourhoods were less likely than those from less deprived neighbourhoods to have received EVT (adjusted odds ratio 0.43, 95% confidence interval 0.24 to 0.77). Neighbourhood deprivation level was not significantly associated with EVT when distance to the nearest CSC was included as a covariate. Mediation analysis suggested that 48% of the total effect that neighbourhood deprivation level had on the odds of receiving EVT was attributable to the distance a person lived from the nearest CSC.

Interpretation: The results suggest that people from more deprived neighbourhoods in Alberta were less likely to be treated with EVT than those from less deprived neighbourhoods. Improving access to EVT for people living in remote locations may improve the equitable distribution of this treatment.

Background: Prior work has shown that a greater proportion of First Nations patients than non-First Nations patients arrive by ambulance to emergency departments in Alberta. The objective of this study was to understand First Nations perspectives on transitions in care involving paramedics, and paramedic perspectives on serving First Nations communities.

Methods: Participants for this participatory qualitative study were selected by means of purposive sampling through author networks, established relationships and knowledge of the Alberta paramedicine system. First Nations research team members engaged First Nations community organizations to identify and invite First Nations participants. Four sharing circles were held virtually in July 2021 via Zoom by the Alberta First Nations Information Governance Centre. We analyzed the data from the sharing circles using a Western thematic approach. The data were reviewed by Indigenous researchers.

Results: Forty-four participants attended the 4 sharing circles (8-14 participants per circle), which ranged from 68 to 88 minutes long. We identified 3 major themes: racism, system barriers and solutions. First Nations participants described being stereotyped as misusing paramedic systems and substance using, which led to racial discrimination by paramedics and emergency department staff. Discrimination and lack of options to return home after care sometimes led First Nations patients to avoid paramedic care, and lack of alternative care options drove patients to access paramedic care. First Nations providers described facing racism from colleagues and completing additional work to act as cultural mentors to non-First Nations providers. Paramedics expressed moral distress when called on to handle issues outside their scope of practice and when they observed discrimination that interfered with patient care. Proposed solutions included First Nations self-determination in paramedic service design, cultural training and education for paramedics, and new paramedicine service models.

Interpretation: First Nations people face discrimination and systemic barriers when accessing paramedicine. Potential solutions include the integration of paramedics in expanded health care roles that incorporate First Nations perspectives and address local priorities, and First Nations should lead in the design of and priority setting for paramedic services in their communities.

Background: First Nations children in Canada experience health inequities. We aimed to determine whether a self-report health app identified children's needs for support earlier in their illness than would typically occur.

Methods: Children (aged 8 to 18 yr) were recruited from a rural First Nation community. Children completed the Aaniish Naa Gegii: the Children's Health and Well-being Measure (ACHWM) and then met with a local mental health worker who determined their risk status. ACHWM Emotional Quadrant Scores (EQS) were compared between 3 groups of children: healthy peers (HP) who were not at risk, those with newly identified needs (NIN) who were at risk and not previously identified, and a typical treatment (TT) group who were at risk and already receiving support.

Results: We included 227 children (57.1% girls), and the mean age was 12.9 (standard deviation [SD] 2.9) years. The 134 children in the HP group had a mean EQS of 80.1 (SD 11.25), the 35 children in the NIN group had a mean EQS of 67.2 (SD 13.27) and the 58 children in the TT group had a mean EQS of 66.2 (SD 16.30). The HP group had significantly better EQS than the NIN and TT groups (p < 0.001). The EQS did not differ between the NIN and TT groups (p = 0.8).

Interpretation: The ACHWM screening process identified needs for support among 35 children, and the associated triage process connected them to local services; the similarity of EQS in the NIN and TT groups highlights the value of community screening to optimize access to services. Future research will examine the impact of this process over the subsequent year in these groups.

Background: Diabetes, a leading cause of visual impairment, is on the rise in Canada. We assessed trends in the prevalence of visual impairment among people in Canada with and without diabetes to inform the development of strategies and policies for the management of visual impairment.

Methods: We analyzed self-reported data from respondents aged 45 years and older in 7 cycles of nationwide surveys (National Population Health Survey and Canadian Community Health Survey) from 1994/95 to 2013/14. The age- and sex-standardized prevalence of visual impairment was calculated. We assessed comparisons by levels of education and income, using sex-standardized prevalence owing to sparse data.

Results: Among people in Canada with diabetes, the age- and sex-standardized prevalence of visual impairment was 7.37% (95% confidence interval [CI] 5.31%-9.43%) in 1994/95 and 1996/97 combined, decreasing to 3.03% (95% CI 2.48%-3.57%) in 2013/14, giving a standardized prevalence ratio of 0.41 (95% CI 0.30-0.56) comparing 2013/14 with 1994/95 and 1996/97 combined. Among people in Canada without diabetes, visual impairment prevalence decreased from 3.72% (95% CI 3.31%-4.14%) in 1994/95 and 1996/97 combined to 1.69% (95% CI 1.52%-1.87%) in 2013/14, with a standardized prevalence ratio of 0.45 (95% CI 0.40-0.52). Decreased sex-standardized prevalence of visual impairment was observed among people with high and low education levels and incomes among those with and without diabetes.

Interpretation: Visual impairment prevalence was roughly 2 times higher among those with versus without diabetes in all survey years; from 1994 to 2014, visual impairment prevalence decreased among those with and without diabetes irrespective of education and income levels. These results suggest effective collective efforts by clinicians, researchers, the public and government.

Background: Pediatric palliative care aims to improve quality of life among infants, children, youth and young adults with serious illnesses, sometimes over years, but estimates of infants, children, youth and young adults requiring pediatric palliative care have been highly variable and need refinement. We sought to describe this population in British Columbia and identify clinical instability to inform program planning in pediatric palliative care.

Methods: We conducted a population-based analysis using linked administrative health data from 2012/13 to 2016/17. We applied a coding framework validated in the United Kingdom to estimate the number of BC residents aged 0-25 years with serious illnesses and to identify 5 clinical stages. We describe demographics, estimate prevalence and model risk of instability, defined as having urgent hospital admissions, admissions to the intensive care unit or death.

Results: About 2500 infants, children, youth and young adults were admitted to hospital with a serious illness diagnosis each study year, of which around 50% were infants, 60% or so of whom had perinatal or congenital diagnoses. Compared with children aged 1-4 years, infants had the highest risk of instability (odds ratio [OR] 6.59, 95% confidence interval [CI] 5.97-7.29). Compared with oncology patients, infants, children, youth and young adults with neurological (OR 1.43, 95% CI 1.21-1.70) and otherwise specified diagnoses (OR 1.55, 95% CI 1.39-1.73) had a higher risk of instability.

Interpretation: The population of infants, children, youth and young adults with serious illnesses in BC is substantially larger than that currently receiving pediatric palliative care. Future planning of these services needs to consider expanding its reach, focusing particularly on infants and other subpopulations with high risk of instability.