CMAJ open最新文献

{"title":"Unmet health care needs during the COVID-19 pandemic among adults: a prospective cohort study in the Canadian Longitudinal Study on Aging.","authors":"Jayati Khattar, Laura N Anderson, Vanessa De Rubeis, Margaret de Groh, Ying Jiang, Aaron Jones, Nicole E Basta, Susan Kirkland, Christina Wolfson, Lauren E Griffith, Parminder Raina","doi":"10.9778/cmajo.20210320","DOIUrl":"10.9778/cmajo.20210320","url":null,"abstract":"<p><strong>Background: </strong>The COVID-19 pandemic affected access to health care services in Canada; however, limited research examines the influence of the social determinants of health on unmet health care needs during the first year of the pandemic. The objectives of this study were to describe unmet health care needs during the first year of the pandemic and to investigate the association of unmet needs with the social determinants of health.</p><p><strong>Methods: </strong>We conducted a prospective cohort study of 23 972 adults participating in the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Study (April-December 2020) to identify the social determinants of health associated with unmet health care needs during the pandemic. Using logistic regression, we assessed the association between several social determinants of health on the following 3 outcomes (separately): experiencing any challenges in accessing health care services, not going to a hospital or seeing a doctor when needed, and experiencing barriers to accessing testing for SARS-CoV-2 infection.</p><p><strong>Results: </strong>From September to December 2020, 25% of participants experienced challenges accessing health care services, 8% did not go to a hospital or see a doctor when needed and 4% faced barriers accessing testing for SARS-CoV-2 infection. The prevalence of all 3 unmet need outcomes was lower among older age groups. Differences were observed by sex, region, education, income and racial background. Immigrants (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.09-1.27) or people with chronic conditions (OR 1.35, 95% CI 1.27-1.43) had higher odds of experiencing challenges accessing health care services and had higher odds of not going to a hospital or seeing a doctor (immigrants OR 1.26, 95% CI 1.11-1.43; chronic conditions OR 1.45, 95% CI 1.31-1.61). Prepandemic unmet health care needs were strongly associated with all 3 outcomes.</p><p><strong>Interpretation: </strong>Substantial unmet health care needs were reported by Canadian adults during the first year of the pandemic. The results of this study have important implications for health equity.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E140-E151"},"PeriodicalIF":0.0,"publicationDate":"2023-02-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/9e/cc/cmajo.20210320.PMC9933993.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9250996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparative effectiveness of metformin versus sulfonylureas on kidney function decline or death among patients with reduced kidney function: a retrospective cohort study.","authors":"Adriana M Hung, Amber J Hackstadt, Marie R Griffin, Carlos G Grijalva, Robert A Greevy, Christianne L Roumie","doi":"10.9778/cmajo.20210207","DOIUrl":"10.9778/cmajo.20210207","url":null,"abstract":"<p><strong>Background: </strong>Diabetes often causes kidney disease. In this study, we sought to evaluate if metformin use was associated with death or kidney events in patients with diabetes and concurrent reduced kidney function.</p><p><strong>Methods: </strong>We used data from the Veterans Health Administration, Medicare and National Death Index databases to assemble a national retrospective cohort of veterans who were using metformin or sulfonylureas from 2001 through 2016 and who began follow-up at an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m². The primary composite outcome was a kidney event (i.e., 40% decline in eGFR or end-stage renal disease) or death. The secondary outcome was a kidney event (eGFR decline or end-stage renal disease). We weighted the cohort using propensity scores and used Cox proportional models to estimate the cause-specific hazard of outcomes and of treatment nonpersistence as a competing risk. We stratified follow-up into 2 periods, namely the first 360 days from the start of follow-up, and 361 days and beyond.</p><p><strong>Results: </strong>In the first 360 days, the propensity score-weighted cohort included 24 883 patients who used metformin and 24 998 who used sulfonylureas. There were 33.5 (95% confidence interval [CI] 30.9-36.3) and 43.0 (95% CI 40.1-46.0) deaths or kidney events per 1000 person-years for patients who used metformin or sulfonylureas, respectively (hazard ratio [HR] 0.78, 95% CI 0.71-0.85). For the secondary outcome of kidney events, the HR was 0.94 (95% CI 0.67-1.33). In the second period from 361 days onward, the primary outcome event rate was 26.5 (95% CI 24.7-28.5) per 1000 person-years for those who used metformin, compared with 36.3 (95% CI 34.2-38.6) per 1000 person-years for those who used sulfonylureas (HR 0.73, 95% CI 0.67-0.79). Results were consistent for kidney events alone (HR 0.73, 95% CI 0.59-0.91).</p><p><strong>Interpretation: </strong>Metformin use for 361 days or longer after reaching an eGFR of less than 60 mL/min/1.73 m² was associated with decreased likelihood of kidney events or death in patients with diabetes, compared with use of sulfonylureas. Metformin provided end-organ protection, in addition to glucose control.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E77-E89"},"PeriodicalIF":0.0,"publicationDate":"2023-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/39/04/cmajo.20210207.PMC9894655.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9243630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital discharges for substance-related injuries before and during the COVID-19 pandemic: a descriptive surveillance study using administrative data.","authors":"Stephanie Toigo, Steven R McFaull, Wendy Thompson","doi":"10.9778/cmajo.20220164","DOIUrl":"10.9778/cmajo.20220164","url":null,"abstract":"<p><strong>Background: </strong>The COVID-19 pandemic and associated behavioural changes have contributed to an increase in substance-related hospital discharges, and has altered the injury epidemiology landscape in Canada. We sought to evaluate hospital discharges for substance-related injuries during the pandemic compared with prepandemic and to identify subpopulations that have been greatly affected by substance-related injuries during the first year of the pandemic.</p><p><strong>Methods: </strong>We compared data on hospital discharges in Canada from before the pandemic (March 2019-February 2020) with discharges during the first year of the pandemic (March 2020-February 2021) using the Discharge Abstract Database. We identified discharges for substance-related injuries using codes from the <i>International Statistical Classification of Diseases and Related Health Problems, 10th Revision</i>. We calculated percent changes, age-standardized rates and age-specific rates of discharges for substance-related injuries.</p><p><strong>Results: </strong>Hospital discharges for substance-related injuries increased by 7.1% during the first year of the pandemic. Discharges for intentional injuries decreased by 6.3%, whereas unintentional substance-related injuries increased by 15.1% during this period. Male patients accounted for 95.6% of the increase in hospital discharges for substance-related injuries during the first year of the pandemic. We observed a percent increase among discharges for injuries related to alcohol, opioid, cannabinoid, hallucinogen, tobacco, volatile solvents, other psychoactive substances and polysubstance use.</p><p><strong>Interpretation: </strong>We observed an increase in hospital discharges for substance-related injuries during the first year of the COVID-19 pandemic, compared with the same time period before the pandemic. This work will provide useful insight into the ongoing management of the COVID-19 pandemic, as well as future policy and health care planning related to substance use in Canada.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E54-E61"},"PeriodicalIF":0.0,"publicationDate":"2023-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/1d/e9/cmajo.20220164.PMC9876582.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9619480","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Inclusion of patient-level emergency department characteristics to classify potentially redirectable visits to subacute care: a modified Delphi consensus study.","authors":"Ryan P Strum, Walter Tavares, Andrew Worster, Lauren E Griffith, Andrew P Costa","doi":"10.9778/cmajo.20220062","DOIUrl":"10.9778/cmajo.20220062","url":null,"abstract":"<p><strong>Background: </strong>Most patients transported by Ontario paramedics to the emergency department have non-emergent conditions and may be more appropriately served by subacute community-based care centres. We sought to determine consensus on a set of patient characteristics that could be useful to classify retrospective emergency department visits that had a high probability of being primary care-like and potentially redirectable to a subacute care centre by paramedics.</p><p><strong>Methods: </strong>We conducted a modified Delphi study to assess expert consensus on characteristics of patients transported by paramedics to the emergency department from August to October 2021. An expert Delphi committee was constructed of emergency and family physicians in Ontario using purposive sampling. Experts rated whether each characteristic was useful to be included in a classification to identify potentially redirectable visits retrospectively, as well as characteristic details (e.g., upper and lower bounds). Consensus was considered 75% agreement.</p><p><strong>Results: </strong>Sixteen experts participated in the study; the experts were mostly male (75%) and evenly divided between emergency and family medicine. After 2 rounds, consensus was achieved on 8 of 9 characteristics (89%). Four characteristics were determined as useful to classify potentially redirectable emergency department visits: age (81%), triage acuity (100%), specialist consult in the emergency department (94%) and emergency department visit outcome (81%). Specifications of each characteristic were refined as follows: young and middle-aged adults with a non-emergent triage acuity, did not receive a specialist physician consult in the emergency department and discharged from the emergency department.</p><p><strong>Interpretation: </strong>Strong consensus was achieved to specify a classification system for potentially redirectable emergency department visits. These results will be combined with knowledge of which subacute care centres could conduct the main physician interventions to retrospectively identify emergency department visits that could have been suitable for paramedic redirection for further research.</p><p><strong>Study registration: </strong>ID ISRCTN22901977.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E70-E76"},"PeriodicalIF":0.0,"publicationDate":"2023-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/34/b5/cmajo.20220062.PMC9876581.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9619482","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Universal ophthalmia neonatorum prophylaxis in Ontario: a cost-effectiveness analysis.","authors":"Ellen C Rowlands Snyder,&nbsp;Elspeth McGregor,&nbsp;Doug Coyle","doi":"10.9778/cmajo.20210226","DOIUrl":"https://doi.org/10.9778/cmajo.20210226","url":null,"abstract":"<p><strong>Background: </strong>Although prophylaxis for ophthalmia neonatorum at birth is required by law in Ontario, declining prevalence of disease and efficacy of prophylaxis have called this practice into question. The objective of this modelling study was to assess the cost-effectiveness of universal prophylaxis for ophthalmia neonatorum to inform decision-makers on the potential impact of a change in this policy.</p><p><strong>Methods: </strong>We compared the cost-effectiveness of prophylaxis for ophthalmia neonatorum with no prophylaxis through cost-utility analysis with a lifetime time horizon, considering a provincial government payer, for a hypothetical population of newborns in Ontario. We assessed both the mean incremental costs of prophylaxis and its mean incremental effectiveness using a hybrid (part decision tree, part Markov) model. We used a scenario analysis to evaluate alternative time horizons and discount rates. We conducted a threshold analysis to evaluate the impact of variations in the cost of prophylaxis and in the prevalence of sexually transmitted infections (gonorrhea and chlamydia).</p><p><strong>Results: </strong>In our model, prophylaxis for ophthalmia neonatorum did not meet a willingness-to-pay threshold of Can$50 000 per quality-adjusted life-year (QALY). Although prophylaxis was effective in reducing morbidity associated with ophthalmia neonatorum, the number needed to treat to prevent 1 case of ophthalmia neonatorum blindness was 500 000, with an associated cost of more than Can$4 000 000. When compared with no prophylaxis, prophylaxis had an incremental cost of Can$355 798 per long-term QALY gained (incremental cost-effectiveness ratio).</p><p><strong>Interpretation: </strong>We found that prophylaxis for ophthalmia neonatorum, although individually inexpensive, leads to very high costs on a population level. These findings contribute to the discussion on mandatory prophylaxis currently underway in several jurisdictions.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E33-E39"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d4/8f/cmajo.20210226.PMC9851624.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9243139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-effectiveness modelling of birth and infant dose vaccination against hepatitis B virus in Ontario from 2020 to 2050.","authors":"Mia J Biondi,&nbsp;Chris Estes,&nbsp;Devin Razavi-Shearer,&nbsp;Kanwar Sahdra,&nbsp;Nechama Lipton,&nbsp;Hemant Shah,&nbsp;Camelia Capraru,&nbsp;Harry L A Janssen,&nbsp;Homie Razavi,&nbsp;Jordan J Feld","doi":"10.9778/cmajo.20210284","DOIUrl":"https://doi.org/10.9778/cmajo.20210284","url":null,"abstract":"Background: The World Health Organization recommends universal birth dose vaccination for hepatitis B virus (HBV), yet only 3 provinces and territories in Canada provide birth dose vaccination, and Canadian-born children in Ontario are acquiring HBV before adolescent vaccination. We sought to determine whether birth and/or infant HBV vaccination is cost-effective. Methods: We used a dynamic HBV model that incorporates population by year, disease stage, sex and the influence of immigration to quantify the disease and economic burden of chronic HBV infection in Ontario from 2020 to 2050. We compared 4 vaccination scenarios, which included a birth dose vaccine and variations of the 2 subsequent doses (either alone or as a part of the hexavalent vaccine) and a hexavalent-only strategy in infancy with the current adolescent vaccination strategy. Our costing estimates were based on values from 2020. Results: All 4 infant vaccination approaches prevented an additional 550–560 acute and 160 chronic pediatric HBV infections from 2020 to 2050 compared with adolescent vaccination. Whereas birth dose could be cost-effective, incorporating vaccination into a hexavalent vaccine was cost saving. By 2050, the hexavalent approach led to $428 000 in cost savings per disability-adjusted life years averted. Interpretation: At the current prevalence in Ontario, a switch to birth dose or infant dose will be cost-effective or even cost saving. Introducing any form of infant HBV immunization in Ontario will prevent acute and chronic pediatric HBV infections.","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E24-E32"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/91/1c/cmajo.20210284.PMC9842099.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9250470","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses.","authors":"Bridget L Ryan,&nbsp;Luke Mondor,&nbsp;Walter P Wodchis,&nbsp;Richard H Glazier,&nbsp;Leslie Meredith,&nbsp;Martin Fortin,&nbsp;Moira Stewart","doi":"10.9778/cmajo.20220006","DOIUrl":"https://doi.org/10.9778/cmajo.20220006","url":null,"abstract":"<p><strong>Background: </strong>Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched).</p><p><strong>Methods: </strong>Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls.</p><p><strong>Results: </strong>There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]).</p><p><strong>Interpretation: </strong>Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods.</p><p><strong>Ontario: </strong>ClinicalTrials.gov : 104191.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E45-E53"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/72/55/cmajo.20220006.PMC9851625.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9250483","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Estimating the test-adjusted incidence of <i>Chlamydia trachomatis</i> infections identified through Public Health Ontario Laboratories in Peel region, Ontario, 2010-2018: a population-based study.","authors":"Lindsay Obress,&nbsp;Olaf Berke,&nbsp;David N Fisman,&nbsp;Shilpa Raju,&nbsp;Ashleigh R Tuite,&nbsp;Monali Varia,&nbsp;Amy L Greer","doi":"10.9778/cmajo.20210236","DOIUrl":"https://doi.org/10.9778/cmajo.20210236","url":null,"abstract":"<p><strong>Background: </strong>Public health guidelines for chlamydia testing are not sex specific, but young females test at a disproportionally higher rate than males and other age groups. This study aims to describe testing trends across age and sex subgroups, then estimate a test-adjusted incidence of chlamydia in these subgroups to identify gaps in current testing practices.</p><p><strong>Methods: </strong>We used a population-based study to examine observed chlamydia rates by age and sex subgroups: 15-19 years, 20-29 years, 30-39 years and older than 40 years. The study included diagnostic test results recorded by Public Health Ontario Laboratories between Jan. 1, 2010, and Dec. 31, 2018, for individuals living in Peel region, Ontario. We then employed meta-regression models as a method of standardization to estimate the effect of sex and age on standardized morbidity ratio, testing ratio and test positivity, then calculate a test-adjusted incidence of chlamydia for each subgroup.</p><p><strong>Results: </strong>Over the study period, infection, testing and test positivity varied across age and sex subgroups. Observed incidence and testing were highest in females aged 20-29 years, whereas males had the highest standardized test positivity across all age groups. After estimating test-adjusted incidence for each age-sex subgroup, males in the 15-19-year and 30-39-year age groups had an increase in incidence of 60.2% and 9.7%, respectively, compared with the observed incidence.</p><p><strong>Interpretation: </strong>We found that estimated test-adjusted incidence was higher than observed incidence in males aged 15-19 years and 30-39 years. This suggests that infections in males are likely being missed owing to differential testing, and this may be contributing to the persistent increase in reported cases in Canada. Public health programming that targets males, especially in high-risk settings and communities, and use of innovative partner notification methods could be critical to curbing overall rates of chlamydia.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E62-E69"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/c0/2b/cmajo.20210236.PMC9876583.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9619481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Physician perceptions of restrictive visitor policies during the COVID-19 pandemic: a qualitative study.","authors":"Kirsten Wentlandt,&nbsp;Kayla T Wolofsky,&nbsp;Andrea Weiss,&nbsp;Lindsay Hurlburt,&nbsp;Eddy Fan,&nbsp;Camilla Zimmermann,&nbsp;Sarina R Isenberg","doi":"10.9778/cmajo.20220048","DOIUrl":"https://doi.org/10.9778/cmajo.20220048","url":null,"abstract":"<p><strong>Background: </strong>Little is understood of the consequences of restrictive visitor policies that were implemented in hospitals to minimize risk of infection during the COVID-19 pandemic. The objective of this study was to describe physician experiences with these policies and reflections of their effects.</p><p><strong>Methods: </strong>We conducted semistructured phone interviews from September 2020 to March 2021 with physicians practising in Ontario hospitals, recruited via professional networks and snowball sampling. We audio-recorded, transcribed and analyzed interviews to describe and interpret overarching themes by thematic analysis.</p><p><strong>Results: </strong>We interviewed 21 physicians (5 intensivists, 5 internists, 11 specialists in palliative care). Four main thematic categories emerged, including provider, system, patient and caregiver effects. Provider-related factors included increased time and effort on communication with a need to establish limits; increased effort to develop rapport with caregivers; lack of caregiver input on patient care; the need to act as a caregiver surrogate; and the emotional toll of being a gatekeeper or advocate for visitors, exacerbated by lack of evidence for restrictions and inconsistent enforcement. System effects included the avoidance of hospital admission and decreased length of stay, leading to readmissions, increased deaths at home and avoidance of transfer to other facilities with similar policies. Patient-related factors included isolation and dying alone; lack of caregiver advocacy; and prioritization of visitor presence that, at times, resulted in a delay or withdrawal of aspects of care. Caregiver-related factors included inability to personally assess patient health, leading to poor understanding of patient status and challenging decision-making; perceived inadequate communication; difficulty accessing caregiver supports; and increased risk of complicated grief. Participants highlighted a disproportionate effect on older adults and people who did not speak English.</p><p><strong>Interpretation: </strong>Our study highlights substantial negative consequences of restrictive visitor policies, with heightened effects on older adults and people who did not speak English. Research is required to identify whether the benefits of visitor restrictions on infection control outweigh the numerous deleterious consequences to patients, families and care providers.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E110-E117"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/51/5f/cmajo.20220048.PMC9911125.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9251141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study.","authors":"Alex M Cressman,&nbsp;Ushma Purohit,&nbsp;Ellen Shadowitz,&nbsp;Edward Etchells,&nbsp;Adina Weinerman,&nbsp;Darren Gerson,&nbsp;Kaveh G Shojania,&nbsp;Lynfa Stroud,&nbsp;Brian M Wong,&nbsp;Steve Shadowitz","doi":"10.9778/cmajo.20220020","DOIUrl":"https://doi.org/10.9778/cmajo.20220020","url":null,"abstract":"<p><strong>Background: </strong>Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.</p><p><strong>Methods: </strong>We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.</p><p><strong>Results: </strong>We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (<i>p</i> < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.</p><p><strong>Interpretation: </strong>Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.</p>","PeriodicalId":10432,"journal":{"name":"CMAJ open","volume":"11 1","pages":"E201-E207"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/77/5a/cmajo.20220020.PMC9981162.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9251652","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}