[show abstract][hide abstract] ABSTRACT: Care giving for children with chronic diseases can lead to financial strain and compromised family well being. Little is known about whether these stresses lead to changes in residential movement patterns as they relate to income adequacy and proximity to care.
We compared the residential movement patterns and associated changes in neighbourhood income of children with mild to severe chronic diseases compared with those that are healthy. A cohort of infants born from 2002--2007 in Ontario, Canada was followed for 5 years and divided into those with single- or multiple- body system complex chronic conditions (CCCs); low birth weight (LBW); asthma/recurrent wheeze (A/RW) and the control group of otherwise healthy children.
Of 598,716 children studied, 15,207 had a single CCC, 3,600 multiple CCCs, 33,206 LBW, 57,137 A/RW and 489,566 were healthy. Lowest income quintile children were most likely to move residence. Compared with healthy controls, chronic disease cohorts, apart from those with asthma, were more likely to be born in the lowest income quintile neighbourhood and to move. Among children who moved, all chronic disease cohorts were significantly more likely to move to a low income quintile neighborhood (adjusted odds ratios for all chronic disease cohorts of 1.1-1.2). There were no differences across cohorts in residential movement close to a children's hospital.
Young children with chronic conditions, particularly those born in low income neighbourhoods, are more likely to move residence than other healthy young children. However, it does not seem that proximity to specialized care is driving this movement. Further research is required to determine if these movement patterns impact the ability of children with chronic conditions to secure health services.
International Journal for Equity in Health 08/2013; 12(1):62. · 1.71 Impact Factor
[show abstract][hide abstract] ABSTRACT: INTRODUCTION: This study aimed to determine the effectiveness of seasonal influenza vaccine in pre- and full-term children aged 6-23 months. METHODS: We examined a cohort of 683,354 young children (7.7% preterm) over five influenza seasons (2004-2005 to 2008-2009) in Ontario, Canada. Vaccine effectiveness was estimated using influenza-coded ambulatory visits during virologically-confirmed influenza season periods as the outcome and multivariable Cox proportional hazards modeling. RESULTS: Full vaccination was associated with a 19% reduction in influenza-coded ambulatory visits (HR=0.81; 95% CI, 0.68-0.97) in all children, and an 18% reduction in full-term children (HR=0.82; 95% CI, 0.68-0.99). We did not find significant vaccine effectiveness for preterm children. No benefit was found for partial vaccination. CONCLUSIONS: In children younger than two years, only full influenza vaccination is associated with reduced influenza-coded ambulatory visits. Since the effectiveness of influenza vaccination in preterm children remains uncertain, further study of this highly vulnerable population is warranted.
[show abstract][hide abstract] ABSTRACT: Objective: A significant decline in the prevalence of neural tube defects (NTD) through food fortification has been reported. Questions remain, however, about the effectiveness of this intervention in reducing the gap in prevalence across socioeconomic status (SES). Study Design: Using health number and through record linkage, children born in Ontario hospitals between 1994 and 2009 were followed for the diagnosis of congenital anomalies. SES quintiles were assigned to each child using census information at the time of birth. Adjusted rates and multivariate models were used to compare trends among children born in different SES groups. Results: Children born in low SES areas had significantly higher rates of NTDs (RR = 1.25, CI: 1.14-1.37). Prevalence of NTDs among children born in low and high SES areas declined since food fortification began in 1999 although has started rising again since 2006. While the crude decline was greater in low SES areas, after adjustment for maternal age, the slope of decline and SES gap in prevalence rates remained unchanged overtime. Conclusions: While food fortification is successful in reducing the prevalence of NTDs, it was not associated with removing the gap between high and low SES groups.
International Journal of Environmental Research and Public Health 01/2013; 10(4):1312-23. · 2.00 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND AND OBJECTIVE:Health care use of children with medical complexity (CMC), such as those with neurologic impairment or other complex chronic conditions (CCCs) and those with technology assistance (TA), is not well understood. The objective of the study was to evaluate health care utilization and costs in a population-based sample of CMC in Ontario, Canada.METHODS:Hospital discharge data from 2005 through 2007 identified CMC. Complete health system use and costs were analyzed over the subsequent 2-year period.RESULTS:The study identified 15 771 hospitalized CMC (0.67% of children in Ontario); 10 340 (65.6%) had single-organ CCC, 1063 (6.7%) multiorgan CCC, 4368 (27.6%) neurologic impairment, and 1863 (11.8%) had TA. CMC saw a median of 13 outpatient physicians and 6 distinct subspecialists. Thirty-six percent received home care services. Thirty-day readmission varied from 12.6% (single CCC without TA) to 23.7% (multiple CCC with TA). CMC accounted for almost one-third of child health spending. Rehospitalization accounted for the largest proportion of subsequent costs (27.2%), followed by home care (11.3%) and physician services (6.0%). Home care costs were a much larger proportion of costs in children with TA. Children with multiple CCC with TA had costs 3.5 times higher than children with a single CCC without TA.CONCLUSIONS:Although a small proportion of the population, CMC account for a substantial proportion of health care costs. CMC make multiple transitions across providers and care settings and CMC with TA have higher costs and home care use. Initiatives to improve their health outcomes and decrease costs need to focus on the entire continuum of care.
[show abstract][hide abstract] ABSTRACT: OBJECTIVE To determine whether children treated in emergency departments (EDs) with evidence-based standardized protocols (EBSPs) containing evidence-based content and format had lower risk of hospital admission or ED return visit and greater follow-up than children treated in EDs with no standardized protocols in Ontario, Canada. DESIGN Retrospective population-based cohort study of children with asthma. We used multivariable logistic regression to estimate risk of outcomes. SETTING All EDs in Ontario (N = 146) treating childhood asthma from April 2006 to March 2009. PARTICIPANTS Thirty-one thousand one hundred thirty-eight children (aged 2 to 17 years) with asthma. MAIN EXPOSURE Type of standardized protocol (EBSPs, other standardized protocols, or none). MAIN OUTCOME MEASURES Hospital admission, high-acuity 7-day return visit to the ED, and 7-day outpatient follow-up visit. RESULTS The final cohort made 46 510 ED visits in 146 EDs. From the index ED visit, 4211 (9.1%) were admitted to the hospital. Of those discharged, 1778 (4.2%) and 7350 (17.4%) had ED return visits and outpatient follow-up visits, respectively. The EBSPs were not associated with hospitalizations, return visits, or follow-up (adjusted odds ratio, 1.17 [95% CI, 0.91-1.49]; adjusted odds ratio, 1.10 [95% CI, 0.86-1.41]; and adjusted odds ratio, 1.08 [95% CI, 0.87-1.35], respectively). CONCLUSIONS The EBSPs were not associated with improvements in rates of hospital admissions, return visits to the ED, or follow-up. Our findings suggest the need to address gaps linking improved processes of asthma care with outcomes.
Archives of pediatrics & adolescent medicine 07/2012; 166(9):834-40. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: The role of public reporting in improving hospital quality of care is controversial. Reporting of hospital-acquired infection rates has been introduced in multiple health care systems, but its relationship to infection rates has been understudied. Our objective was to determine whether mandatory public reporting by hospitals is associated with a reduction in hospital rates of Clostridium difficile infection.
We conducted a longitudinal, population-based cohort study in Ontario (Canada's largest province) between April 1, 2002, and March 31, 2010. We included all patients (>1 y old) admitted to 180 acute care hospitals. Using Poisson regression, we developed a model to predict hospital- and age-specific monthly rates of C. difficile disease per 10,000 patient-days prior to introduction of public reporting on September 1, 2008. We then compared observed monthly rates of C. difficile infection in the post-intervention period with rates predicted by the pre-intervention predictive model. In the pre-intervention period there were 33,634 cases of C. difficile infection during 39,221,113 hospital days, with rates increasing from 7.01 per 10,000 patient-days in 2002 to 10.79 in 2007. In the first calendar year after the introduction of public reporting, there was a decline in observed rates of C. difficile colitis in Ontario to 8.92 cases per 10,000 patient-days, which was significantly lower than the predicted rate of 12.16 (95% CI 11.35-13.04) cases per 10,000 patient-days (p<0.001). Over this period, public reporting was associated with a 26.7% (95% CI 21.4%-31.6%) reduction in C. difficile cases, or a projected 1,970 cases averted per year (95% CI 1,476-2,500). The effect was specific to C. difficile, with rates of community-acquired gastrointestinal infections and urinary tract infections unchanged. A limitation of our study is that this observational study design cannot rule out the influence of unmeasured temporal confounders.
Public reporting of hospital C. difficile rates was associated with a substantial reduction in the population burden of this infection. Future research will be required to discern the direct mechanism by which C. difficile infection rates may have been reduced in response to public reporting. Please see later in the article for the Editors' Summary.
PLoS Medicine 07/2012; 9(7):e1001268. · 15.25 Impact Factor
[show abstract][hide abstract] ABSTRACT: To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC).
A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates.
At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates.
With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate.
Academic Emergency Medicine 07/2012; 19(7):828-36. · 1.76 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine physician-administered influenza vaccine coverage for children aged 6 to 23 months in a jurisdiction with a universal influenza immunization program during 2002-2009 and to describe predictors of vaccination.
By using hospital records, we identified all infants born alive in Ontario hospitals from April 2002 through March 2008. Immunization status was ascertained by linkage to physician billing data. Children were categorized as fully, partially, or not immunized depending on the number and timing of vaccines administered. Generalized linear mixed models determined the association between immunization status and infant, physician, and maternal characteristics.
Influenza immunization was low for the first influenza season of the study period (1% fully immunized during the 2002-2003 season), increased for the following 3 seasons (7% to 9%), but then declined (4% to 6% fully immunized during the 2006-2007 to 2008-2009 seasons). Children with chronic conditions or low birth weight were more likely to be immunized. Maternal influenza immunization (adjusted odds ratio 4.31; 95% confidence interval 4.21-4.40), having a pediatrician as the primary care practitioner (adjusted odds ratio 1.85; 95% confidence interval 1.68-2.04), high visit rates, and better continuity of care were all significantly associated with full immunization, whereas measures of social disadvantage were associated with nonimmunization. Low birth weight infants discharged from neonatal care in the winter were more likely to be immunized.
Influenza vaccine coverage among children aged 6 to 23 months in Ontario is low, despite a universal vaccination program and high primary care visit rates. Interventions to improve coverage should target both physicians and families.
[show abstract][hide abstract] ABSTRACT: To describe the follow-up care within 28 days of an emergency department (ED) visit for asthma and to determine the association of follow-up visits within 28 days with ED re-visits and hospital admissions in the subsequent year.
Population-based retrospective cohort study of children with asthma aged 2-17 years treated in an ED in Ontario, Canada between April 14, 2006 and February 28, 2009. Multiple linked health administrative datasets and Cox proportional hazard multivariable survival models were used to test the association of characteristics of 28-day follow-up visits with 1-year outcomes.
The final cohort consisted of 29391 children, of whom 32.8% had follow-up, 6496 (22.1%) had an ED re-visit, and 801 (2.7%) had a hospital admission. Having a follow-up visit was not associated with ED re-visit or hospitalizations (hazard ratio 0.98; 95% CI 0.93, 1.03 and hazard ratio 1.06; 95% CI 0.92, 1.23, respectively). Younger children and those with indices of more severe acute or chronic asthma were more likely to have ED re-visits and hospitalizations. Other follow-up care characteristics (number of visits, type of physician providing care) were not associated with outcomes.
Despite a universal healthcare setting, most children did not access follow-up care after an ED visit for asthma, and those that did had no associated benefit in terms of reduced ED re-visits and hospitalizations in the subsequent year.
The Journal of pediatrics 04/2012; 161(2):208-13.e1. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.
To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.
The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital's end-of-life expenditure index for hospital, physician, and emergency department services.
The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.
Patients' baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).
Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
JAMA The Journal of the American Medical Association 03/2012; 307(10):1037-45. · 29.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: We validated population-based hospital, emergency room, and physician claim databases for the detection of surgical site infections against the reference standard of clinical surveillance. Although these data sets are highly specific and could be used to define research cohorts, their low sensitivity and positive predictive value make them inadequate for use as quality indicators.
Infection Control and Hospital Epidemiology 12/2011; 32(12):1213-5. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: A twofold increase in the prevalence of congenital heart defects (CHDs) has been reported since the early 1970s with higher rates among children from low socioeconomic status (SES). This increase and the observed SES gap are postulated to be reflective of higher ascertainment, especially increased use of ultrasound and echography. The purpose of this study was to examine if trends over time in the prevalence of CHD were the same for high and low SES groups.
Using the child's health number as a unique identifier and through record linkage, children born in Ontario between 1994 and 2007 were followed for the diagnosis of CHD. Using postal codes and census information, SES quintiles were assigned to each child. We used adjusted rates and used multivariate models to compare trends in the prevalence rate among children born in different SES groups.
Children born in low SES areas (23% of all births) had significantly higher rates of CHDs (rate ratio = 1.20; 95% confidence interval [CI] = 1.15-1.24). While prevalence of nonsevere CHDs declined in all SES groups since 2000, severe CHDs, especially atrial septal defects were on the rise during the study period.
It is assumed that increased ascertainment is responsible for observed increase in the prevalence of CHD, especially minor defects. While the trend and pattern over time changed for severe and nonsevere CHDs, the SES gap remained consistent during the study period. Our results indicate that even free and universal access to a health care system does not eliminate the SES gap observed in the prevalence of CHD.
Birth Defects Research Part A Clinical and Molecular Teratology 12/2011; 91(12):1011-8. · 2.27 Impact Factor
[show abstract][hide abstract] ABSTRACT: In Ontario, clinical decision units (CDUs) were implemented as a pilot project in 2008 by the Ministry of Health and Long-Term Care as part of its strategy to reduce emergency department (ED) waiting times. Our objective was to describe general characteristics of the program at each of the participating sites and to examine barriers and facilitators to integrating CDUs into practice.
On-site small-group interviews were conducted in two phases with ED and hospital staff at participating sites, first at 8 to 12 weeks and again at 12 months postimplementation. Interview data were analyzed using the framework approach. Unstructured field notes and CDU clinical care protocols and documentation were also reviewed.
The qualitative analysis identified 10 key themes related to integrating CDUs into EDs: shift in clinical and operational practice; administrative aspects of implementation; team building and stakeholder involvement; use of clinical care protocols; physical or virtual model of care; responsive ancillary services; involvement of specialist services; coordination with hospital and community supports; appropriate use of the CDU; and ongoing evaluation and monitoring. Each theme represents an important insight from the perspective of clinical and administrative staff at participating sites.
The implementation of CDUs is a complex process, with no single preferred clinical care or operational model. This study identifies a number of key considerations relevant to the future implementation of CDUs.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 11/2011; 13(6):363-71. · 1.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: Recent advances have been made in the care of children with inflammatory bowel disease (IBD). We aimed to describe trends in medication use, associated health services, and outcomes (hospitalization and surgical rates) between 1994-2007 in children with IBD.
Children <18 years diagnosed 1994-2004 with IBD living in Ontario were identified and grouped by era of diagnosis (1994-1997, 1998-2000, 2001-2004). We tested the association between era and hospitalizations and surgery. Medication use (in children on social assistance), and physician provider specialty were described.
IBD-related outpatient health services were increasingly provided by pediatric gastroenterologists, with decreasing care by adult gastroenterologists, surgeons, and generalists. Children diagnosed in 2001-2004 with Crohn's disease (CD) were more likely to use an immunomodulator within 3 years of diagnosis (P = 0.01). In all children with IBD, numbers of hospitalizations and physician visits remained stable over time; however, the age-adjusted odds of being hospitalized was higher in recent years for CD (adjusted odds ratio [aOR] 3.22, 95% confidence intervals [CI] 2.15-4.83) and ulcerative colitis (UC) (aOR 2.83 95% CI 1.55-5.19). Surgical rates within 3 years of diagnosis with CD decreased from 18.8% to 13.6% over time (P = 0.035). This decrease was significant in children with CD diagnosed ≥10 years old (aOR 0.67, 95% CI 0.48-0.93). No change was demonstrated in UC.
Treatment changes in children with IBD between 1994-2007 (including increased immunomodulator use and increased outpatient care by pediatric gastroenterologists) were associated with reduced surgical rates in children with CD but not UC.
[show abstract][hide abstract] ABSTRACT: The evaluation of emergency department (ED) quality of care is hampered by the absence of consensus on appropriate measures. We sought to develop a consensus on a prioritized and parsimonious set of evidence-based quality of care indicators for EDs.
The process was led by a nationally representative steering committee and expert panel (representatives from hospital administration, emergency medicine, health information, government, and provincial quality councils). A comprehensive review of the scientific literature was conducted to identify candidate indicators. The expert panel reviewed candidate indicators in a modified Delphi panel process using electronic surveys; final decisions on inclusion of indicators were made by the steering committee in a guided nominal group process with facilitated discussion. Indicators in the final set were ranked based on their priority for measurement. A gap analysis identified areas where future indicator development is needed. A feasibility study of measuring the final set of indicators using current Canadian administrative databases was conducted.
A total of 170 candidate indicators were generated from the literature; these were assessed based on scientific soundness and their relevance or importance. Using predefined scoring criteria in two rounds of surveys, indicators were coded as "retained" (53), "discarded" (78), or "borderline" (39). A final set of 48 retained indicators was selected and grouped in nine categories (patient satisfaction, ED operations, patient safety, pain management, pediatrics, cardiac conditions, respiratory conditions, stroke, and sepsis or infection). Gap analysis suggested the need for new indicators in patient satisfaction, a healthy workplace, mental health and addiction, elder care, and community-hospital integration. Feasibility analysis found that 13 of 48 indicators (27%) can be measured using existing national administrative databases.
A broadly representative modified Delphi panel process resulted in a consensus on a set of 48 evidence-based quality of care indicators for EDs. Future work is required to generate technical definitions to enable the uptake of these indicators to support benchmarking, quality improvement, and accountability efforts.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 09/2011; 13(5):300-9, E28-43. · 1.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events.
Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7.
All emergency department patients who were not admitted (seen and discharged; left without being seen).
Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital.
13,934,542 patients were seen and discharged and 617,011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥ 6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital.
Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.
[show abstract][hide abstract] ABSTRACT: To examine healthcare utilization according to family income in children with inflammatory bowel disease (IBD).
A population-based cohort of children aged <18 years diagnosed with IBD between 1994 and 2004 was followed using health administrative data. Multivariate models were used to test the association between mean neighborhood income quintile and physician and emergency department visits, hospitalizations, or surgeries.
Compared with children from higher-income neighborhoods, children from low-income neighborhoods were more likely to be hospitalized at least once (hazard ratio, 1.17; 95% CI, 1.05 to 1.30) or to visit the emergency department (hazard ratio, 1.21; 95% CI, 1.09 to 1.35), and had more IBD-related physician visits (OR, 3.73; 95% CI, 1.05 to 13.27). Children from low-income neighborhoods with Crohn's disease (but not those with ulcerative colitis) were more likely to undergo intra-abdominal surgery within 3 years of diagnosis (OR, 1.22; 95% CI, 1.01 to 1.49), especially when diagnosed after 2000 (OR, 1.79; 95% CI, 1.27 to 2.53).
Lower income was associated with a higher rate of health services utilization in children with IBD and with a greater risk of surgery in children with Crohn's disease.
The Journal of pediatrics 01/2011; 158(6):960-967.e1-4. · 4.02 Impact Factor