Sharon E. Straus’s research while affiliated with University of Toronto and other places

Introduction Point of care multiplex rapid antigen testing (RAT) is a tool that can be used to mitigate and respond to facility-based infectious disease outbreaks. However, little is known about how to optimally implement this testing in congregate living settings (CLSs), including long term care homes (LTCHs), retirement homes (RHs), and shelters serving people experiencing homelessness. Our objective was to explore the barriers and facilitators to implementing a new device for multiplex RAT for COVID-19 and influenza across CLSs in the Greater Toronto Area, Canada. Materials and methods Using key informant interviews, we assessed barriers and facilitators to implementing multiplex RAT across CLSs. Qualitative coding using the framework approach was used to identify themes. We used the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR) to identify individual and contextual-level barriers and facilitators to implementation. Identified barriers were then mapped to implementation strategies using theoretically-rooted frameworks and tools. Results We completed 45 interviews with staff at CLSs (8 LTCHs, 4 RHs, 12 shelters) between January 2022 and March 2023. Four barriers to RAT implementation in CLSs emerged including: limited material resources for implementation; insufficient staff capacity to perform RAT testing; complexity of RAT implementation; and reluctance among staff to adopt a new testing process. Five facilitators to implementation were described including: training and implementation support for staff at the CLSs; site-level implementation champions; access to materials to support testing; perceived advantages of simultaneous testing for COVID-19 and influenza; and the usability and functionality of the RAT testing device. Twenty implementation strategies were identified through implementation strategy mapping. Discussion Multiplex RAT options can empower CLS staff to promptly identify and respond to viral respiratory outbreaks. The use of evidence-based implementation strategies can enhance the effectiveness of using multiplex RAT to control outbreaks in CLSs.

Understanding patterns of SARS-CoV-2 seroprevalence among Long-Term Care Home and Retirement Home (LTCH/RH) staff is critical to designing effective public health interventions. We estimated SARS-CoV-2 seroprevalence among LTCH/RH staff in Ontario, Canada between May 2021-October 2022 using a cross-sectional analysis. Eligible participants completed a demographic questionnaire and provided a dried blood spot sample. Positive seroprevalence was defined as the proportion of individuals in a population who were positive for a SARS-CoV-2 infection, determined using anti-nucleocapsid total IgG antibodies analyzed with a validated chemiluminescent ELISA. We report age-adjusted prevalence ratios [PR; confidence interval, CI] by participant socio-demographic, household, neighbourhood, and occupational characteristics and stratified the analyses over two time periods (period 1: 2021-05-17 to 2021-12-31; period 2: 2022-01-02 to 2022-10-25). A total of 603 staff were included in our analysis; n=235 (39%) were enrolled in period 1 and n=368 (61%) were enrolled in period 2. Seroprevalence was 24% and 44% in periods 1 and 2, respectively. Age-adjusted prevalence ratios were nearly 2-fold higher among Black [PR 1.78; CI 1.28-2.48], East and Southeast Asian [PR 1.55, CI 1.18-2.04] and other racialized participants [PR 1.42, CI 1.03-1.96] compared to White participants. We did not observe a pattern across household characteristics, although we observed a trend towards higher seropositivity among participants living in COVID-19 hotspots. Prevalence ratios were lower for participants in higher income neighbourhoods [PR 0.72, CI 0.58-0.98]. We did not observe variability in seroprevalence across occupational characteristics with the exception of paid sick leave which was higher among participants with home-provided paid sick leave at the time of the survey [PR 0.58, CI 0.45-0.75]. Among LTCH/RH staff, we found important sources of variability of SARS-CoV-2 seroprevalence and strong correlations with socioeconomic disparities. Our findings show the importance of designing equity-rooted health interventions that recognize the intersection between community and the workplace.

Background With a shortage of geriatricians, the appropriate distribution of geriatricians across healthcare settings (e.g., acute care, rehabilitation, or community clinics) is unknown. Our objective was to determine which setting(s) geriatricians should preferentially staff to be most economically attractive for the Canadian healthcare system. Methods We conducted a cost‐effectiveness analysis using a two‐dimensional microsimulation model. The model simulated a population of frail adults aged ≥ 65 years. The simulation was done over a lifetime horizon from the Ontario public payer perspective. Strategies included (1) usual care (baseline proportions of geriatrician CGAs in each setting), (2) acute care only (100% receive CGA in acute care), (3) community care only, (4) rehabilitation only, (5) acute care and community combined, (6) acute care and rehabilitation combined, (7) community and rehabilitation combined, and (8) acute care, community, and rehabilitation combined. Primary model outputs included quality‐adjusted life months (QALMs), lifetime costs, and incremental cost‐effectiveness ratios (ICERs). Results The acute care and rehabilitation combined strategy was undominated at a lifetime cost of C$139,987 and with an effectiveness of 42.09 QALM. At an ICER of C$1203 per QALM, the combination strategy of acute care, rehabilitation, and community clinics was cost‐effective relative to acute care and rehabilitation, assuming a cost‐effectiveness threshold of C$4167 per QALM (equivalent to C$50,000 per quality‐adjusted life year). The other six strategies were dominated. When individually compared to usual care, all of the strategies were dominant or cost‐effective. Conclusions An undominated strategy of staffing geriatricians was in the acute care and rehabilitation settings, with the option of adding community clinics if cost and resources permit.

Background In microsimulation models of diseases with an early, acute phase requiring short cycle lengths followed by a chronic phase, fixed short cycles may lead to computational inefficiency. Examples include epidemic or resource constraint models with early short cycles where long-term economic consequences are of interest for individuals surviving the epidemic or ultimately obtaining the resource. In this article, we demonstrate methods to improve efficiency in such scenarios. Furthermore, we show that care must be taken when applying these methods to epidemic or resource constraint models to avoid bias. Methods To demonstrate efficiency, we compared the model runtime among 3 versions of a microsimulation model: with short fixed cycles for all states (FCL), with dynamic cycle length (DCL) defined locally for each state, and with DCL features plus a discrete-event-like hybrid component. To demonstrate bias mitigation, we compared discounted lifetime costs for 3 versions of a resource constraint model: with a fixed horizon where simulation stops, with a fixed entry horizon beyond which new individuals could not enter the model, and with a fixed entry horizon plus a mechanism to maintain a constant level of competition for the resource after the horizon. Results The 3 versions of the microsimulation model had average runtimes of 515 (95% credible interval [CI]: 477 to 545; FCL), 2.70 (95% CI: 1.48 to 2.92; DCL), and 1.45 (95% CI: 1.26 to 2.61; DCL-pseudo discrete event simulation) seconds, respectively. The first 2 resource constraint versions underestimated costs relative to the constant competition version: $20,055 (95$19,000 to 21,120), 27,030 (95% CI: $24,680 to$29,412), and $33,424 (95$27,510 to $44,484), respectively. Limitations The magnitude of improvements in efficiency and reduction in bias may be model specific. Conclusion Changing time representation in microsimulation may offer computational advantages. Highlights Short cycle lengths may be required to model the acute phase of an illness but lead to computational inefficiency in a subsequent chronic phase in microsimulation models. A solution is to create state-specific cycle lengths so that cycle lengths change dynamically as the simulation progresses. Computational efficiency can be enhanced further by using a hybrid model containing discrete-event-simulation-like features. Hybrid models can efficiently handle events subsequent to exit from an epidemic or resource constraint model provided steps are taken to mitigate potential bias.

STANDFIRST This scoping review represents the initial step in updating the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for network meta-analysis (NMA) to improve the usability and relevance of systematic reviews with NMA for diverse audiences. The update will address gaps in reporting, such as documenting methods for assessing NMA homogeneity and transitivity, defining intervention nodes, and considering advances in statistical modeling. It will align with PRISMA 2020 and incorporate input from diverse knowledge users, including patients and the public. This scoping review included 61 studies, comprising 23 guidance documents and 38 overviews of reviews evaluating the completeness of reporting and methodological quality of published NMAs. We identified 37 additional NMA items for inclusion in the next step—the Delphi survey. Building on a 2014 scoping review by our team, we incorporated recent studies to inform the PRISMA-NMA update, adhering to established standards for guideline development. SUMMARY POINTS Network meta-analyses (NMAs) are increasingly prominent in evidence synthesis, but their methodological transparency and reporting completeness remain inconsistent, which affects the reliability of results. This scoping review highlights the need to update PRISMA-NMA to address evolving methodologies (e.g., component NMA) and reporting challenges to improve accessibility and utility of NMA findings. The review underscores progress and gaps in NMA reporting since the 2015 PRISMA-NMA extension, focusing on synthesis methods, homogeneity, consistency and transitivity assessments, and network geometry. Key recommendations, such as defining pre-specified nodes, specifying statistical methods, and addressing competing interests, were often overlooked in NMA reporting, but addressing these gaps could enhance transparency, reproducibility, and trust in NMA results.

Background The COVID-19 pandemic disproportionally affected congregate living settings, including shelters. COVID-19 transmission can have more adverse outcomes in these settings due to the vulnerability of residents. Point of care rapid antigen testing (RAT) represents a strategy with potential benefits for COVID-19 detection in shelters, including rapid results, ease of use, cost-effectiveness, and early detection. Objectives Our primary objective was to assess the real-world test accuracy of RAT for COVID-19 using the Quidel Sofia 2 Flu + SARS Antigen fluorescent immunoassay (Sofia RAT) compared to polymerase chain reaction (PCR) testing among shelter residents in Ontario, Canada. Study Design A consecutive sample of 102 residents across six shelters who were symptomatic for, or exposed to COVID-19 were included. The RAT and PCR samples were taken on the same day for each participant. Results from the Sofia RAT were compared to PCR test results to determine test accuracy. Participant demographic data could not be collected due to workforce constraints. Results We reported our methods and findings using the QUality Assessment tool of Diagnostic Accuracy Studies (QUADAS-2) guidelines. Sofia 2 RAT specificity was 97.9% (95% CI: 92.7% to 99.7%) for COVID-19 compared to PCR. Due to a lack of true positive cases, sensitivity could not accurately be calculated (0.00% (95% CI: 0.00% to 52.2%)). Conclusion These data suggest that the Sofia RAT is a highly specific test for COVID-19. Keywords Rapid antigen testing (RAT), Homeless shelter, Test accuracy, COVID-19 detection, SARS-CoV-2

Introduction We sought to explore healthcare providers (HCPs)' perceptions of and experiences with stigma during the COVID-19 pandemic in Canada and Singapore. Methods We conducted a qualitative study (May 2020–February 2021) with HCPs in Canada and Singapore and developed a semi-structured interview guide rooted in the Health Stigma and Discrimination Framework (HSDF). We recruited participants online and through word of mouth via newsletters, blogs and social media. Participants were eligible to participate if they worked as a healthcare provider in Singapore or Canada during COVID-19. Following participant consent, data were recorded, transcribed verbatim, and coded using a framework approach. Coded data were charted into a framework matrix and used to compare themes in each country. Results We conducted 51 interviews (23 in Canada; 28 in Singapore). HCPs perceived that patient fears coupled with mistrust of the health system impacted health behaviors. HCPs reported discrimination and stigmatization of population subsets. In Singapore, this included Chinese tourists and migrant workers and in Canada, this included people of Chinese ethnicity and people experiencing homelessness. This stigma was often attributed to pre-existing prejudices including perceptions that these populations were at increased risk of COVID-19 or not adhering to public health recommendations. HCPs feared spreading COVID-19 to family, peers and patients, often resulting in participants choosing to isolate from social circles. HCPs in both countries experienced occupation-based stigma, including stigma related to public health practices (masking, testing); in Canada, this intersected with race-based prejudice for participants of Chinese ethnicity. HCPs in both samples witnessed and experienced stigmatizing behavior; some participants also experienced discrimination. Conclusions Secondary stigma related to occupation was experienced by HCPs during COVID-19. HCPs experienced intersecting stigma based on race/ethnicity and observed stigmatization of marginalized patient populations. Most themes were consistent across Canada and Singapore. Strategies to mitigate COVID-19 related stigma toward HCPs and at-risk patient populations are warranted.

Objective The objective of this scoping review is to develop a list of items for potential inclusion in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guidelines for network meta-analysis (NMA), scoping reviews (ScRs), and rapid reviews (RRs). Introduction The PRISMA extensions for NMA and ScRs were published in 2015 and 2018. However, since then, their methodologies and innovations, including automation, have evolved. There is no reporting guideline for RRs. In 2020, an updated PRISMA statement was published, reflecting advances in the conduct and reporting of systematic reviews. These advances are not yet incorporated into these PRISMA extensions. We will update our previous methods scoping reviews to inform the update of PRISMA-NMA and PRISMA-ScR as well as the development of the PRISMA-RR reporting guidelines. Inclusion criteria This review will include any study designs evaluating the completeness of reporting, or offering reporting guidance, or assessing methods relevant to NMA, ScRs, or RRs. Editorial guidelines and tutorials that describe items related to reporting completeness will also be eligible. Methods We will follow the JBI guidance for scoping reviews. For each PRISMA extension, we will (1) search multiple electronic databases from inception, (2) search for unpublished studies, and (3) scan the reference lists of included studies. There will be no language limitations. Screening and data extraction will be conducted by 2 researchers independently. A third researcher will resolve discrepancies. We will conduct frequency analyses of the identified items. The final list of items will be considered for potential inclusion in the relevant PRISMA reporting guidelines. Review registration NMA protocol (OSF: https://doi.org/10.17605/OSF.IO/7BKWY); ScR protocol (OSF: https://doi.org/10.17605/OSF.IO/MTA4P); RR protocol (OSF: https://doi.org/10.17605/OSF.IO/3JCPE); EQUATOR registration link: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-systematic-reviews/

Background With a shortage of geriatricians and an aging population, strategies are needed to optimise the distribution of geriatricians across different healthcare settings (acute care, rehabilitation and community clinics). The perspectives of knowledge users on staffing geriatricians in different healthcare settings are unknown. We aimed to understand the acceptability and feasibility (including barriers and facilitators) of implementing a geriatrician-led comprehensive geriatric assessment (CGA) in acute care, rehabilitation, and community clinic settings. Methods A qualitative description approach was used to explore the experience of those implementing (administrative staff), providing (healthcare providers), and receiving (patients/family caregivers) a geriatrician-led CGA in acute care, rehabilitation and community settings. Semi-structured interviews were conducted in Toronto, Canada. The theoretical domains framework and consolidated framework for implementation research informed the interview guide development. Analysis was conducted using a thematic approach. Results Of the 27 participants (8 patients/caregivers, 9 physicians, 10 administrators), the mean age was 53 years and 14 participants (52%) identified as a woman (13 [48%] identified as a man). CGAs were generally perceived as acceptable but there was a divergence in opinion about which healthcare setting was most important for geriatricians to staff. Acute care was reported to be most important by some because no other care provider has the intersection of acute medicine skills with geriatric training. Others reported that community clinics were most important to manage geriatric syndromes before hospitalization was necessary. The rehabilitation setting appeared to be viewed as important but as a secondary setting. Facilitators to implementing a geriatrician-led CGA included (i) a multidisciplinary team, (ii) better integration with primary care, (iii) a good electronic patient record system, and (iv) innovative ways to identify patients most in need of a CGA. Barriers to implementing a geriatrician-led CGA included (i) lack of resources or administrative support, (ii) limited team building, and (iii) consultative model where recommendations were made but not implemented. Conclusions Overall, participants found CGAs acceptable yet had different preferences of which setting to prioritise staffing if there was a shortage of geriatricians. The main barriers to implementing the geriatrician-led CGA related to lack of resources. Clinical trial number Not applicable.