Factors associated with plans for early retirement among Ontario family physicians during the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: Higher numbers of family physicians (FPs) stopped practicing or retired during the COVID-19 pandemic, worsening the family doctor shortage in Canada. Our study objective was to determine which factors were associated with FPs' plans to retire earlier during the COVID-19 pandemic. METHODS: We administered two cross-sectional online surveys to Ontario FPs asking whether they were "planning to retire earlier" as a result of the pandemic during the first and third COVID-19 pandemic waves (Apr-Jun 2020 and Mar-Jul 2021). We used logistic regression to determine which factors were associated with early retirement planning, adjusting for age. RESULTS: The age-adjusted proportion of FP respondents planning to retire earlier was 8.2% (of 393) in the first-wave and 20.5% (of 454) in the third-wave. Planning for earlier retirement during the third-wave was associated with age over 50 years (50-59 years odds ratio (OR) 5.37 (95% confidence interval (CI):2.33-12.31), 60 years and above OR 4.18 (95% CI: 1.90-10.23)), having difficulty handling increased non-clinical responsibilities (OR 2.95 (95% CI: 1.79-4.94)), feeling unsupported to work virtually (OR 1.96 (95% CI: 1.19-3.23)) or in-person (OR 2.70 (95% CI: 1.67-4.55)), feeling unable to provide good care (OR 1.82 (95% CI: 1.10-3.03)), feeling work was not valued (OR 1.92 (95% CI: 1.15-3.23)), feeling frightened of dealing with COVID-19 (OR 2.01 (95% CI: 1.19-3.38)), caring for an elderly relative (OR 2.36 (95% CI: 1.69-3.97)), having difficulty obtaining personal protective equipment (OR 2.00 (95% CI: 1.16-3.43)) or difficulty implementing infection control practices in clinic (OR 2.10 (95% CI: 1.12-3.89)). CONCLUSIONS: Over 20% of Ontario FP respondents were considering retiring earlier by the third-wave of the COVID-19 pandemic. Supporting FPs in their clinical and non-clinical roles, such that they feel able to provide good care and that their work is valued, reducing non-clinical (e.g., administrative) responsibilities, dealing with pandemic-related fears, and supporting infection control practices and personal protective equipment acquisition in clinic, particularly in those aged 50 years or older may help increase family physician retention during future pandemics.

Prevalence and Incidence Trends of Attention Deficit/Hyperactivity Disorder in Children and Youth Aged 1-24 Years in Ontario, Canada: A Validation Study of Health Administrative Data Algorithms: Tendances de la prévalence et de l'incidence du trouble de déficit de l'attention/hyperactivité chez les enfants et les jeunes âgés de 1 à 24 ans, en Ontario, Canada: une étude de validation des algorithmes de données administratives de santé.

OBJECTIVE: To estimate prevalence and incidence rates over time in children and youth with attention deficit/hyperactivity disorder from the validation of population-based administrative data algorithms using family physicians' electronic medical records as a reference standard. METHODS: A retrospective cohort study was conducted in Ontario, Canada to identify attention deficit/hyperactivity disorder among children and youth aged 1-24 years in health administrative data derived from case-finding algorithms using family physicians' electronic medical records. Multiple administrative data algorithms identifying attention deficit/hyperactivity disorder cases were developed and tested from physician-diagnosis of attention deficit/hyperactivity disorder in the electronic medical record to determine their diagnostic accuracy. We calculated algorithm performance using sensitivity, specificity, and predictive values. The most optimal algorithm was used to estimate prevalence and incidence rates of attention deficit/hyperactivity disorder from 2014 to 2021 in Ontario. RESULTS: The optimal performing algorithm was "2 physician visits for attention deficit/hyperactivity disorder in 1 year or 1 attention deficit/hyperactivity disorder-specific prescription" with sensitivity: 83.2% (95% confidence interval [CI], 81.8% to 84.5%), specificity: 98.6% (95% CI, 98.5% to 98.7%), positive predictive value: 78.6% (95% CI, 77.1% to 80.0%) and negative predictive value: 98.9% (95% CI, 98.8% to 99.0%). From 2014, prevalence rates for attention deficit/hyperactivity disorder increased from 5.29 to 7.48 per 100 population in 2021 (N = 281,785). Males had higher prevalence rates (7.49 to 9.59 per 100 population, 1.3-fold increase) than females (2.96-5.26 per 100 population, 1.8-fold increase) from 2014 to 2021. Incidence rates increased from 2014 (0.53 per 100 population) until 2018, decreased in 2020 then rose steeply in 2021 (0.89 per 100 population, N = 34,013). Males also had higher incidence rates than females from 2014 to 2020 with females surpassing males in 2021 (0.70-0.81 per 100 male population,1.2-fold increase versus 0.36-0.97 per 100 female population, 2.7-fold increase). CONCLUSIONS: Attention deficit/hyperactivity disorder is increasing in prevalence. We developed an administrative data algorithm that can reliably identify children and youth with attention deficit/hyperactivity disorder with good diagnostic accuracy.

Actualisation 2023 des lignes directrices de pratique clinique pour la prise en charge de l'ostéoporose et la prévention des fractures au Canada.

CONTEXTE: Au Canada, plus de 2 millions de personnes vivent avec l'ostéoporose, une maladie qui accroît le risque de fracture, ce qui fait augmenter la morbidité et la mortalité, et entraîne une perte de qualité de vie et d'autonomie. La présente actualisation des lignes directrices vise à accompagner les professionnelles et professionnels de la santé au Canada dans la prestation de soins visant à optimiser la santé osseuse et à prévenir les fractures chez les femmes ménopausées et les hommes de 50 ans et plus. MÉTHODES: Le présent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d'Ostéoporose Canada sur le diagnostic et la prise en charge de l'ostéoporose au pays. Nous avons utilisé l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectué l'assurance de la qualité conformément aux normes de qualité et de présentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les médecins de premier recours et les patientes et patients partenaires ont été représentés à tous les niveaux des comités et des groupes ayant participé à l'élaboration des lignes directrices, et ont participé à toutes les étapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des intérêts concurrents a été entamé avant l'élaboration des lignes directrices et s'est poursuivi sur toute sa durée, selon les principes du Réseau international en matière de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et préférences de la patientèle, des ressources, de l'équité, de l'acceptabilité et de la faisabilité; la force de chacune des recommandations a été déterminée en fonction du cadre GRADE. RECOMMANDATIONS: Les 25 recommandations et les 10 énoncés de bonne pratique sont répartis en sections : activité physique, alimentation, évaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, durée et séquence du traitement, et monitorage. La prise en charge de l'ostéoporose devrait se fonder sur le risque de fracture, établi au moyen d'une évaluation clinique réalisée avec un outil d'évaluation du risque de fracture validé. L'activité physique, l'alimentation et la pharmacothérapie sont des éléments essentiels à la stratégie de prévention des fractures, qui devraient être personnalisés. INTERPRÉTATION: Les présentes lignes directrices ont pour but d'outiller les professionnelles et professionnels de la santé et la patientèle afin qu'ensemble ils puissent parler de l'importance de la santé osseuse et du risque de fracture tout au long de la vie adulte avancée. La détection et la prise en charge efficace de la fragilité osseuse peuvent contribuer à réduire les fractures et à préserver la mobilité, l'autonomie et la qualité de vie.

Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update.

BACKGROUND: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older. METHODS: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework. RECOMMENDATIONS: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized. INTERPRETATION: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life.

Trends in health service use among persons with Parkinson's disease by rurality: A population-based repeated cross-sectional study.

BACKGROUND: The global burden of Parkinson's disease (PD) has more than doubled over the past three decades, and this trend is expected to continue. Despite generally poorer access to health care services in rural areas, little previous work has examined health system use in persons with PD by rurality. We examined trends in the prevalence of PD and health service use among persons with PD by rurality in Ontario, Canada. METHODS: We conducted a repeated, cross-sectional analysis of persons with prevalent PD aged 40+ years on April 1st of each year from 2000 to 2018 using health administrative databases and calculated the age-sex standardized prevalence of PD. Prevalence of PD was also stratified by rurality and sex. Negative binomial models were used to calculate rate ratios with 95% confidence intervals comparing rates of health service use in rural compared to urban residents in 2018. RESULTS: The age-sex standardized prevalence of PD in Ontario increased by 0.34% per year (p<0.0001) and was 459 per 100,000 in 2018 (n = 33,479), with a lower prevalence in rural compared to urban residents (401 vs. 467 per 100,000). Rates of hospitalizations and family physician visits declined over time in both men and women with PD in rural and urban areas, while rates of emergency department, neurologist, and other specialist visits increased. Adjusted rates of hospitalizations were similar between rural and urban residents (RR = 1.04, 95% CI [0.96, 1.12]), while rates of emergency department visits were higher among rural residents (RR = 1.35, 95% CI [1.27, 1.42]). Rural residents had lower rates of family physician (adjusted RR = 0.82, (95% CI [0.79, 0.84]) and neurologist visits (RR = 0.74, 95% CI [0.72, 0.77]). INTERPRETATION: Lower rates of outpatient health service use among persons residing in rural regions, contrasting with higher rates of emergency department visits suggest inequities in access. Efforts to improve access to primary and specialist care for persons with PD in rural regions are needed.

Patient visits and prescriptions for attention-deficit/hyperactivity disorder from 2017-2021: Impacts of COVID-19 pandemic in primary care.

OBJECTIVE: To determine whether more patients presented with Attention-deficit/hyperactivity disorder (ADHD)-related visits and/or sought care from family physicians more frequently during the COVID-19 pandemic. METHODS: Electronic medical records from the University of Toronto Practice-Based Research Network were used to characterize changes in family physician visits and prescriptions for ADHD medications. Annual patient prevalence and visit rates pre-pandemic (2017-2019) were used to calculate the expected rates in 2020 and 2021. The expected and observed rates were compared to identify any pandemic-related changes. RESULTS: The number of patients presenting for ADHD-related visits during the pandemic was consistent with pre-pandemic trends. However, observed ADHD-related visits in 2021 were 1.32 times higher than expected (95% CI: 1.05-1.75), suggesting that patients visited family physicians more frequently than before the pandemic. CONCLUSION: Demand for primary care services related to ADHD has continued to increase during the pandemic, with increased health service use among those accessing care.

Assessing Primary Care Blood Pressure Documentation for Hypertension Management During the COVID-19 Pandemic by Patient and Provider Groups.

Background: Primary care electronic medical record (EMR) data can be used to identify, manage, and screen hypertension cases. However, this approach relies on completeness and accessibility of documented blood pressure (BP) values. With the large switch to virtual care due to the COVID-19 pandemic, we assessed BP documentation in primary care EMRs during the pandemic, across patient and physician groups. Methods: Hypertension-related visits were identified during the pre-pandemic (January 2017 to February 2020) and pandemic (March 2020 to December 2021) periods from a primary care EMR database in Ontario, Canada. Clustered logistic regression models were used to analyze the relationship of physician and patient characteristics with an outcome variable of documented BP. A chart review of 3200 hypertension visits without a BP recorded in structured data fields was conducted to determine if BP was recorded in progress notes. Results: Pre-pandemic, 75.7% of hypertension-related visits (113,966 of 150,511) had a BP recorded in structured documentation, but this significantly decreased to 36.4% (26,660 of 73,239) during the pandemic (odds ratio [OR] = 0.18, 95% confidence interval [CI]: 0.18-0.19). For virtual visits, 14.3% (6357 of 44,572) had a documented BP, vs 74.0% (20,056 of 27,089) for in-person visits. Chart review found that 55.9% of hypertension visits had no associated BP in structured documentation, but did have a BP recorded in the progress note. Male providers, compared to female providers, were less likely to record BPs pre-pandemic (OR = 0.45, 95% CI: 0.32-0.63) and during the pandemic, for both virtual visits (OR = 0.48, 95% CI: 0.32-0.71) and in-person visits (OR = 0.46, 95% CI: 0.33-0.64). Conclusions: BP documented in primary care EMRs declined during the pandemic, most likely due to high rates of virtual visits impacting hypertension detection and management.

Contexte: Les données des dossiers médicaux électroniques (DME) provenant des soins primaires peuvent être utilisées pour détecter, prendre en charge et dépister les cas d'hypertension. Cependant, cette approche dépend de l'accessibilité et de l'exhaustivité des valeurs de pression artérielle (PA) consignées aux dossiers. Étant donné l'important passage aux soins virtuels attribuable à la pandémie de COVID-19, nous avons évalué la façon dont la PA avait été consignée dans les DME de soins primaires pendant la pandémie, parmi des groupes de patients et de médecins. Méthodologie: Les consultations liées à l'hypertension pendant les périodes pré-pandémique (de janvier 2017 à février 2020) et pandémique (de mars 2020 à décembre 2021) ont été recueillies d'une banque de données de DME de soins primaires en Ontario (Canada). Des modèles de régression logistique regroupée ont été utilisés pour analyser le lien entre les caractéristiques des médecins et de patients et une variable de résultats des PA consignées. Une revue des dossiers portant sur 3200 consultations pour hypertension sans consignation de la PA dans les champs de données structurés a été effectuée afin de déterminer si la PA avait été notée dans les notes d'évolution. Résultats: Avant la pandémie, la PA avait été consignée dans une documentation structurée pour 75,7 % (113 966 sur 150 511) des consultations pour hypertension, mais cette proportion a chuté considérablement à 36,4 % (26 660 sur 73 239) pendant la pandémie (rapport des cotes [RC] = 0,18; intervalle de confiance [IC] à 95 % : 0,18-0,19). Pour ce qui est des consultations virtuelles, la PA a été consignée dans 14,3 % (6357 sur 44 572) des cas, comparativement à 74,0 % (20 056 sur 27 089) pour les consultations en personne. Une analyse des dossiers a révélé que pour 55,9 % des consultations pour hypertension, aucune mesure de PA ne figurait dans la documentation structurée, mais qu'une valeur de PA avait toutefois été consignée dans les notes d'évolution. Les professionnels de la santé masculins, comparativement aux femmes, ont été moins susceptibles de consigner les valeurs de PA avant la pandémie (RC = 0,45; IC à 95 % : 0,32-0,63) et pendant la pandémie, tant lors des consultations virtuelles (RC = 0,48; IC à 95 % : 0,32-0,71) que des consultations en personne (RC = 0,46; IC à 95 % : 0,33-0,64). Conclusions: L'inscription des valeurs de PA dans les DME de soins primaires a décliné pendant la pandémie, fort probablement en raison de la proportion élevée de consultations virtuelles, ce qui a eu une incidence sur la détection et la prise en charge de l'hypertension.

Identification of Early Onset Dementia in Population-Based Health Administrative Data: A Validation Study Using Primary Care Electronic Medical Records.

BACKGROUND: Early onset dementia (EOD) occurs when symptoms of dementia begin between 45 to 64 years of age. OBJECTIVE: We developed and validated health administrative data algorithms for EOD and compared demographic characteristics and presence of comorbid conditions amongst adults with EOD, late onset dementia (LOD) and adults with no dementia in Ontario, Canada. METHODS: Patients aged 45 to 64 years identified as having EOD in their primary care electronic medical records had their records linked to provincial health administrative data. We compared several combinations of physician's claims, hospitalizations, emergency department visits and prescriptions. Age-standardized incidence and prevalence rates of EOD were estimated from 1996 to 2016. RESULTS: The prevalence of EOD for adults aged 45 to 64 years in our primary care reference cohort was 0.12%. An algorithm of ≥1 hospitalization or ≥3 physician claims at least 30 days apart in a two-year period or ≥1 dementia medication had a sensitivity of 72.9% (64.5-81.3), specificity of 99.7% (99.7-99.8), positive predictive value (PPV) of 23.7% (19.1-28.3), and negative predictive value of 100.0%. Multivariate logistic regression found adults with EOD had increased odds ratios for several health conditions compared to LOD and no dementia populations. From 1996 to 2016, the age-adjusted incidence rate increased slightly (0.055 to 0.061 per 100 population) and the age-adjusted prevalence rate increased three-fold (0.11 to 0.32 per 100 population). CONCLUSION: While we developed a health administrative data algorithm for EOD with a reasonable sensitivity, its low PPV limits its ability to be used for population surveillance.

Effects of COVID-19 pandemic on anxiety and depression in primary care: A cohort study in Ontario, Canada.

Context: Many people have experienced poorer mental health and increased distress during the COVID-19 pandemic. It is unclear to what extent this has resulted in increases in the number of patients presenting with anxiety and/or depression in primary care. Objective: To determine if there are more patients are visiting their family doctor for anxiety/depression during the COVID-19 pandemic compared to before the pandemic, and to determine whether these effects varied based on patient demographic characteristics. Study Design: A retrospective cohort study of family medicine patients from 2017-2020. Data Source: Electronic medical records (EMRs) from the University of Toronto Practice Based-Research Network (UTOPIAN) Data Safe Haven. The majority of physicians in the UTOPIAN EMR database practice in the Greater Toronto Area, a high-COVID region of Canada. Population Studied: Active family practice patients aged 10 and older with at least 1 year of EMR data. Outcome Measures: Visits for anxiety and/or depression; prescriptions for antidepressant medications. Results: Changes in visits for anxiety and depression during the COVID-19 pandemic were consistent with an increased demand for mental healthcare and an increase in the number of individuals with anxiety and depression. Increases in visits for anxiety and depression were larger for younger patients, women, and later in the pandemic. Among younger patients, prescriptions for antidepressants were substantially reduced during the first few months of the pandemic (April-May 2020) but incidences rates increased later in 2020. Increases in visit volume during the pandemic were consist with more frequent visits for anxiety/depression and more new patients presenting with anxiety or depression. Conclusion: The COVID-19 pandemic has resulted in an increased demand for mental health services from family physicians. Increases in anxiety and depression were especially pronounced among younger female patients and increased throughout the pandemic. Our findings highlight the need for continued efforts to support and addresses mental health concerns in primary care.

Effects of COVID-19 pandemic on anxiety and depression in primary care: A retrospective cohort study.

BACKGROUND: Population-based surveys indicate that many people experienced increased psychological distress during the COVID-19 pandemic. We aimed to determine if there was a corresponding increase in patients receiving services for anxiety and depression from their family physicians. METHODS: Electronic medical records from the University of Toronto Practice Based-Research Network (UTOPIAN; N = 322,920 patients) were used to calculate incidence rates for anxiety/depression related visits and antidepressant prescriptions before the COVID-19 pandemic (January 2018-February 2020) and during the COVID-19 pandemic (March-December 2020). Data from the pre-pandemic period were used to predict expected rates during the pandemic period which was compared to the observed rate. RESULTS: The number of patients presenting with anxiety/depression symptoms in primary care varied across age groups, sex, and time since pandemic onset. Among the youngest patients (ages 10-18 years), there were fewer patients than pre-pandemic visiting for new episodes of anxiety/depression and being prescribed antidepressants in April 2020, but by the end of 2020 this trend had reversed such that incidence rates for anxiety/depression related visits were higher than pre-pandemic levels. Among older adults, incidence rates of anxiety/depression related visits increased in April 2020 with the onset of the pandemic, and remained higher than expected throughout 2020. LIMITATIONS: A convenience sample of 362 family physicians in Ontario was used. CONCLUSION: Demand for mental health services from family physicians varied by patient age and sex and changed with the onset of the COVID-19 pandemic. By the end of 2020, more patients were seeking treatment for anxiety/depression related concerns.

The effects of Pilates on health-related outcomes in individuals with increased risk of fracture: a systematic review.

This systematic review examined the effect of Pilates on health-related outcomes in individuals with increased fracture risk to inform the 2021 Clinical Practice Guidelines for Management of Osteoporosis and Fracture Prevention in Canada. Seven electronic databases were searched to December 2020. Studies of Pilates in men and postmenopausal women aged ≥50 years with low bone mineral density (BMD), history of fragility fracture, or moderate-high risk of fragility fracture were included. Two reviewers independently screened studies and performed risk of bias assessment. Of 7286 records and 504 full-text articles, 5 studies were included, encompassing data from 143 participants (99% female). Data were insufficient for meta-analyses. There is low-certainty evidence that Pilates improved physical functioning and health-related quality of life. The effect of Pilates on falls and BMD is uncertain. No evidence was available for the effect of Pilates on mortality, fractures, or adverse events. Overall, Pilates may improve physical functioning and quality of life. Evidence of benefits relative to harms of Pilates in people with increased fracture risk, particularly males, is limited. PROSPERO registration: CRD42019122685. Novelty: Pilates may improve physical functioning and quality of life in women with osteoporosis. Evidence of the effect of Pilates on BMD, falls, fractures, or adverse events is limited.

Effect of yoga on health-related outcomes in people at risk of fractures: a systematic review.

We summarized the effects of yoga on health-related outcomes and adverse events in men and postmenopausal women ≥50 years-old at increased risk of fracture, to inform the updated Osteoporosis Canada clinical practice guidelines. Six databases were searched for observational studies, randomized controlled trials and case series. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation handbook. Nine studies were included and reported using narrative syntheses due to the limited available evidence. Overall, the available evidence was of very low certainty. There was no effect of yoga on health-related quality of life in randomized trials. Effects on other health-related outcomes were mixed or not available in the literature. Five studies reported no adverse events directly related to the study intervention, and 2 studies did not report whether adverse events occurred. However, 2 case series reported vertebral fractures related to yoga participation, possibly due to excessive spinal flexion. Due to the limited and very low certainty evidence, guideline developers will need to draw indirect evidence from yoga studies among middle aged or older adults that are not at fracture risk. PROSPERO: CRD42019124898. Novelty: Evidence in general was of very low certainty. Yoga had no effect on health-related quality of life in randomized trials. Evidence was mixed or unavailable for other outcomes. Case studies reported yoga poses involving spinal flexion coincided with incidents of vertebral compression fracture among older adults with increased fracture risk.

Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada.

PURPOSE: We aimed to determine the degree to which reasons for primary care visits changed during the COVID-19 pandemic. METHODS: We used data from the University of Toronto Practice Based Research Network (UTOPIAN) to compare the most common reasons for primary care visits before and after the onset of the COVID-19 pandemic, focusing on the number of visits and the number of patients seen for each of the 25 most common diagnostic codes. The proportion of visits involving virtual care was assessed as a secondary outcome. RESULTS: UTOPIAN family physicians (N = 379) conducted 702,093 visits, involving 264,942 patients between March 14 and December 31, 2019 (pre-pandemic period), and 667,612 visits, involving 218,335 patients between March 14 and December 31, 2020 (pandemic period). Anxiety was the most common reason for visit, accounting for 9.2% of the total visit volume during the pandemic compared to 6.5% the year before. Diabetes and hypertension remained among the top 5 reasons for visit during the pandemic, but there were 23.7% and 26.2% fewer visits and 19.5% and 28.8% fewer individual patients accessing care for diabetes and hypertension, respectively. Preventive care visits were substantially reduced, with 89.0% fewer periodic health exams and 16.2% fewer well-baby visits. During the pandemic, virtual care became the dominant care format (77.5% virtual visits). Visits for anxiety and depression were the most common reasons for a virtual visit (90.6% virtual visits). CONCLUSION: The decrease in primary care visit volumes during the COVID-19 pandemic varied based on the reason for the visit, with increases in visits for anxiety and decreases for preventive care and visits for chronic diseases. Implications of increased demands for mental health services and gaps in preventive care and chronic disease management may require focused efforts in primary care.

Changes in family medicine visits across sociodemographic groups after the onset of the COVID-19 pandemic in Ontario: a retrospective cohort study.

BACKGROUND: It has been suggested that the COVID-19 pandemic has worsened socioeconomic disparities in access to primary care. Given these concerns, we investigated whether the pandemic affected visits to family physicians differently across sociodemographic groups. METHODS: We conducted a retrospective cohort study using electronic medical records from family physician practices within the University of Toronto Practice-Based Research Network. We evaluated primary care visits for a fixed cohort of patients who were active within the database as of Jan. 1, 2019, to estimate the number of patients who visited their family physician (visitor rate) and the number of distinct visits (visit volume) between Jan. 1, 2019, to June 30, 2020. We compared trends in visitor rate and visit volume during the pandemic (Mar. 14 to June 30, 2020) with the same period in the previous year (Mar. 14 to June 30, 2019) across sociodemographic factors, including age, sex, neighbourhood income, material deprivation and ethnic concentration. RESULTS: We included 365 family physicians and 372 272 patients. Compared with the previous year, visitor rates during the pandemic period dropped by 34.5%, from 357 visitors per 1000 people to 292 visitors per 1000 people. Declines in visit volume during the pandemic were less pronounced (21.8% fewer visits), as the mean number of visits per patient increased during the pandemic (from 1.64 to 1.96). The declines in visitor rate and visit volume varied based on patient age and sex, but not socioeconomic status. INTERPRETATION: Although the number of visits to family physicians dropped substantially during the first few weeks of the COVID-19 pandemic in Ontario, patients from communities with low socioeconomic status did not appear to be disproportionately affected. In this primary care setting, the pandemic appears not to have worsened socioeconomic disparities in access to care.

The Effect of Impact Exercise (Alone or Multicomponent Intervention) on Health-Related Outcomes in Individuals at Risk of Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Exercise is commonly recommended to prevent and manage osteoporosis. High magnitude strains at rapid rate and short bouts should theoretically elicit an osteogenic response; however, the effects of different levels of impact exercises on several outcomes in people at risk of fracture are still unknown. OBJECTIVE: To report the effect of impact exercise on falls, fractures, adverse events, mortality, bone mineral density (BMD), physical functioning, and health-related quality of life (QoL). METHODS: We included randomized controlled trials testing the effect of impact exercise compared with a non-exercise control on outcomes in adults ≥ 50 years with low BMD or fragility fractures. Two reviewers selected studies and extracted data. Where possible, we pooled outcomes using mean difference (MD) with a fixed-effects model and 95% confidence interval (CI). We reported risk of bias using Cochrane and certainty of evidence using GRADE. RESULTS: We included 29 trials; 19 studies evaluated impact exercise alone, and the remaining trials combined impact with resistance or balance training. Impact exercise alone or combined with resistance training improved Timed Up-and-Go values (MD - 0.95 s, 95% CI - 1.09 to - 0.81, low certainty evidence) and lumbar spine (MD 0.04 g/cm2, 95% CI 0.02-0.06, low certainty evidence) and femoral neck BMD (MD 0.04 g/cm2, 95% CI 0.02-0.07, low certainty evidence). Impact exercise did not improve health-related QoL assessed with QUALEFFO-41 (MD 0.06, 95% CI - 2.18 to 2.30, moderate certainty evidence). The effects of impact exercise on falls, fractures, and mortality are uncertain due to insufficient data. Many trials had a high risk of bias for two or more items. CONCLUSIONS: There is low certainty evidence that impact exercise may improve physical function and BMD in people at risk of fracture. The effect of impact exercises on falls, fractures, and mortality remains unclear. Our findings should be interpreted with caution due to risk of bias and small sample sizes. TRIAL REGISTRATION: Registered in Prospero (CRD42018115579) on January 30, 2019.

The Effects of Walking or Nordic Walking in Adults 50 Years and Older at Elevated Risk of Fractures: A Systematic Review and Meta-Analysis.

Walking is a common activity among older adults. However, the effects of walking on health-related outcomes in people with low bone mineral density (BMD) are unknown. The authors included randomized controlled trials comparing walking to control in individuals aged ≥50 years with low BMD and at risk of fractures. The authors identified 13 randomized controlled trials: nine multicomponent interventions including walking, one that was walking only, and three Nordic walking trials. Most studies had a high risk of bias. Nordic walking may improve the Timed Up-and-Go values (1.39 s, 95% CI [1.00, 1.78], very low certainty). Multicomponent interventions including walking improved the 6-min walk test (39.37 m, 95% CI [21.83, 56.91], very low certainty) and lumbar spine BMD (0.01 g/cm2, 95% CI [0.00, 0.03], low certainty evidence). The effects on quality of life or femoral neck BMD were not significant. There were insufficient data on fractures, falls, or mortality. Nordic walking may improve physical functioning. The effects on other outcomes are less certain; one may need to combine walking with other exercises to be of benefit.

Ethnic and Immigrant Variations in the Time Trends of Dementia and Parkinsonism.

OBJECTIVE: We assessed long-term incidence and prevalence trends of dementia and parkinsonism across major ethnic and immigrant groups in Ontario. METHODS: Linking administrative databases, we established two cohorts (dementia 2001-2014 and parkinsonism 2001-2015) of all residents aged 20 to 100 years with incident diagnosis of dementia (N = 387,937) or parkinsonism (N = 59,617). We calculated age- and sex-standardized incidence and prevalence of dementia and parkinsonism by immigrant status and ethnic groups (Chinese, South Asian, and the General Population). We assessed incidence and prevalence trends using Poisson regression and Cochran-Armitage trend tests. RESULTS: Across selected ethnic groups, dementia incidence and prevalence were higher in long-term residents than recent or longer-term immigrants from 2001 to 2014. During this period, age- and sex-standardized incidence of dementia in Chinese, South Asian, and the General Population increased, respectively, among longer-term immigrants (by 41%, 58%, and 42%) and long-term residents (28%, 7%, and 4%), and to a lesser degree among recent immigrants. The small number of cases precluded us from assessing parkinsonism incidence trends. For Chinese, South Asian, and the General Population, respectively, prevalence of dementia and parkinsonism modestly increased over time among recent immigrants but significantly increased among longer-term immigrants (dementia: 134%, 217%, and 117%; parkinsonism: 55%, 54%, and 43%) and long-term residents (dementia: 97%, 132%, and 71%; parkinsonism: 18%, 30%, and 29%). Adjustment for pre-existing conditions did not appear to explain incidence trends, except for stroke and coronary artery disease as potential drivers of dementia incidence. CONCLUSION: Recent immigrants across major ethnic groups in Ontario had considerably lower rates of dementia and parkinsonism than long-term residents, but this difference diminished with longer-term immigrants.

Progressive Resistance Training for Improving Health-Related Outcomes in People at Risk of Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Osteoporosis clinical practice guidelines recommend exercise to prevent fractures, but the efficacy of exercise depends on the exercise types, population studied, or outcomes of interest. The purpose of this systematic review was to assess the effects of progressive resistance training (PRT) on health-related outcomes in people at risk of fracture. METHODS: Multiple databases were searched in October 2019. Eligible articles were randomized controlled trials of PRT interventions in men and women ≥50 years with low bone mineral density (BMD) or fracture history. Descriptive information and mean difference (MD) and SD were directly extracted for included trials. A total of 53 studies were included. RESULTS: The effects of PRT on the total number of falls (incidence rate ratio [IRR] = 1.05; 95% CI = 0.91 - 1.21; 7 studies) and on the risk of falling (risk ratio [RR] = 1.23; 95% CI = 1.00 - 1.51; 5 studies) are uncertain. PRT improved performance on the Timed "Up and Go" test (MD = -0.89 seconds; 95% CI = -1.01 to -0.78; 13 studies) and health-related quality of life (standardized MD = 0.32; 95% CI = 0.22-0.42; 20 studies). PRT may increase femoral neck (MD = 0.02 g/cm2; 95% CI = 0.01-0.03; 521 participants, 5 studies) but not lumbar spine BMD (MD = 0.02 g/cm2; 95% CI = -0.01-0.05; 4 studies), whereas the effects on total hip BMD are uncertain (MD = 0.00 g/cm2; 95% CI = 0.00-0.01; 435 participants, 4 studies). PRT reduced pain (standardized MD = -0.26; 95% CI = -0.37 to -0.16; 17 studies). Sensitivity analyses, including PRT-only studies, confirmed these findings. CONCLUSION: Individuals at risk of fractures should be encouraged to perform PRT, as it may improve femoral neck BMD, health-related quality of life, and physical functioning. PRT also reduced pain; however, whether PRT increases or decreases the risk of falls, the number of people experiencing a fall, or the risk of fall-related injuries is uncertain. IMPACT: Individuals at risk of fractures should be encouraged to perform PRT, as it may have positive effects on femoral neck BMD, health-related quality of life, physical functioning, and pain, and adverse events are rare. LAY SUMMARY: Exercise is recommended for people at risk of osteoporotic fractures. Our study showed that progressive resistance training improves physical functioning, quality of life, and reduces pain. The effects of progressive resistance training on the risk of falling are unclear. Adverse events are rare, and often minor (eg, soreness, pain, musculoskeletal injury). Considering the benefits and safety, people at risk of fractures should engage in progressive resistance training interventions.

A patient-oriented approach to the development of a primary care physical activity screen for embedding into electronic medical records.

Physical activity questionnaires exist, but effective implementation in primary care remains an issue. We sought to develop a physical activity screen (PAS) for electronic medical record (EMR) integration by 1) identifying healthcare professionals' (HCPs), patients' and stakeholders' barriers to and preferences for physical activity counselling in primary care; and 2) using the information to co-create the PAS. We conducted semi-structured interviews with primary care HCPs, patients and stakeholders, and used content and thematic analyses to inform iterative co-design of the PAS. Interviews with 38 participants (mean age 41 years) resulted in 2 themes: 1) HCPs are willing to conduct physical activity screening, but acknowledge they don't do it well; and 2) HCPs have limited opportunity and capacity to discuss physical activity, and need a streamlined process for EMR that goes beyond quantifying physical activity. HCPs, patients and stakeholders co-designed a physical activity screen for integration into the EMR that can be tested for feasibility and effects on HCP behaviour and patients' physical activity levels. Novelty: EMR-integration of physical activity screening needs to go beyond just asking about physical activity minutes. Primary care professionals have variable knowledge and time, and need physical activity counselling prompts and resources. We co-developed a physical activity EMR tool with patients and primary care providers.

Patient- and Physician-Level Factors Associated With Adherence to C-CHANGE Recommendations in Primary Care Settings in Ontario.

BACKGROUND: We previously found large variation among family physicians in adherence to the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). We assessed the role of patient- and physician-level factors in the variation in adherence to recommendations for managing cardiovascular disease risk factors. METHODS: We conducted a retrospective study using multilevel logistic regression analyses with the Electronic Medical Record Administrative data Linked Database (EMRALD) housed at ICES in Ontario. Five quality indicators based on C-CHANGE guidelines were modelled. Effects of clustering and between-group variation, patient-level (sociodemographics, comorbidities) and physician-level characteristics (demographic and practice information) were assessed to determine odds ratios of receiving C-CHANGE recommended care. RESULTS: In all, 324 Ontario physicians practicing in 41 clinics who provided care to 227,999 adult patients were studied. We found significant variation in quality indicators, with 15% to 39% of the total variation attributable to nonpatient factors. The largest variation was in performing 2-hour plasma glucose testing in prediabetic patients. Patient-level factors most frequently associated with recommendation adherence included sex, age, and multi-comorbidities. Women were more likely than men to have their body mass index measured, and their blood pressure controlled, but less likely to receive antiplatelet medications and liver-enzyme testing if overweight or obese. CONCLUSIONS: The majority of variations in adherence were attributable to patient attributes, but a substantial proportion of unexplained variation was due to differences among physicians and clinics. This finding may signal suboptimal processes or structures and warrant further investigation to improve the quality of primary care management of cardiovascular disease in Ontario.

CONTEXTE: Nous avions déjà constaté que l'observance des recommandations canadiennes en matière de prévention et de gestion des maladies cardiovasculaires de l'initiative C-CHANGE ( C anadian C ardiovascular H armonization of N ational G uidelines E ndeavour) varie beaucoup d'un médecin de famille à l'autre. Nous avons évalué l'effet de caractéristiques des patients et des médecins sur l'observance de ces recommandations pour la gestion des facteurs de risque de maladies cardiovasculaires. MÉTHODOLOGIE: Nous avons mené une étude rétrospective reposant sur des analyses de régression logistique multiniveaux au sein de la base de données liée aux dossiers médicaux électroniques EMRALD ( E lectronic M edical R ecord A dministrative data L inked D atabase) qui se trouve à l'ICES, en Ontario. Nous avons modélisé cinq indicateurs de la qualité en nous basant sur les recommandations de l'initiative C-CHANGE. Nous avons évalué les effets de regroupement, de la variation entre les groupes, des caractéristiques des patients (données sociodémographiques, maladies concomitantes), des caractéristiques des médecins (données démographiques et renseignements sur la pratique) afin de déterminer les risques relatifs approchés associés aux soins conformes aux recommandations de l'initiative C-CHANGE. RÉSULTATS: L'étude a porté sur un total de 324 médecins ontariens pratiquant dans 41 cliniques et ayant prodigué des soins à 227 999 adultes. Nous avons observé une variation significative entre les indicateurs de qualité, et de 15 % à 39 % de la variation totale était attribuable aux caractéristiques non reliées aux patients. La variation la plus importante concernait le test d'hyperglycémie provoquée (2 heures) chez les patients prédiabétiques. Les caractéristiques des patients qui étaient le plus souvent associées à l'observance des recommandations étaient le sexe, l'âge et la présence de multiples maladies concomitantes. L'indice de masse corporelle et la pression artérielle étaient plus souvent mesurés chez les femmes que chez les hommes, mais les femmes étaient moins susceptibles de recevoir un traitement antiplaquettaire ou de subir une analyse des enzymes hépatiques si elles étaient en surpoids ou obèses. CONCLUSIONS: La plus grande partie des variations dans l'observance des recommandations était liée aux caractéristiques des patients, mais une proportion importante de variations injustifiées était associée aux différences entre les médecins et entre les cliniques. Ces observations pourraient indiquer la présence de processus ou de structures sous-optimales et méritent une analyse approfondie qui permettra d'améliorer la qualité de la prise en charge des maladies cardiovasculaires par les médecins de soins primaires en Ontario.