Prescription Medication Use in Pregnancy in People with Disabilities: A Population-Based Cohort Study.

Background: Individuals with disabilities may require specific medications in pregnancy. The prevalence and patterns of medication use, overall and for medications with known teratogenic risks, are largely unknown. Methods: This population-based cohort study in Ontario, Canada, 2004-2021, comprised all recognized pregnancies among individuals eligible for public drug plan coverage. Included were those with a physical (n = 44,136), sensory (n = 13,633), intellectual or developmental (n = 2,446) disability, or multiple disabilities (n = 5,064), compared with those without a disability (n = 299,944). Prescription medication use in pregnancy, overall and by type, was described. Modified Poisson regression generated relative risks (aRR) for the use of medications with known teratogenic risks and use of ≥2 and ≥5 medications concurrently in pregnancy, comparing those with versus without a disability, adjusting for sociodemographic and clinical factors. Results: Medication use in pregnancy was more common in people with intellectual or developmental (82.1%), multiple (80.4%), physical (73.9%), and sensory (71.9%) disabilities, than in those with no known disability (67.4%). Compared with those without a disability (5.7%), teratogenic medication use in pregnancy was especially higher in people with multiple disabilities (14.2%; aRR 2.03, 95% confidence interval [CI]: 1.88-2.20). Furthermore, compared with people without a disability (3.2%), the use of ≥5 medications concurrently was more common in those with multiple disabilities (13.4%; aRR 2.21, 95% CI: 2.02-2.41) and an intellectual or developmental disability (9.3%; aRR 2.13, 95% CI: 1.86-2.45). Interpretation: Among people with disabilities, medication use in pregnancy is prevalent, especially for potentially teratogenic medications and polypharmacy, highlighting the need for preconception counseling/monitoring to reduce medication-related harm in pregnancy.

Prenatal opioid exposure and well-child care in the first 2 years of life: population-based cohort study.

OBJECTIVES: To quantify well-child visits by age 2 years and developmental screening at the 18-month enhanced well-child visit among children with prenatal opioid exposure (POE) and to identify factors associated with study outcomes. DESIGN: Population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: 22 276 children with POE born 2014-2018 were classified as (1) 1-29 days of prescribed opioid analgesia, (2) 30+ days of prescribed opioid analgesia, (3) medication for opioid use disorder (MOUD), (4) MOUD and opioid analgesia, or (5) unregulated opioids. MAIN OUTCOME MEASURES: Attending ≥5 well-child visits by age 2 years and the 18-month enhanced well-child visit. Modified Poisson regression was used to examine factors associated with outcomes. RESULTS: Children with POE to 1-29 days of analgesics were most likely to attend ≥5 well-child visits (61.2%). Compared with these children, adjusted relative risks (aRRs) for ≥5 well-child visits were lower among those exposed to 30+ days of opioid analgesics (0.95, 95% CI 0.91 to 0.99), MOUD (0.83, 95% CI 0.79 to 0.88), MOUD and opioid analgesics (0.78 95% CI 0.68 to 0.90) and unregulated opioids (0.89, 95% CI 0.83 to 0.95). Relative to children with POE to 1-29 days of analgesics (58.5%), respective aRRs for the 18-month enhanced well-child visit were 0.92 (95% CI 0.88 to 0.96), 0.76 (95% CI 0.72 to 0.81), 0.76 (95% CI 0.66 to 0.87) and 0.82 (95% CI 0.76 to 0.88). Having a regular primary care provider was positively associated with study outcomes; socioeconomic disadvantage, rurality and maternal mental health were negatively associated. CONCLUSION: Well-child visits are low in children following POE, especially among offspring of mothers receiving MOUD or unregulated opioids. Strategies to improve attendance will be important for child outcomes.

Safety of prenatal opioid analgesics: Do results differ between public health insurance beneficiary and population-based cohorts?

BACKGROUND: Pregnant patients with particular types of health insurance may have distinct demographic and medical characteristics that have a biologic effect on associations between opioid analgesics and congenital anomalies (CA). METHODS: We followed 199,884 pregnant prescription beneficiaries in Ontario, Canada (1996-2018). Opioid analgesics dispensed in the first trimester and CA were identified from universal-access administrative health records. We estimated propensity score adjusted risk ratios (RR) between first trimester exposure and CA (any, major, minor, specific). RRs were compared to those published from an Ontario population-based cohort (N = 599,579, 2013-2018). RESULTS: 15,724 (7.9%) were exposed to first trimester opioid analgesics, mainly codeine (58.1%) or oxycodone (21.3%); CA prevalence in exposed was 3.1%. RRs in the beneficiary cohort appeared higher than the population-based cohort for any CA with hydromorphone (RR = 2.34, 95% CI: 1.65, 3.30) and oxycodone (RR = 1.73, 95% CI: 1.46, 2.05) and major CA with hydromorphone (RR = 2.74, 95% CI: 1.91, 3.94) and oxycodone (RR = 1.72, 95% CI: 1.42, 2.08). Other RRs that appeared higher in the beneficiary cohort included cardiovascular (codeine, oxycodone), gastrointestinal (oxycodone), musculoskeletal (any, hydromorphone, oxycodone), CNS (oxycodone), chromosomal (codeine), and neoplasm and tumor (oxycodone) anomalies. The beneficiary cohort had higher opioid doses, was younger, had lower socioeconomic status, and greater comorbidities. CONCLUSIONS: Increased risks of CA after first trimester opioid analgesics were observed in low-income prescription beneficiaries, and some estimates were higher than a population-based cohort from the same setting. Biological differences associated with younger age, lower socioeconomic status and greater comorbidity may affect generalizability of results from pregnant low-income beneficiaries.

Categorization of Opioid Use Among Pregnant People and Association With Overdose or Death.

Importance: Early identification of people who use opioids in pregnancy may improve health outcomes for pregnant people and infants. However, characterization of diverse circumstances surrounding type of opioid use and indications for opioid use are lacking. Objective: To develop clinically distinct groups of people who use opioids in pregnancy and to evaluate their association with drug overdose or death up to 1 year post partum. Design, Setting, and Participants: This is a population-based, repeated cross-sectional study conducted in Ontario, Canada, with participants who used opioids in pregnancy who had a live birth or stillbirth between January 1, 2014, and December 31, 2019, identified in health administrative databases. Data were analyzed from August 2020 to January 2021. Exposures: Prenatal opioid use. Main Outcomes and Measures: Latent class analysis (LCA), based on prenatal opioid use and 19 socioeconomic and medical characteristics, first identified clinically distinct groups of opioid users. Then, within the optimally derived LCA-derived group, adjusted relative risks (aRRs) were generated for the outcome of drug overdose or all-cause death within 1 year post partum, adjusting for birthing parent age and year of delivery. Results: The analysis included 31 241 people with prenatal opioid use (mean [SD] age, 30.0 [5.6] years; 86.1% [26 908 individuals] Canadian-born; 30.6% [9574 individuals] lived in low-income neighborhoods). LCA generated a 5-group model that optimally distinguished opioid users in pregnancy as follows: short-term analgesia with low comorbidity (group 1), analgesia in young people (group 2), medication for opioid use disorder or unregulated opioid use (group 3), pain management with comorbidity (group 4), and mixed opioid use plus high social and medical needs (group 5). The overall risk of postpartum drug overdose or death was 1.5%. Using the 5-group model, compared with people in group 1, the aRR of overdose or death was highest among those in group 5 (aRR, 14.0; 95% CI, 10.1-19.5), followed by group 3 (aRR, 4.6; 95% CI, 3.3-6.5), group 2 (aRR, 3.3; 95% CI, 2.2-4.7), and group 4 (aRR, 3.2; 95% CI, 2.3-4.4). Conclusions and Relevance: In this cross-sectional study, distinct groups of people with opioid use in pregnancy were associated with increasing degrees of risk of postpartum drug overdose or death. Group characteristics can be used to identify people with high risk and inform harm reduction, home visiting programs, and other interventions.

Prescribed opioid analgesics in early pregnancy and the risk of congenital anomalies: a population-based cohort study.

BACKGROUND: Recent data suggest an increased risk of congenital anomalies with prenatal exposure to opioid analgesics. We sought to further quantify the risk of anomalies after opioid analgesic exposure during the first trimester in a population-based cohort study. METHODS: Using administrative health data from Ontario, we followed 599 579 gestational parent-infant pairs from singleton pregnancies without opioid use disorder. We identified opioid analgesics dispensed in the first trimester and congenital anomalies diagnosed during the first year of life. We estimated propensity score-adjusted risk ratios (RRs) between first trimester exposure (any opioid analgesic and specific agents) and congenital anomalies (any anomaly, organ system anomalies, major or minor anomalies and specific anomalies). RESULTS: The prevalence of congenital anomalies was 2.8% in exposed infants and 2.0% in unexposed infants. Relative to unexposed infants, we observed elevated risks among those who were exposed for some anomaly groups, including gastrointestinal anomalies (any opioid analgesic: adjusted RR 1.46, 95% confidence interval [CI] 1.15-1.85; codeine: adjusted RR 1.53, 95% CI 1.12-2.09; tramadol: adjusted RR 2.69, 95% CI 1.34-5.38) and several specific anomalies, including ankyloglossia (any opioid: adjusted RR 1.88, 95% CI 1.30-2.72; codeine: adjusted RR 2.14, 95% CI 1.35-3.40). These findings persisted in sensitivity analyses. INTERPRETATION: Although the absolute risk of congenital anomalies was low, our findings add to accumulating data that suggest a small increased risk of some organ system anomalies and specific anomalies with first trimester exposure to opioid analgesics. These findings further quantify the potential risks associated with prenatal exposure to opioid analgesics to inform treatment choices for pain in pregnancy.

Reviewing the Evidence on Prenatal Opioid Exposure to Inform Child Development Policy and Practice.

Prenatal opioid use is increasingly common and can have adverse impacts on maternal and child health. In Ontario, there are no clear guidelines or universal programs to support the healthy development of children with prenatal opioid exposure. We present the epidemiology of prenatal opioid exposure in Ontario, summarize research examining child health outcomes with a focus on child development, review emerging guidelines for child health and developmental surveillance and highlight promising programs. We emphasize the need to strengthen current Canadian recommendations for routine enhanced developmental and vision screening and ensure funding for evidence-based integrated maternal/child services.

Prenatal Opioid Analgesics and the Risk of Adverse Birth Outcomes.

BACKGROUND: It is unclear whether confounding accounts for the increased risk of preterm birth and small for gestational age (SGA) birth in opioid analgesic exposed pregnancies. METHODS: Using universal coverage health data for Ontario, we assembled a cohort of mother-infant pairs without opioid use disorder (627,172 pregnancies and 509,522 women). We estimated risk ratios (RRs) between opioid analgesics and preterm birth, SGA birth, and stillbirth; neonatal abstinence syndrome was a secondary outcome. We used high-dimensional propensity scores and sensitivity analyses for confounding adjustment. RESULTS: 4% of pairs were exposed, mainly to codeine (2%), morphine (1%), and oxycodone (1%). Compared with unexposed, the adjusted risk of preterm birth was higher with any (1.3, 95% confidence interval [CI] = 1.2, 1.3), first- (RR: 1.2, 95% CI = 1.2, 1.3), and second-trimester (RR: 1.3, 95% CI = 1.2, 1.4) opioid analgesic exposure. Preterm birth risk was higher for first- and second-trimester codeine, morphine, and oxycodone exposure, and for third-trimester morphine. There was a small increase in SGA with first-trimester exposure to any opioid analgesic or to codeine. Exposed pregnancies had an elevated stillbirth risk with any (RR: 1.6, 95% CI = 1.4, 1.8), first- and second-trimester exposure. Few infants had neonatal abstinence syndrome (N = 143); the risk was higher in exposed (RR: 3.6, 95% CI = 2.1, 6.0). In sensitivity analyses of unmeasured confounding, an elevated risk in exposed pregnancies persisted for preterm birth but not SGA. CONCLUSIONS: Opioid analgesic-exposed pregnancies had a small increased risk of preterm birth and possibly stillbirth after accounting for confounding by indication and sociodemographic factors.

Identification of Prenatal Opioid Exposure Within Health Administrative Databases.

BACKGROUND: Health administrative data offer a vital source of data on maternal prenatal opioid exposure (POE). The impact of different methods to estimate POE, especially combining maternal and newborn records, is not known. METHODS: This population-based cross-sectional study included 454 746 hospital births with linked administrative data in Ontario, Canada, in 2014-2017. POE ascertainment included 3 sources: (1) prenatal opioid prescriptions, (2) maternal opioid-related hospital records, and (3) newborn hospital records with neonatal abstinence syndrome (NAS). Positive percent agreement was calculated comparing cases identified by source, and a comprehensive method was developed combining all 3 sources. We replicated common definitions of POE and NAS from existing literature and compared both number of cases ascertained and maternal socio-demographics and medical history using the comprehensive method. RESULTS: Using all 3 data sources, there were 9624 cases with POE (21.2 per 1000 births). Among these, positive percent agreement (95% confidence interval) was 79.0% (78.2-79.8) for prenatal opioid prescriptions, 19.0% (18.2-19.8) for maternal opioid-related hospital records, and 44.7% (43.7-45.7) for newborn NAS. Compared with other definitions, our comprehensive method identified up to 523% additional cases. Contrasting ascertainment with maternal opioid-related hospital records, newborn NAS, and prenatal opioid prescriptions respective rates of maternal low income were 57%, 48%, and 39%; mental health hospitalization history was 33%, 28%, and 17%; and infant discharge to social services was 8%, 13%, and 5%. CONCLUSIONS: Combining prenatal opioid prescriptions and maternal and newborn opioid-related hospital codes improves identification of a broader population of mothers and infants with POE.

Evaluating the impact of implementing public bicycle share programs on cycling: the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS).

BACKGROUND: Despite rapid expansion of public bicycle share programs (PBSP), there are limited evaluations of the population-level impacts of these programs on cycling, leaving uncertainty as to whether these programs lead to net health gains at a population level or attract those that already cycle and are sufficiently physically active. Our objective was to determine whether the implementation of PBSPs increased population-level cycling in cities across the US and Canada. METHODS: We conducted repeat cross-sectional surveys with 23,901 residents in cities with newly implemented PBSPs (Chicago, New York), existing PBSPs (Boston, Montreal, Toronto) and no PBSPs (Detroit, Philadelphia, Vancouver) at three time points (Fall 2012, 2013, 2014). We used a triple difference in differences analysis to assess whether there were increases in cycling over time amongst those living in closer proximity (< 500 m) to bicycle share docking stations in cities with newly implemented and existing PBSPs, relative to those in cities with no PBSPs. RESULTS: Living in closer proximity to bicycle share predicted increases in cycling over time for those living in cities with newly implemented PBSPs at 2-year follow-up. No change was seen over time for those living in closer proximity to bicycle share in cities with existing PBSPs relative to those in cities with no PBSP. CONCLUSION: These findings indicate that PBSPs are associated with increases in population-level cycling for those who live near to a docking station in the second year of program implementation.

A Census of Midsize to Large Supermarkets in Toronto: A Cross-Sectional Analysis of the Consumer Nutrition Environment.

OBJECTIVE: Assess the consumer nutrition environment in midsize to large supermarkets by supermarket type and area-level socioeconomic variables. DESIGN: Cross-sectional census of 257 supermarkets using the Toronto Nutrition Environment Measures Survey in Stores. SETTING: Toronto, Canada. VARIABLES MEASURED: Availability; price and linear shelf space of fruits and vegetables vs energy-dense snack foods by supermarket type; after-tax, low-income measure; and neighborhood improvement area. ANALYSIS: Multivariate linear regression. RESULTS: There was a high availability of fruits (7.7 of 8) and vegetables (9.5 of 11). There was similar linear shelf space for fruits and vegetables vs energy-dense snack foods (ratio, 1.1 m). Adjusted fruit prices were lowest in quintiles 1 (ß = -$1.30; P = .008), 2 (ß = -$1.41; P = .005), and 3 (ß = -$1.89; P < .001) vs quintile 5 (lowest percentage of people living with low income) and in ethnic (ß = -$3.47; P < .001) and discount stores (ß = -$5.64; P < .001) vs conventional. Adjusted vegetable prices were lowest in quintiles 2 (ß = -$1.87; P = .04), 3 (ß = -$1.78; P = .03), and 4 (ß = -$2.65; P = .001) vs quintile 5 and in ethnic (ß = -$7.10; P < .001) and discount (ß = -$5.49; P < .001) stores. They were highest in other (ß = + $3.08; P = .003) vs conventional stores. Adjusted soda and chips prices were lower in discount (ß = -$1.16; P < .001) and higher in other stores (ß = + $0.67; P < .001) vs conventional. CONCLUSIONS AND IMPLICATIONS: Findings do not indicate inequities in shelf space, availability, or price across diverse neighborhoods. Practitioners can use findings to help consumers navigate supermarkets to make healthy choices.

Evaluating the impact of environmental interventions across 2 countries: the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS) Study protocol.

BACKGROUND: Few international studies examine public bicycle share programs (PBSP) health impacts. We describe the protocol for the International Bikeshare Impacts on Cycling and Collisions Study (IBICCS). METHODS: A quasi-experimental non-equivalent groups design was used. Intervention cities (Montreal, Toronto, Boston, New York and Vancouver) were matched to control cities (Chicago, Detroit, and Philadelphia) on total population, population density, cycling rates, and average yearly temperature. The study used three repeated, cross-sectional surveys in intervention and control cities in Fall 2012 (baseline), 2013 (year 1), and 2014 (year 2). A non-probabilistic online panel survey with a sampling frame of individuals residing in and around areas where PBSP are/would be implemented was used. A total of 12,000 respondents will be sampled. In each of the 8 cities 1000 respondents will be sampled with an additional 4000 respondents sampled based on the total population of the city. Survey questions include measures of self-rated health, and self-reported height and weight, knowledge and experience using PBSP, physical activity, bicycle helmet use and history of collisions and injuries while cycling, socio-demographic questions, and home/workplace locations. Respondents could complete questionnaires in English, French, and Spanish. Two weights will be applied to the data: inverse probability of selection and post-stratification on age and sex.A triple difference analysis will be used. This approach includes in the models, time, exposure, and treatment group, and interaction terms between these variables to estimate changes across time, between exposure groups and between cities. DISCUSSION: There are scientific and practical challenges in evaluating PBSP. Methodological challenges included: appropriate sample recruitment, exchangeability of treatment and control groups, controlling unmeasured confounding, and specifying exposure. Practical challenges arise in the evaluation of environmental interventions such as a PBSP: one of the companies involved filed for bankruptcy, a Hurricane devastated New York City, and one PBSP was not implemented. Overall, this protocol provides methodological and practical guidance for researchers wanting to study PBSP impacts on health.

The impact of pedestrian countdown signals on pedestrian-motor vehicle collisions: a reanalysis of data from a quasi-experimental study.

OBJECTIVE: To perform a more sophisticated analysis of previously published data that advances the understanding of the efficacy of pedestrian countdown signal (PCS) installation on pedestrian-motor vehicle collisions (PMVCs), in the city of Toronto, Canada. METHODS: This is an updated analysis of the same dataset from Camden et al. A quasi-experimental design was used to evaluate the effect of PCS on PMVC. A Poisson regression analysis, using a one-group comparison of PMVC, pre-PCS installation to post-PCS installation was used, controlling for season and temporal effects. The outcome was the frequency of reported PMVC (January 2000-December 2009). Similar models were used to analyse specific types of collisions defined by age of pedestrian, injury severity, and pedestrian and vehicle action. Incidence rate ratios with 95% CI are presented. RESULTS: This analysis included 9262 PMVC, 2760 during or after PCS installation, at 1965 intersections. There was a 26% increase in the rate of collisions, pre to post-PCS installation (incidence rate ratio=1.26, 95% CI 1.11 to 1.42). CONCLUSIONS: The installation of PCS at 1965 signalised intersections in the city of Toronto resulted in an increase in PMVC rates post-PCS installation. PCSs may have an unintended consequence of increasing pedestrian-motor vehicle collisions in some settings.

Helmet use in BIXI cyclists in Toronto, Canada: an observational study.

OBJECTIVE: To investigate the use of helmets for cyclists choosing to use BIXI bikes in comparison to personal bike riders in the City of Toronto. DESIGN: Cross-sectional study design. SETTING: Cyclists were observed in Toronto, Canada. PARTICIPANTS: Of the 6732 sample size, 306 cyclists on BIXI bikes and 6426 personal bike riders were observed. OUTCOME MEASURE: The outcome of interest was helmet use. RESULTS: Overall, 50.3% of cyclists wore helmets. The proportion of BIXI bike riders using helmets was significantly lower than the proportion of helmet users on personal bikes (20.9% vs 51.7%, respectively, p<0.0001). CONCLUSIONS: Although the BIXI bike programme has provided an alternate means for Torontonians to use a bicycle, cyclists using BIXI bikes are much less likely to wear a helmet. Since the prevalence of helmet use in cyclists in general is already low, helmet use should be especially promoted in BIXI bike riders in order to promote a safe and healthy environment for cyclists.

Pedestrian crossing location influences injury severity in urban areas.

BACKGROUND: Pedestrian incidents represent an increasing proportion of serious injuries resulting from motor vehicle collisions in Canada. However, few studies have examined the effect of pedestrian crossing location in urban areas on injury severity. The objective of this study was to investigate the relationship between pedestrian-motor vehicle collision injury severity and crossing location. METHODS: This study was a population-based analysis of police-reported pedestrian collision data. The study group was pedestrian collisions from 1 January 2000 to 31 December 2009 in Toronto. Main outcome measures were a binary indicator of severe injury, and a four-level categorical variable of injury severity. The exposure variable was crossing at mid-block with no traffic control compared to signalised intersection. Analysis was via binary and multinomial logistic regression models to estimate ORs of injury severity with 95% CIs. RESULTS: The analysis included 9575 pedestrian-motor vehicle collisions, of which 7325 occurred at signalised intersections when crossing and 2230 occurred at uncontrolled mid-block locations when crossing without right of way. Uncontrolled mid-block collisions resulted in greater injury severity when controlling for road type. The odds of severe injury were 1.75 (95% CI 1.07 to 2.86) for children, 2.55 (95% CI 2.13 to 3.05) for adults and 1.68 (95% CI 1.23 to 2.28) for older adults. The odds of death at uncontrolled mid-block crossings were 4.97 (95% CI 3.11 to 7.94) in adults and 3.49 (95% CI 2.07 to 5.89) in older adults. CONCLUSIONS: Crossing at uncontrolled mid-block locations resulted in greater injury severity compared with crossing at signalised intersections. This has important implications for pedestrian behaviour and traffic environment design and emphasises the need for safe pedestrian crossings on urban roads.

The impact of pedestrian countdown signals on pedestrian-motor vehicle collisions: a quasi-experimental study.

OBJECTIVE: To determine whether pedestrian countdown signals (PCS) reduce pedestrian-motor vehicle collisions in the city of Toronto, Canada. METHODS: A quasi-experimental study design was used to evaluate the effect of PCS on the number of pedestrian-motor vehicle collisions in the city of Toronto, from January 2000 to December 2009. Each intersection acted as its own control. We compared the number of pedestrian-motor vehicle collisions per intersection-month before and after the intervention. Stratified models were used to evaluate effect modification by pedestrian age, injury severity and location (urban vs inner suburbs). Poisson regression analysis with repeated measures (generalised estimating equations) was used to estimate the RR and 95% CI. RESULTS: The analysis included 9262 pedestrian-motor vehicle collisions at 1965 intersections. The RR of collisions after PCS installation was 1.014 (95% CI 0.958 to 1.073), indicating no statistically significant effect of PCS on collisions. There was no evidence to suggest effect modification between PCS and collisions by age, injury severity or location. CONCLUSION: The installation of PCS at 1965 signalised intersections in Toronto did not reduce the number of pedestrian-motor vehicle collisions at these intersections.