Defining the Longitudinal Risk of CIN 3+ for

OBJECTIVE: To determine the baseline and cumulative risk of cervical intraepithelial neoplasia (CIN)3 and invasive cervical cancer in participants referred to colposcopy with high-grade cytology and

Are Women with Antecedent Low-Grade Cytology and <CIN2 Findings in Colposcopy Being Overmanaged?

OBJECTIVE: To determine the baseline and cumulative risks of cervical intraepithelial lesion grade 3 (CIN3) and invasive cervical cancer in patients with <CIN2 colposcopy findings after a low-grade screening cytology finding (atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion [LSIL]). METHODS: By linking administrative databases, including cytology, pathology, cancer registries, and physician billing history, a population-based cohort study was performed on participants with <CIN2 initial colposcopy results after a low-grade antecedent cytology finding, between January 2012 and December 2013. Three and 5-year risks of CIN3 and invasive cervical cancer were generated using Kaplan-Meier survival analysis. RESULTS: Among the 36 887 participants included in the study, CIN3 incidence based on referral cytology were as follows at 3 and 5 years, respectively: normal, 0.7% and 0.9%; ASCUS, 4.31% and 5.6%; and LSIL, 5.9% and 7.2%. Three- and 5-year incidence of invasive cancer were 0% and 0.02% for normal cytology, 0.08% and 0.11% for ASCUS, and 0.04% and 0.07% for LSIL, respectively. Stratifying risk by biopsy result at initial colposcopy, 3- and 5-year CIN3 incidences were 2.85% and 3.81% with a negative biopsy, 7.09% and 8.32% with an LSIL biopsy, and 4.11% and 5.2% when no biopsy was done, respectively. Three- and 5-year incidence of invasive cancer was 0% and 0.05% after a negative biopsy, 0% and 0% after LSIL biopsy, and 0.05% and 0.08% when no biopsy was done, respectively. CONCLUSION: When initial colposcopy is done after a low-grade screening cytology result and <CIN2 is identified, the risk of CIN3 and invasive cancer is low, particularly when biopsies indicate LSIL. Surveillance strategies should balance the likelihood of detecting CIN3 with the potential harms over management with too frequent screening or colposcopic interventions in low-risk patients.

Measuring the impact of the COVID-19 pandemic on organized cancer screening and diagnostic follow-up care in Ontario, Canada: A provincial, population-based study.

It is essential to quantify the impacts of the COVID-19 pandemic on cancer screening, including for vulnerable sub-populations, to inform the development of evidence-based, targeted pandemic recovery strategies. We undertook a population-based retrospective observational study in Ontario, Canada to assess the impact of the pandemic on organized cancer screening and diagnostic services, and assess whether patterns of cancer screening service use and diagnostic delay differ across population sub-groups during the pandemic. Provincial health databases were used to identify age-eligible individuals who participated in one or more of Ontario's breast, cervical, colorectal, and lung cancer screening programs from January 1, 2019-December 31, 2020. Ontario's screening programs delivered 951,000 (-41%) fewer screening tests in 2020 than in 2019 and volumes for most programs remained more than 20% below historical levels by the end of 2020. A smaller percentage of cervical screening participants were older (50-59 and 60-69 years) during the pandemic when compared with 2019. Individuals in the oldest age groups and in lower-income neighborhoods were significantly more likely to experience diagnostic delay following an abnormal breast, cervical, or colorectal cancer screening test during the pandemic, and individuals with a high probability of living on a First Nation reserve were significantly more likely to experience diagnostic delay following an abnormal fecal test. Ongoing monitoring and management of backlogs must continue. Further evaluation is required to identify populations for whom access to cancer screening and diagnostic care has been disproportionately impacted and quantify impacts of these service disruptions on cancer incidence, stage, and mortality. This information is critical to pandemic recovery efforts that are aimed at achieving equitable and timely access to cancer screening-related care.

Survival of Older Women With Cervical Cancer Based on Screening History.

OBJECTIVE: A population-level retrospective cohort study was conducted to determine the influence of cervical screening history on the survival from cervical cancer in women 50 years or older. METHODS: The study included women diagnosed with invasive cervical cancer in Ontario, Canada, between 2005 and 2012, who were followed for at least 4 years. Screening history was observed for the 5 years before diagnosis. Health care administrative databases were linked to determine demographic, affiliation with primary care physicians, stage (available 2010-2012), treatment, and survival data. Kaplan-Meier and multivariate analyses were carried out to evaluate the impact of cervical screening on overall survival (OS). RESULTS: There were eligible 1,422 women diagnosed with invasive cervical cancer between 2005 and 2012 of whom 566 had been screened within the 5 years before diagnosis. There were 856 women who did not undergo screening within the 5 years before diagnosis. Unscreened women were more likely to present with locally advanced disease (69.3%) compared with the screened women (42.9%). Four-year OS was significantly greater in the screened group (79.9% vs 58.2%). In our univariate analysis, screening was significantly related to survival (hazard ratio = 2.1, p < .01). In our multivariate analysis after adjusting for age, treatment, affiliation with a primary care physician, and income, screening was still significantly associated with improved survival (hazard ratio = 1.5, p < .01). CONCLUSIONS: Our results demonstrate a survival benefit to screening in women 50 years or older who are diagnosed with cervical cancer. Screening participation must be encouraged in women older than 50 years as rates decline in this age group.

Cervical Screening and Colposcopy Management of Women Age 24 and Under.

OBJECTIVES: In 2012, Ontario's cervical cancer screening program changed the age of initial screening from 18 years of age to 21 and identified women aged 21-24 years as a special population whose cervical squamous intraepithelial lesions should be managed conservatively. In order to provide insight into these changes, we sought to examine patient, provider, and clinical characteristics of cervical cancer screening and colposcopy care in women aged 12-24 years. METHODS: We conducted a retrospective population-based cohort study of all women in Ontario, aged 12-24 years, who underwent a Pap test between 2012 and 2014. Variables measured included, patient age, cytologic result of the index Pap test; colposcopy and definitive treatment within 1.5 years of the index Pap test; and carcinoma in situ (CIS) and invasive cervical cancer (ICC) 1.5 years after the index Pap test. Descriptive statistics were calculated for variables, and incidence rates per 100 000 women screened were calculated for CIS and ICC. RESULTS: A total of 270 391 index Pap tests were performed. The majority of patients were between 18 and 24 years of age (12-17 y: 5.5%; 18-20 y: 24.3%; 21-24 y: 70.1%). Overall, 87.0% of Pap tests were normal, 6.9% of women underwent subsequent colposcopy, and 1.1% received any treatment. Of women with a high-grade result, 86.6% (n = 1279) underwent colposcopy and 42.8% (n=632) received any treatment. Of women with a low-grade result, 42.3% (n = 13 856) underwent colposcopy, and 6.0% (n = 1955) had any treatment. Age-standardized rates of CIS and ICC in were 161.5 and 1.0 per 100 000 women, respectively. CONCLUSIONS: Despite the change in the screening guidelines, women under the age of 21 continue to be screened. This study highlights the low risk of ICC in women under age 25 and lays groundwork for re-examining screening guidelines for women in this age group. Furthermore, colposcopy referrals for women with a low-grade result on an index Pap test, and treatment of women under 24 years of age continue to be high. Future work must address the over-utilization of population-based screening, as well as factors related to adherence to screening guidelines.

Risk of Recurrence After Treatment for Cervical Intraepithelial Neoplasia 3 and Adenocarcinoma In Situ of the Cervix: Recurrence of CIN 3 and AIS of Cervix.

OBJECTIVES: The aim of the study was to evaluate recurrence risk of cervical intraepithelial neoplasia (CIN) 3+ and adenocarcinoma in situ (AIS)+ in a large population cohort of women previously treated for CIN 3/AIS. METHODS: Merging administrative databases with information on health services utilization and jurisdictional cancer registry, we identified all women undergoing treatment for CIN 3 or AIS from 2006 to 2010. Recurrence rate 1-5 years after treatment was defined as a biopsy finding of CIN 3/AIS or retreatment (loop electrosurgical excision procedure [LEEP], laser, cone, hysterectomy). Logistic regression was used to determine odds of recurrence. RESULTS: A total of 15,177 women underwent treatment for CIN 3 (n = 14,668) and AIS (n = 509). The recurrence rate for 5 years was greater for AIS (9.0%) compared with CIN 3 (6.1%). In a multivariate analysis, increased risk of recurrence was shown for age older than 45 years (hazard ratio (HR) = 1.3, 95% CI = 1.1-1.6), AIS compared with CIN 3 (HR = 2.2, 95% CI = 1.5-3.5) first cytology after treatment showing high grade (HR = 12.4, 95% CI = 9.7-15.7), and no normal Pap smears after treatment (HR = 2.8, 95% CI = 2.2-3.7). There was no difference in recurrence risk with treatment type (cone vs LEEP: HR = 1.0, 95% CI = 0.8-1.2, and laser vs LEEP: HR = 1.1, 95% CI = 0.8-1.4) or number of procedures per year performed by physicians (<40 vs >40 procedures: HR = 1.1, 95% CI = 0.9-1.3). CONCLUSIONS: Recurrence risk of CIN 3 and AIS is related to age, histology, and posttreatment cytology, which should assist with discharge planning from colposcopy. Definitive treatment with hysterectomy should be considered in women older than 45 years with additional risk factors for recurrence.

Performance Indicators for Colposcopy in Ontario.

OBJECTIVE: This study sought to evaluate the delivery of colposcopy assessments and treatments in Ontario from 2009 to 2017 according to specific performance measures, derived from guidelines on colposcopy use. METHODS: This population-based descriptive analysis included screen-eligible women ages 21 to 69 in Ontario who underwent cervical screening between 2009 and 2017. Performance measures that describe the quality of colposcopy services in the province were calculated. RESULTS: Five performance measures were used to assess the use of colposcopy in Ontario from 2009 to 2017. From 2013 to 2017, the percentage of women seen for colposcopy after a first diagnosis of atypical squamous cells of undetermined significance (ASCUS), without evidence of repeat cytology, remained stable, ranging from 5.9% to 6.3%. The median wait time to colposcopy for atypical glandular cells (AGC), atypical squamous cells (ASC-H), cannot rule out high-grade squamous intraepithelial lesions, and high-grade squamous intraepithelial lesions (HSIL), remained relatively stable from 2013 to 2017. In addition, the percentage of women with high-grade Pap test results who were seen in colposcopy within 6 months increased from 74.7% to 83.5%. The percentage of women who were not seen in follow-up within 12 months after treatment for cervical dysplasia remained stable, as did the percentage of women who discontinued colposcopy after three normal Pap test results following treatment for cervical dysplasia. CONCLUSION: This study developed five performance indicators and used them to assess the delivery of colposcopic services in Ontario from 2009 to 2017. Performance indicators have previously been used effectively in the field of colorectal cancer screening to identify strengths and weaknesses in the delivery of healthcare services. This had never previously been done in colposcopy.

Why Do Women Get Cervical Cancer in an Organized Screening Program in Canada?

OBJECTIVE: The aim of the study was to determine factors associated with the development of cervical malignancy among women participating in an organized cervical screening program. MATERIALS AND METHODS: A population-based retrospective cohort study was performed examining the screening histories 2 to 10 years before diagnosis of invasive cancer in Ontario women between 2011 and 2014. RESULTS: A total of 2,002 cases of cervical cancer were identified; 1,358 (68%) were squamous cell carcinomas and 644 (32%) were adenocarcinomas. The mean age at the time of diagnosis was 50.3 years. More than 60% of the cohort had at least 1 cytology test within 2 to 10 years of their diagnosis. Of the women having a cytology result 24 to 36 months before diagnosis, 69% had a normal cytology whereas only 7% had a high-grade cytology result. Stage of cancer was most advanced in women who did not have cytology in the 2 to 10 years before their diagnosis. On multivariate regression, those with cervical cancer who were less likely to have undergone screening include older age, advanced stage, lower income, not having a family physician, and those diagnosed with adenocarcinoma. CONCLUSIONS: Although nonparticipation in screening is the greatest factor associated with cervical cancer diagnosis, failure of cervical cytology to detect cytologic abnormalities in women 2 to 3 and 3 to 5 years before diagnosis is of concern. Efforts must be directed to recruitment of women for screening as well as improving the sensitivity of screening tests to detect existing abnormalities.

Estimates and predictors of health care costs of esophageal adenocarcinoma: a population-based cohort study.

BACKGROUND: Esophageal adenocarcinoma (EAC) incidence is increasing rapidly. Esophageal cancer has the second lowest 5-year survival rate of people diagnosed with cancer in Canada. Given the poor survival and the potential for further increases in incidence, phase-specific cost estimates constitute an important input for economic evaluation of prevention, screening, and treatment interventions. The study aims to estimate phase-specific net direct medical costs of care attributable to EAC, costs stratified by cancer stage and treatment, and predictors of total net costs of care for EAC. METHODS: A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data from 2003 to 2011. The mean net costs of EAC care per 30 patient-days (2016 CAD) were estimated from the payer perspective using phase of care approach and generalized estimating equations. Predictors of net cost by phase of care were based on a generalized estimating equations model with a logarithmic link and gamma distribution adjusting for sociodemographic and clinical factors. RESULTS: The mean net costs of EAC care per 30 patient-days were $1016 (95% CI, $955-$1078) in the initial phase, $669 (95% CI, $594-$743) in the continuing care phase, and $8678 (95% CI, $8217-$9139) in the terminal phase. Overall, stage IV at diagnosis and surgery plus radiotherapy for EAC incurred the highest cost, particularly in the terminal phase. Strong predictors of higher net costs were receipt of chemotherapy plus radiotherapy, surgery plus chemotherapy, radiotherapy alone, surgery alone, and chemotherapy alone in the initial and continuing care phases, stage III-IV disease and patients diagnosed with EAC later in a calendar year (2007-2011) in the initial and terminal phases, comorbidity in the continuing care phase, and older age at diagnosis (70-74 years), and geographic region in the terminal phase. CONCLUSIONS: Costs of care vary by phase of care, stage at diagnosis, and type of treatment for EAC. These cost estimates provide information to guide future resource allocation decisions, and clinical and policy interventions to reduce the burden of EAC.

Pap tests in the diagnosis of cervical cancer: Help or hinder?

OBJECTIVE: To evaluate the impact of pap tests on the time to diagnosis of cervical cancer. METHODS: In this population-based retrospective cohort study, Ontario women ≥21 years diagnosed with cervical cancer between 2011 and 2014 were identified and database data collected. The presence or absence of a pap test 0-2 years preceding cancer diagnosis was identified. Descriptive and modelling analyses were performed to determine the effect of pap results on cancer diagnosis. RESULTS: 2002 patients were identified, 75% received a pap test. 1250 patients had known cytology - 13% normal, 8% low-grade and 7.5% suspicious for cancer. Across all FIGO stages at diagnosis, 5-10% of cytology was low grade, 3-11.5% was positive for carcinoma and 4-41% was normal, which increased with advancing stage. For all cytology and FIGO stages (except stage 1A), OBGYNs had a significantly shorter time to diagnosis compared to family physicians. Factors increasing the odds of low-grade cytology were advanced stage (OR 4.5 (2.4-8.0), p < 0.01) and adenocarcinoma (OR 1.5 (1.1-2.1), p < 0.01). Low grade cytology resulted in the longest delay to diagnosis (p < 0.001). CONCLUSION: Pap tests are performed frequently in the 0-2 years prior to the diagnosis of cervical cancer which can result in false negative cytology and diagnostic delay in patients with advanced cancers.

Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV.

We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.

Propensity score matching and complex surveys.

Researchers are increasingly using complex population-based sample surveys to estimate the effects of treatments, exposures and interventions. In such analyses, statistical methods are essential to minimize the effect of confounding due to measured covariates, as treated subjects frequently differ from control subjects. Methods based on the propensity score are increasingly popular. Minimal research has been conducted on how to implement propensity score matching when using data from complex sample surveys. We used Monte Carlo simulations to examine two critical issues when implementing propensity score matching with such data. First, we examined how the propensity score model should be formulated. We considered three different formulations depending on whether or not a weighted regression model was used to estimate the propensity score and whether or not the survey weights were included in the propensity score model as an additional covariate. Second, we examined whether matched control subjects should retain their natural survey weight or whether they should inherit the survey weight of the treated subject to which they were matched. Our results were inconclusive with respect to which method of estimating the propensity score model was preferable. In general, greater balance in measured baseline covariates and decreased bias was observed when natural retained weights were used compared to when inherited weights were used. We also demonstrated that bootstrap-based methods performed well for estimating the variance of treatment effects when outcomes are binary. We illustrated the application of our methods by using the Canadian Community Health Survey to estimate the effect of educational attainment on lifetime prevalence of mood or anxiety disorders.

Effects of socioeconomic status on esophageal adenocarcinoma stage at diagnosis, receipt of treatment, and survival: A population-based cohort study.

The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003-2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.

Cost-effectiveness analysis of treatment with non-curative or palliative intent for hepatocellular carcinoma in the real-world setting.

Hepatocellular carcinoma (HCC) presentation is heterogeneous necessitating a variety of therapeutic interventions with varying efficacies and associated prognoses. Poor prognostic patients often undergo non-curative palliative interventions including transarterial chemoembolization (TACE), sorafenib, chemotherapy, or purely supportive care. The decision to pursue one of many palliative interventions for HCC is complex and an economic evaluation comparing these interventions has not been done. This study evaluates the cost-effectiveness of non-curative palliative treatment strategies such as TACE alone or TACE+sorafenib, sorafenib alone, and non-sorafenib chemotherapy compared with no treatment or best supportive care (BSC) among patients diagnosed with HCC between 2007 and 2010 in a Canadian setting. Using person-level data, we estimated effectiveness in life years and quality-adjusted life years (QALYs) along with total health care costs (2013 US dollars) from the health care payer's perspective (3% annual discount). A net benefit regression approach accounting for baseline covariates with propensity score adjustment was used to calculate incremental net benefit to generate incremental cost-effectiveness ratio (ICER) and uncertainty measures. Among 1,172 identified patients diagnosed with HCC, 4.5%, 7.9%, and 5.6%, received TACE alone or TACE+sorafenib, sorafenib, and non-sorafenib chemotherapy clone, respectively. Compared with no treatment or BSC (81.9%), ICER estimates for TACE alone or TACE+sorafenib was $6,665/QALY (additional QALY: 0.47, additional cost: $3,120; 95% CI: -$18,800-$34,500/QALY). The cost-effectiveness acceptability curve demonstrated that if the relevant threshold was $50,000/QALY, TACE alone or TACE+sorafenib, non-sorafenib chemotherapy, and sorafenib alone, would have a cost-effectiveness probability of 99.7%, 46.6%, and 5.5%, respectively. Covariates associated with the incremental net benefit of treatments are age, sex, comorbidity, and cancer stage. Findings suggest that TACE with or without sorafenib is currently the most cost-effective active non-curative palliative treatment approach to HCC. Further research into new combination treatment strategies that afford the best tumor response is needed.

A cross-sectional population-based study of breast cancer screening among women with HIV in Ontario, Canada.

BACKGROUND: As women with HIV live longer, the need for age-appropriate breast cancer screening will increase. We compared rates of screening mammography among women with and without HIV. METHODS: We used administrative health databases to identify all women in Ontario, Canada, who were eligible for screening mammography (aged 50 to 74 yr and no history of breast cancer) as of Apr. 1, 2011. We used multivariable log-binomial regression to compare the 2-year period prevalence of screening mammography in 2011 to 2013 among women with and without HIV and to examine the correlates of screening among women with HIV. RESULTS: We identified 1 447 015 screen-eligible women, among whom 623 (0.04%) were women with HIV. Women with HIV were less likely to undergo screening than women without HIV (50.1% v. 63.4%, p < 0.001). Following multivariable adjustment, HIV-positive status was associated with significantly lower odds of undergoing mammography (adjusted prevalence ratio [PR] 0.83, 95% confidence interval [CI] 0.77-0.89). Compared with women with HIV receiving regular care from both a family physician and an HIV specialist, women with HIV receiving neither kind of care (adjusted PR 0.64, 95% CI 0.50-0.83) or predominantly specialist care (adjusted PR 0.77; 95% CI 0.60 to 0.97) were less likely to undergo screening mammography. INTERPRETATION: Women with HIV are less likely to undergo breast cancer screening mammography than women without HIV. Addressing this disparity requires optimizing care delivery to ensure adequate provision of comprehensive primary care to people with HIV.

Provider- and patient-related determinants of diabetes self-management among recent immigrants: Implications for systemic change.

OBJECTIVE: To examine provider- and patient-related factors associated with diabetes self-management among recent immigrants. DESIGN: Demographic and experiential data were collected using an international survey instrument and adapted to the Canadian context. The final questionnaire was pretested and translated into 4 languages: Mandarin, Tamil, Bengali, and Urdu. SETTING: Toronto, Ont. PARTICIPANTS: A total of 130 recent immigrants with a self-reported diagnosis of type 2 diabetes mellitus who had resided in Canada for 10 years or less. MAIN OUTCOME MEASURES: Diabetes self-management practices (based on a composite of 5 diabetes self-management practices, and participants achieved a score for each adopted practice); and the quality of the provider-patient interaction (measured with a 5-point Likert-type scale that consisted of questions addressing participants' perceptions of discrimination and equitable care). RESULTS: A total of 130 participants in this study were recent immigrants to Canada from 4 countries of origin-Sri Lanka, Bangladesh, Pakistan, and China. Two factors were significant in predicting diabetes self-management among recent immigrants: financial barriers, specifically, not having enough money to manage diabetes expenses (P = .0233), and the quality of the provider-patient relationship (P = .0016). Participants who did not have enough money to manage diabetes were 9% less likely to engage in self-management practices; and participants who rated the quality of their interactions with providers as poor were 16% less likely to engage in self-management practices. CONCLUSION: Financial barriers can undermine effective diabetes self-management among recent immigrants. Ensuring that patients feel comfortable and respected and that they are treated in culturally sensitive ways is also critical to good diabetes self-management.

Self-rated health and mental health of lone fathers compared with lone mothers and partnered fathers: a population-based cross-sectional study.

BACKGROUND: Lone parenthood is associated with poorer health; however, the vast majority of previous studies have examined lone mothers and only a few have focused on lone fathers. We aimed to examine the self-rated health and mental health status among a large population-based cross-sectional sample of Canadian lone fathers compared with both partnered fathers and lone mothers. METHODS: We investigated differences in self-rated health and mental health among 1058 lone fathers compared with 20 692 partnered fathers and 5725 lone mothers using the Ontario component of the Canadian Community Health Survey (2001-2013). Multivariable logistic regression was used to compare the odds of poor/fair self-rated health and mental health between the study groups while adjusting for a comprehensive list of sociodemographic factors, stressors and lifestyle factors. RESULTS: Lone fathers and lone mothers showed similar prevalence of poor/fair self-rated health (11.6% and 12.5%, respectively) and mental health (6.2% and 8.4%, respectively); the odds were similar even after multivariable adjustment. Lone fathers showed higher odds of poor/fair self-rated health (OR 1.53, 95% CI 1.07 to 2.17) and mental health (OR 2.09, 95% CI 1.26 to 3.46) than partnered fathers after adjustment for sociodemographic factors; however, these differences were no longer significant after accounting for stressors, including low income and unemployment. CONCLUSIONS: In this large population-based study, lone fathers had worse self-rated health and mental health than partnered fathers and similarly poor self-rated health and mental health as lone mothers. Interventions, supports and social policies designed for single parents should also recognise the needs of lone fathers.

Comparing stage of diagnosis of cervical cancer at presentation in immigrant women and long-term residents of Ontario: a retrospective cohort study.

BACKGROUND: Globally, cervical cancer is the fourth most common cancer in women and 7th most common cancer overall. Cervical cancer is highly preventable with screening. Previous work has shown that immigrants are less likely to undergo screening than nonimmigrants in Ontario, Canada. We examined whether immigrant women are more likely to present with later stage cervical cancer than long-term residents of the province. METHODS: We conducted a retrospective matched cohort study of women with cervical cancer diagnosed between 2010 and 2014 using provincial administrative health data. We compared the odds of late-stage diagnosis between immigrants and long-term residents, adjusting for socioeconomic measures, comorbidities and health care use. The outcome of interest was stage of cervical cancer diagnosis, defined as early (stage I) or late (stages II-IV). We confirmed results with a cohort of women with cancer diagnosed between 2007 and 2012. RESULTS: Complete staging data were available for 218 immigrants and 1348 matched long-term residents. We found no association between immigrant status and stage at diagnosis (adjusted odds ratio [OR] 0.94, 95% confidence interval [CI] 0.63-1.39). Factors that did show significant association with late-stage diagnosis were physician characteristics, whether a woman had previously undergone screening and had visited a gynecologist in the past 3 years. These results were echoed in the 2007-2012 cohort (immigrants v. long-term residents, OR 0.94, 95% CI 0.71-1.20). INTERPRETATION: Our results show that being an immigrant is not associated with late-stage diagnosis of cervical cancer in Ontario. Programs broadly aimed at immigrants may require a targeted approach to address higher-risk subgroups.

Using physician billing claims from the Ontario Health Insurance Plan to determine individual influenza vaccination status: an updated validation study.

BACKGROUND: Owing to the absence of a vaccination registry in Ontario, administrative data are currently the best available source to determine population-based individual-level influenza vaccination status. Our objective was to validate physician billing claims for influenza vaccination in the Ontario Health Insurance Plan database against the Canadian Community Health Survey. METHODS: We used self-reported seasonal influenza vaccination status of Ontario residents surveyed between 2007 and 2009 as the reference standard. The survey responses were linked to physician claims database records to validate billing codes for influenza vaccination. We calculated sensitivity, specificity, positive predictive value and negative predictive value with 95% confidence intervals (CIs). We stratified the data by several covariates and comorbidities to determine stratum-specific performance characteristics. We used these estimates to adjust an estimate of influenza vaccine effectiveness for the 2010/11 influenza season. RESULTS: For the 47 301 patients included in the analysis, the sensitivity for the billing codes was 49.8% (95% CI 49.0%-50.5%), specificity was 95.7% (95% CI 95.5%-96.0%), positive predictive value was 88.4% (95% CI 87.8%-89.0%) and negative predictive value was 74.5% (95% CI 74.0%-74.9%). Performance measures were optimized in patients aged 65 years and older, particularly those with comorbidities. INTERPRETATION: Although administrative data have limitations for determining influenza vaccination status, owing to the high positive predictive value, they are well suited for self-controlled study designs that are often used to assess vaccine safety. For studies of coverage and effectiveness, restricting the cohort to patients aged 65 years and older will minimize misclassification bias. Performance characteristics from this study can be used to mitigate misclassification bias.

Use of Mental Health Services by Youths and Young Adults Before and During Correctional Custody: A Population-Based Study.

OBJECTIVE: The authors measured use of mental health services among young people before and during incarceration. METHODS: Administrative data were used to describe mental health services received by 13,919 youths and young adults (ages 12-24) while incarcerated in Ontario, Canada, correctional centers (physician visits, April 1, 2010-March 31, 2012) and, for a subset of the population, during the five years prior to incarceration. RESULTS: Forty-two percent had a mental health-related visit during incarceration. Thirty-five percent had no mental health contact for five years before the beginning of the correctional episode. Forty percent of individuals with schizophrenia had a psychiatric hospitalization in the year before entering custody. CONCLUSIONS: For one-third of young people with a mental health visit while incarcerated, the visit was the first mental health contact in at least five years. Yet high use of psychiatric services before entering custody among individuals with schizophrenia may indicate gaps in continuity of mental health care.