The impact of expanded access to direct acting antivirals for Hepatitis C virus on patient outcomes in Canada.

BACKGROUND: Hepatitis C virus (HCV) has high global prevalence and can lead to liver complications and death. Access to direct-acting antivirals (DAAs) in Canada increased following several policy changes, however the real-world impact of expanded DAA access and increased use of these drugs is unknown. OBJECTIVE: We aimed to determine the early change in rates of HCV-related hospitalizations overall and HCV-related hospitalizations with hepatocellular carcinoma (HCC) after expanded DAA access. METHODS: We conducted a population-based time series analysis using national administrative health databases in Canada. Rates of HCV-related hospitalizations and HCV-related hospitalizations with HCC were enumerated monthly between April 2006 and March 2020. We used Autoregressive Integrated Moving Average (ARIMA) models with ramp functions in October 2014 and January 2017 to evaluate the impact of policies to expand DAA access on hospitalization outcomes. RESULTS: Rates of HCV-related hospitalizations in Canada increased between 2006 and 2014, and gradually declined thereafter. The decrease after October 2014, or the first policy change, was significant (p = 0.0355), but no further change was found after the second policy change in 2017 (p = 0.2567). HCV-related hospitalizations with HCC increased until end of 2013, followed by a plateau, before declining in 2016. No significant shifts were found after the first policy change in 2014 (p = 0.1291) nor the second policy change in 2017 (p = 0.6324). Subgroup analyses revealed that those aged 50-64 and males had observable declines in rates of HCV-related hospitalizations in the year prior to the first policy change. CONCLUSIONS: Expanding DAA access was associated with a drop in HCV-related hospitalizations in the overall Canadian population coinciding with the 2014 policy change. In light of the time required for HCV-related complications to manifest, continued ongoing research examining the real-world effectiveness of DAAs is required.

Association between long-term exposure to ambient air pollution and COVID-19 severity: a prospective cohort study.

BACKGROUND: The tremendous global health burden related to COVID-19 means that identifying determinants of COVID-19 severity is important for prevention and intervention. We aimed to explore long-term exposure to ambient air pollution as a potential contributor to COVID-19 severity, given its known impact on the respiratory system. METHODS: We used a cohort of all people with confirmed SARS-CoV-2 infection, aged 20 years and older and not residing in a long-term care facility in Ontario, Canada, during 2020. We evaluated the association between long-term exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2) and ground-level ozone (O3), and risk of COVID-19-related hospital admission, intensive care unit (ICU) admission and death. We ascertained individuals' long-term exposures to each air pollutant based on their residence from 2015 to 2019. We used logistic regression and adjusted for confounders and selection bias using various individual and contextual covariates obtained through data linkage. RESULTS: Among the 151 105 people with confirmed SARS-CoV-2 infection in Ontario in 2020, we observed 8630 hospital admissions, 1912 ICU admissions and 2137 deaths related to COVID-19. For each interquartile range increase in exposure to PM2.5 (1.70 µg/m3), we estimated odds ratios of 1.06 (95% confidence interval [CI] 1.01-1.12), 1.09 (95% CI 0.98-1.21) and 1.00 (95% CI 0.90-1.11) for hospital admission, ICU admission and death, respectively. Estimates were smaller for NO2. We also estimated odds ratios of 1.15 (95% CI 1.06-1.23), 1.30 (95% CI 1.12-1.50) and 1.18 (95% CI 1.02-1.36) per interquartile range increase of 5.14 ppb in O3 for hospital admission, ICU admission and death, respectively. INTERPRETATION: Chronic exposure to air pollution may contribute to severe outcomes after SARS-CoV-2 infection, particularly exposure to O3.

Vaccine Effectiveness Against SARS-CoV-2 Infection and Severe Outcomes in the Maintenance Dialysis Population in Ontario, Canada.

BACKGROUND: Vaccination studies in the hemodialysis population have demonstrated decreased antibody response compared with healthy controls, but vaccine effectiveness for preventing SARS-CoV-2 infection and severe disease is undetermined. METHODS: We conducted a retrospective cohort study in the province of Ontario, Canada, between December 21, 2020, and June 30, 2021. Receipt of vaccine, SARS-CoV-2 infection, and related severe outcomes (hospitalization or death) were determined from provincial health administrative data. Receipt of one and two doses of vaccine were modeled in a time-varying cause-specific Cox proportional hazards model, adjusting for baseline characteristics, background community infection rates, and censoring for non-COVID death, recovered kidney function, transfer out of province, solid organ transplant, and withdrawal from dialysis. RESULTS: Among 13,759 individuals receiving maintenance dialysis, 2403 (17%) were unvaccinated and 11,356 (83%) had received at least one dose by June 30, 2021. Vaccine types were BNT162b2 (n=8455, 74%) and mRNA-1273 (n=2901, 26%); median time between the first and second dose was 36 days (IQR 28-51). The adjusted hazard ratio (HR) for SARS-CoV-2 infection and severe outcomes for one dose compared with unvaccinated was 0.59 (95% CI, 0.46 to 0.76) and 0.54 (95% CI, 0.37 to 0.77), respectively, and for two doses compared with unvaccinated was 0.31 (95% CI, 0.22 to 0.42) and 0.17 (95% CI, 0.1 to 0.3), respectively. There were no significant differences in vaccine effectiveness among age groups, dialysis modality, or vaccine type. CONCLUSIONS: COVID-19 vaccination is effective in the dialysis population to prevent SARS-CoV-2 infection and severe outcomes, despite concerns about suboptimal antibody responses.

Is 'conflict of interest' a Misnomer? Managing interests in immunization research and evaluation.

Potential conflicts of interest in vaccine research can lead to negative consequences that undermine public trust and thereby put communities at risk. However, collaborations that may give rise to potential conflicts between interests can also greatly facilitate appropriate, scientifically robust, and timely vaccine development, implementation, and evaluation. At present, policies regarding the management of potential conflicts between interests are not ideal. To optimally manage interests in vaccine research, we recommend acknowledging all forms of interests and treating them all as relevant, developing appropriate collaborations, referring to all "conflicts of interest" simply as "interests" or "declarations," and promoting transparency through developing consistent reporting mechanisms.

Association of Influenza Activity and Environmental Conditions With the Risk of Invasive Pneumococcal Disease.

Importance: Streptococcus pneumoniae is the most commonly identified cause of bacterial pneumonia, and invasive pneumococcal disease (IPD) has a high case fatality rate. The wintertime coseasonality of influenza and IPD in temperate countries has suggested that pathogen-pathogen interaction or environmental conditions may contribute to IPD risk. Objectives: To evaluate the short-term associations of influenza activity and environmental exposures with IPD risk in temperate countries and to examine the generalizability of such associations across multiple jurisdictions. Design, Setting, and Participants: This case-crossover analysis of 19 566 individuals with IPD from 1998 to 2011 combined individual-level outcomes of IPD and population-level exposures. Participants lived in 12 jurisdictions in Canada (the province of Alberta and cities of Toronto, Vancouver, and Halifax), Australia (Perth, Sydney, Adelaide, Brisbane, and Melbourne), and the United States (Baltimore, Providence, and Philadelphia). Data were analyzed in 2019. Exposures: Influenza activity, mean temperature, absolute humidity, and UV radiation at delays of 1 to 3 weeks before case occurrence in each jurisdiction. Main Outcomes and Measures: Matched odds ratios (ORs) for IPD associated with changes in exposure variables, estimated using multivariable conditional logistic regression models. Heterogeneity in effects across jurisdictions were evaluated using random-effects meta-analytic models. Results: This study included 19 566 patients: 9629 from Australia (mean [SD] age, 42.8 [30.8] years; 5280 [54.8%] men), 8522 from Canada (only case date reported), and 1415 from the United States (only case date reported). In adjusted models, increased influenza activity was associated with increases in IPD risk 2 weeks later (adjusted OR [aOR] per SD increase, 1.07; 95% CI, 1.01-1.13). Increased humidity was associated with decreased IPD risk 1 week later (aOR per 1 g/m3, 0.98; 95% CI, 0.96-1.00). Other associations were heterogeneous; metaregression suggested that combinations of environmental factors might represent unique local risk signatures. For example, the heterogeneity in effects of UV radiation and humidity at a 2-week lag was partially explained by variation in temperature (UV index: coefficient, 0.0261; 95% CI, 0.0078 to 0.0444; absolute humidity: coefficient, -0.0077; 95% CI, -0.0125 to -0.0030). Conclusions and Relevance: In this study, influenza was associated with increased IPD risk in temperate countries. This association was not explained by coseasonality or case characteristics and appears generalizable. Absolute humidity was associated with decreased IPD risk in the same jurisdictions. The generalizable nature of these associations has important implications for influenza control and advances the understanding of the seasonality of this important disease.

HCV-infected individuals have higher prevalence of comorbidity and multimorbidity: a retrospective cohort study.

BACKGROUND: Almost 1% of Canadians are hepatitis C (HCV)-infected. The liver-specific complications of HCV are established but the extra-hepatic comorbidity, multimorbidity, and its relationship with HCV treatment, is less well known. We describe the morbidity burden for people with HCV and the relationship between multimorbidity and HCV treatment uptake and cure in the pre- and post-direct acting antiviral (DAA) era. METHODS: We linked adults with HCV at The Ottawa Hospital Viral Hepatitis Program as of April 1, 2017 to provincial health administrative data and matched on age and sex to 5 Ottawa-area residents for comparison. We used validated algorithms to identify the prevalence of mental and physical health comorbidities, as well as multimorbidity (2+ comorbidities). We calculated direct age- and sex-standardized rates of comorbidity and comparisons were made by interferon-based and interferon-free, DAA HCV treatments. RESULTS: The mean age of the study population was 54.5 years (SD 11.4), 65% were male. Among those with HCV, 4% were HIV co-infected, 26% had liver cirrhosis, 47% received DAA treatment, and 57% were cured of HCV. After accounting for age and sex differences, the HCV group had greater multimorbidity (prevalence ratio (PR) 1.38, 95% confidence interval (CI) 1.20 to 1.58) and physical-mental health multimorbidity (PR 2.71, 95% CI 2.29-3.20) compared to the general population. Specifically, prevalence ratios for people with HCV were significantly higher for diabetes, renal failure, cancer, asthma, chronic obstructive pulmonary disease, substance use disorder, mood and anxiety disorders and liver failure. HCV treatment and cure were not associated with multimorbidity, but treatment prevalence was significantly lower among middle-aged individuals with substance use disorders despite no differences in prevalence of cure among those treated. CONCLUSION: People with HCV have a higher prevalence of comorbidity and multimorbidity compared to the general population. While HCV treatment was not associated with multimorbidity, people with substance use disorder were less likely to be treated. Our results point to the need for integrated, comprehensive models of care delivery for people with HCV.

Methods used for immunization coverage assessment in Canada, a Canadian Immunization Research Network (CIRN) study.

Accurate and complete immunization data are necessary to assess vaccine coverage, safety and effectiveness. Across Canada, different methods and data sources are used to assess vaccine coverage, but these have not been systematically described. Our primary objective was to examine and describe the methods used to determine immunization coverage in Canada. The secondary objective was to compare routine infant and childhood coverage estimates derived from the Canadian 2013 Childhood National Immunization Coverage Survey (cNICS) with estimates collected from provinces and territories (P/Ts). We collected information from key informants regarding their provincial, territorial or federal methods for assessing immunization coverage. We also collected P/T coverage estimates for select antigens and birth cohorts to determine absolute differences between these and estimates from cNICS. Twenty-six individuals across 16 public health organizations participated between April and August 2015. Coverage surveys are conducted regularly for toddlers in Quebec and in one health authority in British Columbia. Across P/Ts, different methodologies for measuring coverage are used (e.g., valid doses, grace periods). Most P/Ts, except Ontario, measure up-to-date (UTD) coverage and 4 P/Ts also assess on-time coverage. The degree of concordance between P/T and cNICS coverage estimates varied by jurisdiction, antigen and age group. In addition to differences in the data sources and processes used for coverage assessment, there are also differences between Canadian P/Ts in the methods used for calculating immunization coverage. Comparisons between P/T and cNICS estimates leave remaining questions about the proportion of children fully vaccinated in Canada.

Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada.

OBJECTIVES: We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings. METHODS: We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates. RESULTS: Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable. CONCLUSIONS: We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

The good, bad, and ugly of online recruitment of parents for health-related focus groups: lessons learned.

BACKGROUND: We describe our experiences with identifying and recruiting Ontario parents through the Internet, primarily, as well as other modes, for participation in focus groups about adding the influenza vaccine to school-based immunization programs. OBJECTIVE: Our objectives were to assess participation rates with and without incentives and software restrictions. We also plan to examine study response patterns of unique and multiple submissions and assess efficiency of each online advertising mode. METHODS: We used social media, deal forum websites, online classified ads, conventional mass media, and email lists to invite parents of school-aged children from Ontario, Canada to complete an online questionnaire to determine eligibility for focus groups. We compared responses and paradata when an incentive was provided and there were no software restrictions to the questionnaire (Period 1) to a period when only a single submission per Internet protocol (IP) address (ie, software restrictions invoked) was permitted and no incentive was provided (Period 2). We also compared the median time to complete a questionnaire, response patterns, and percentage of missing data between questionnaires classified as multiple submissions from the same Internet protocol (IP) address or email versus unique submissions. Efficiency was calculated as the total number of hours study personnel devoted to an advertising mode divided by the resultant number of unique eligible completed questionnaires . RESULTS: Of 1346 submitted questionnaires, 223 (16.6%) were incomplete and 34 (2.52%) did not meet the initial eligibility criteria. Of the remaining 1089 questionnaires, 246 (22.6%) were not from Ontario based on IP address and postal code, and 469 (43.1%) were submitted from the same IP address or email address (multiple submissions). In Period 2 vs Period 1, a larger proportion of questionnaires were submitted from Ontario (92.8%, 141/152 vs 75.1%, 702/937, P<.001), and a smaller proportion of same IP addresses (7.9%, 12/152 vs 47.1%, 441/937, P<.001) were received. Compared to those who made unique submissions, those who made multiple submissions spent less time per questionnaire (166 vs 215 seconds, P<.001), and had a higher percentage of missing data among their responses (15.0% vs 7.6%, P=.004). Advertisements posted on RedFlagDeals were the most efficient for recruitment (0.03 hours of staff time per questionnaire), whereas those placed on Twitter were the least efficient (3.64 hours of staff time per questionnaire). CONCLUSIONS: Using multiple online advertising strategies was effective for recruiting a large sample of participants in a relatively short period time with minimal resources. However, risks such as multiple submissions and potentially fraudulent information need to be considered. In our study, these problems were associated with providing an incentive for responding, and could have been partially avoided by activating restrictive software features for online questionnaires.

Admission to hospital for pneumonia and influenza attributable to 2009 pandemic A/H1N1 influenza in First Nations communities in three provinces of Canada.

BACKGROUND: Early reports of the 2009 A/H1N1 influenza pandemic (pH1N1) indicated that a disproportionate burden of illness fell on First Nations reserve communities. In addition, the impact of the pandemic on different communities may have been influenced by differing provincial policies. We compared hospitalization rates for pneumonia and influenza (P&I) attributable to pH1N1 influenza between residents of First Nations reserve communities and the general population in three Canadian provinces. METHODS: Hospital admissions were geocoded using administrative claims data from three Canadian provincial data centres to identify residents of First Nations communities. Hospitalizations for P&I during both waves of pH1N1 were compared to the same time periods for the four previous years to establish pH1N1-attributable rates. RESULTS: Residents of First Nations communities were more likely than other residents to have a pH1N1-attributable P&I hospitalization (rate ratio [RR] 2.8-9.1). Hospitalization rates for P&I were also elevated during the baseline period (RR 1.5-2.1) compared to the general population. There was an average increase of 45% over the baseline in P&I admissions for First Nations in all 3 provinces. In contrast, admissions overall increased by approximately 10% or less in British Columbia and Manitoba and by 33% in Ontario. Subgroup analysis showed no additional risk for remote or isolated First Nations compared to other First Nations communities in Ontario or Manitoba, with similar rates noted in Manitoba and a reduction in P&I admissions during the pandemic period in remote and isolated First Nations communities in Ontario. CONCLUSIONS: We found an increased risk for pH1N1-related hospital admissions for First Nations communities in all 3 provinces. Interprovincial differences may be partly explained by differences in age structure and socioeconomic status. We were unable to confirm the assumption that remote communities were at higher risk for pH1N1-associated hospitalizations. The aggressive approach to influenza control in remote and isolated First Nations communities in Ontario may have played a role in limiting the impact of pH1N1 on residents of those communities.

Patterns of emergency room visits, admissions and death following recommended pediatric vaccinations - a population based study of 969,519 vaccination events.

BACKGROUND: The risk of immediate adverse events due to the inflammation created by a vaccine is a potential concern for pediatric vaccine programs. METHODS: We analyzed data on children born between March 2006 and March 2009 in the province of Ontario. Using the self-controlled case series design, we examined the risk of the combined endpoint of emergency room visit and hospital admission in the immediate 3 days post vaccination to a control period 9-18 days after vaccination. We examined the end points of emergency room visits, hospital admissions and death separately as secondary outcomes. RESULTS: We examined 969,519 separate vaccination events. The relative incidence of our combined end point was 0.85 (0.80-0.90) for vaccination at age 2 months, 0.74 (0.69-0.79) at age 4 months and 0.68 (0.63-0.72) at age 6 months. The relative incidence was reduced for the individual endpoints of emergency room visits, admissions and death. There were 5 or fewer deaths in the risk interval of all 969,519 vaccination events. In a post hoc analysis we observed a large reduction in events in the immediate 3 days prior to vaccination suggesting a large healthy vaccinee effect. CONCLUSION: There was no increased incidence of the combined end point of emergency room visits and hospitalizations in the 3-day period immediately following vaccination, nor for individual endpoints or death. The health vaccinee effect could create the perception of worsening health following vaccines in the absence of any vaccine adverse effect and could also mask an effect in the immediate post-vaccination period.

Trends in influenza vaccination in Canada, 1996/1997 to 2005.

OBJECTIVES: This article reports recent trends in influenza vaccination rates in Canada, provides data on predictors of vaccination in Canada for 2005, and examines longer-term effects of Ontario's universal influenza immunization program on vaccine uptake. DATA SOURCES: Data are from the 1996/1997 National Population Health Survey (NPHS) and the 2000/2001, 2003, and 2005 Canadian Community Health Survey (CCHS). ANALYTICAL TECHNIQUES: NPHS and CCHS data were used to estimate influenza vaccination rates of the population aged 12 or older. The Z test was used to assess differences between surveys, and the chi-squared test for trend was used to examine trends over time. Logistic regression was used to identify predictors of vaccination and to compare the odds of being vaccinated in Ontario versus other provinces. MAIN RESULTS: Nationally, influenza vaccination rates rose from 15% in 1996/1997 to 27% in 2000/2001, stabilized between 2000/2001 and 2003, and increased further to 34% by 2005. Vaccination rates for most high-risk groups still fall short of national targets. Ontarians continue to be more likely to be vaccinated than are residents of any other province, while residents of two of the territories--Nunavut and the Northwest Territories--are even more likely to be vaccinated than are Ontarians.

The effect of universal influenza immunization on vaccination rates in Ontario.

OBJECTIVES: This article examines the association between introduction of Ontario's Universal Influenza Immunization Program and changes in vaccination rates over time in Ontario, compared with the other provinces combined. DATA SOURCES: The data are from the 1996/97 National Population Health Survey and the 2000/01 and 2003 Canadian Community Health Survey, both conducted by Statistics Canada. ANALYTICAL TECHNIQUES: Cross-tabulations were used to estimate vaccination rates for the total population aged 12 or older, for groups especially vulnerable to the effects of influenza, and by selected socio-demographic variables. Z tests and multiple logistic regression were used to examine differences between estimates. MAIN RESULTS: Between 1996/97 and 2000/01, the increase in the overall vaccination rate in Ontario was 10 percentage points greater than the increase in the other provinces combined. Increases in Ontario were particularly pronounced among people who were: younger than 65, more educated, and had a higher household income. Between 2000/01 and 2003, vaccination rates were stable in Ontario, while rates continued to rise in the other provinces. Even so, Ontario's 2003 rates exceeded those in the other provinces.

Oral vitamin B12 therapy in the primary care setting: a qualitative and quantitative study of patient perspectives.

BACKGROUND: Although oral replacement with high doses of vitamin B12 is both effective and safe for the treatment of B12 deficiency, little is known about patients' views concerning the acceptability and effectiveness of oral B12. We investigated patient perspectives on switching from injection to oral B12 therapy. METHODS: This study involved a quantitative arm using questionnaires and a qualitative arm using semi-structured interviews, both to assess patient views on injection and oral therapy. Patients were also offered a six-month trial of oral B12 therapy. One hundred and thirty-three patients who receive regular B12 injections were included from three family practice units (two hospital-based academic clinics and one community health centre clinic) in Toronto. RESULTS: Seventy-three percent (63/86) of respondents were willing to try oral B12. In a multivariate analysis, patient factors associated with a "willingness to switch" to oral B12 included being able to get to the clinic in less than 30 minutes (OR 9.3, 95% CI 2.2-40.0), and believing that frequent visits to the health care provider (OR 5.4, 95% CI 1.1-26.6) or the increased costs to the health care system (OR 16.7, 95% CI 1.5-184.2) were disadvantages of injection B12. Fifty-five patients attempted oral therapy and 52 patients returned the final questionnaire. Of those who tried oral therapy, 76% (39/51) were satisfied and 71% (39/55) wished to permanently switch. Factors associated with permanently switching to oral therapy included believing that the frequent visits to the health care provider (OR 35.4, 95% CI 2.9-432.7) and travel/parking costs (OR 8.7, 95% CI 1.2-65.3) were disadvantages of injection B12. Interview participants consistently cited convenience as an advantage of oral therapy. CONCLUSION: Switching patients from injection to oral B12 is both feasible and acceptable to patients. Oral B12 supplementation is well received largely due to increased convenience. Clinicians should offer oral B12 therapy to their patients who are currently receiving injections, and newly diagnosed B12-deficient patients who can tolerate and are compliant with oral medications should be offered oral supplementation.

A comparison of Canadian medical students from rural and non-rural backgrounds.

CONTEXT: Very little is known about medical students from rural areas currently enrolled in Canadian medical schools. PURPOSE: We aimed to compare rural and non-rural students in terms of demographics, socioeconomic status, financial status and career choices. METHODS: As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, we conducted post-hoc analyses to compare students from rural and non-rural areas. Canada Post's classification system was used to determine rural status. To compare differences between rural and non-rural students, we used logistical regression models for categorical variables and factorial analysis of variance for continuous variables. RESULTS: We received responses from 2994 (68.5%) of 4368 medical students. Eleven percent of Canadian medical students come from rural backgrounds. Rural students tend to be older and originate from families of lower socioeconomic status. Students from rural areas report higher levels of debt, increased rates of paid part-time and summer employment, and greater stress from their finances. Nevertheless, rural students are not more likely to state that financial considerations will affect their choice of specialty or practice location. CONCLUSIONS: Canadian medical students who come from rural backgrounds are different from their non-rural counterparts. Students from rural areas face numerous financial barriers in obtaining a medical education and report greater levels of financial stress. Medical schools should examine and address barriers to admission of rural students and they should consider directing more financial resources toward this financially vulnerable group.

Sex differences in first-year students at Canadian medical schools.

OBJECTIVES: To compare male and female medical students by age, level of education before admission to medical school, race/ethnicity, parental education level, socioeconomic status, and attitudes toward public health care. METHODS: In 2001, we conducted an Internet-based survey of all students enrolled in the 16 medical schools across Canada. Based on the high response rate, first-year medical students at Canadian medical schools outside of Quebec were included in this analysis. The interactions between sex and age, years of premedical education, race/ethnicity, parental occupation, education and household income, impact of finances on choice of medical school, future specialty and practice location, attitudes toward private funding in the Canadian health care system were examined using descriptive statistics and chi2 tests. RESULTS: There were no significant differences between male and female medical students in age, level of education before admission, and race/ethnicity. Female students' fathers (p=.046) and mothers (p=.061) were more likely to hold positions of higher occupational status than were those of male students. There was no significant difference between the parental household incomes of male and female students. Male students were more likely than female students to state that financial considerations would affect their choice of specialty (p=.002) and practice location (p=.002). Male students were more likely to express a positive attitude toward private funding in the health care system, both with respect to increasing the amount of private funding (p=.007) and the addition of private paying patients (p=.002). CONCLUSION: Although women have almost reached equity with men in undergraduate medical education, female students are more likely than male students to have highly educated parents, suggesting that some barriers to access may still exist. The differences in attitudes of female and male medical students to finances and the public health care system become increasingly important as more women practice medicine. These sex differences need to be investigated further, as they could have implications for health policy.

Effects of rising tuition fees on medical school class composition and financial outlook.

BACKGROUND: Since 1997, tuition has more than doubled at Ontario medical schools but has remained relatively stable in other Canadian provinces. We sought to determine whether the increasing tuition fees in Ontario affected the demographic characteristics and financial outlook of medical students in that province as compared with those of medical students in the rest of Canada. METHODS: As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, we compared the respondents from Ontario schools with those from the other schools (control group). Respondents were asked about their age, sex, self-reported family income (as a direct indicator of socioeconomic status), the first 3 digits of their postal code at graduation from high school (as an indirect indicator of socioeconomic status), and importance of financial considerations in choosing a specialty and location of practice. We used logistic regression models to see if temporal changes (1997 v. 2000) among Ontario medical students differed from those among medical students elsewhere in Canada apart from Quebec. RESULTS: Responses were obtained from 2994 (68.5%) of 4368 medical students. Across the medical schools, there was an increase in self-reported family income between 1997 and 2000 (p = 0.03). In Ontario, the proportion of respondents with a family income of less than $40,000 declined from 22.6% to 15.0%. However, compared with the control respondents, the overall rise in family income among Ontario students was not statistically significant. First-year Ontario students reported higher levels of expected debt at graduation than did graduating students (median $80,000 v. $57,000) (p < 0.001), and the proportion of students expecting to graduate with debt of at least $100,000 more than doubled. Neither of these differences was observed in the control group. First-year Ontario students were also more likely than fourth-year Ontario students to report that their financial situation was "very" or "extremely" stressful and to cite financial considerations as having a major influence on specialty choice or practice location. These differences were not observed in the control group. INTERPRETATION: At Canadian medical schools, there are fewer students from low-income families in general. However, Ontario medical students report a large increase in expected debt on graduation, an increased consideration of finances in deciding what or where to practise, and increasing financial stress, factors that are not observed among students in other provinces.

Characteristics of first-year students in Canadian medical schools.

BACKGROUND: The demographic and socioeconomic profile of medical school classes has implications for where people choose to practise and whether they choose to treat certain disadvantaged groups. We aimed to describe the demographic and socioeconomic characteristics of first-year Canadian medical students and compare them with those of the Canadian population to determine whether there are groups that are over- or underrepresented. Furthermore, we wished to test the hypothesis that medical students often come from privileged socioeconomic backgrounds. METHODS: As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, first-year students were asked to give their age, sex, self-described ethnic background using Statistics Canada census descriptions and educational background. Postal code at the time of high school graduation served as a proxy for socioeconomic status. Respondents were also asked for estimates of parental income and education. Responses were compared when possible with Canadian age-group-matched data from the 1996 census. RESULTS: Responses were obtained from 981 (80.2%) of 1223 first-year medical students. There were similar numbers of male and female students (51.1% female), with 65% aged 20 to 24 years. Although there were more people from visible minorities in medical school than in the Canadian population (32.4% v. 20.0%) (p < 0.001), certain minority groups (black and Aboriginal) were underrepresented, and others (Chinese, South Asian) were overrepresented. Medical students were less likely than the Canadian population to come from rural areas (10.8% v. 22.4%) (p< 0.001) and were more likely to have higher socioeconomic status, as measured by parents' education (39.0% of fathers and 19.4% of mothers had a master's or doctoral degree, as compared with 6.6% and 3.0% respectively of the Canadian population aged 45 to 64), parents' occupation (69.3% of fathers and 48.7% of mothers were professionals or high-level managers, as compared with 12.0% of Canadians) and household income (15.4% of parents had annual household incomes less than $40,000, as compared with 39.7% of Canadian households; 17.0% of parents had household incomes greater than $160,000, as compared with 2.7% of Canadian households with an income greater than $150,000). Almost half (43.5%) of the medical students came from neighbourhoods with median family incomes in the top quintile (p < 0.001). A total of 57.7% of the respondents had completed 4 years or less of postsecondary studies before medical school, and 29.3% had completed 6 or more years. The parents of the medical students tended to have occupations with higher social standing than did working adult Canadians; a total of 15.6% of the respondents had a physician parent. INTERPRETATION: Canadian medical students differ significantly from the general population, particularly with regard to ethnic background and socioeconomic status.