Functional Decline in Long-Term Care Homes in the First Wave of the COVID-19 Pandemic: A Population-based Longitudinal Study in Five Canadian Provinces.

OBJECTIVE: We aimed to examine whether functional decline accelerated during the first wave of the COVID-19 pandemic (March to June 2020) for persons in long-term care facilities (LTCs) in Canada compared with the pre-pandemic period. DESIGN: We conducted a population-based longitudinal study of persons receiving care in LTC homes in 5 Canadian provinces before and during the COVID-19 pandemic. SETTING AND PARTICIPANTS: Residents in 1326 LTC homes within the Canadian provinces of Alberta, British Columbia, Manitoba, Newfoundland & Labrador, and Ontario between January 31, 2019, and June 30, 2020, with activities of daily living Hierarchy scale less than 6 and so, who still have potential for decline (6 being the worst of the 0-6 scale). METHODS: We fit a generalized estimating equation model with adjustment for repeated measures to obtain the adjusted odds of functional decline between COVID period exposed and unexposed pre-pandemic residents. RESULTS: LTC residents experienced slightly higher rates of functional decline during the first wave of the COVD-19 pandemic compared with the pre-pandemic period (23.3% vs 22.3%; P < .0001). The adjusted odds of functional decline were slightly greater during the pandemic (odds ratio [OR], 1.17; 95% CI, 1.15-1.20). Likewise, residents receiving care in large homes (OR, 1.20; 95% CI, 1.17-1.24) and urban-located LTC homes (OR, 1.20; 95% CI, 1.17-1.23), were more likely to experience functional decline during the COVID-19 pandemic. The odds of functional decline were also only significantly higher during the pandemic for LTC home residents in British Columbia (OR, 1.17; 95% CI, 1.11-1.23) and Ontario (OR, 1.25; 95% CI, 1.21-1.29). CONCLUSIONS AND IMPLICATIONS: This study provides evidence that the odds of experiencing functional decline were somewhat greater during the first wave of the COVID-19 pandemic. It highlights the need to maintain physical activity and improve nutrition among older adults during periods of stress. The information would be helpful to health administrators and decision-makers seeking to understand how the COVID-19 pandemic and associated public health measures affected LTC residents' health outcomes.

Multistate Competing Risk Analysis of Transition Back to the Community Among Long-Term Care Home (LTC) Destined Patients: A Brief Report.

OBJECTIVE: The demand for long-term care in community and facilitybased settings in Canada is expected to increase with population growth. The Toronto Grace Health Center piloted an intervention program that aims to support return to the community of acute hospital patients designated for LTC placement. We investigated whether this program was effective in transitioning the program patients back to their homes in the community and the factors associated with transitioning patients to different destinations. METHOD: We performed a competing risk multi-state analysis of 111 patients enrolled into the Harbour Light (HL) transitional unit program between January 2020 and June 2023. RESULTS: At the time of the study, 92 enrolled patients had been discharged and of those these, 48.9% (45) were successfully transitioned back to their private home in the community. The remaining 51.1% (46) were discharged to other destinations. Being a female was the only positive predictor of transitioning back home. Higher CPS scores (HR 0.53, 95% CI 0.31-0.88), PADDRS scale of 1+, and higher ADL Hierarchy scale, strongly predicted lower odds of transitioning back to the community. CONCLUSION: Within the context of rising LTC bed demand and lengthy waiting time in Canada, with appropriate measures, this program successfully transitioned LTC home bound persons back to their homes. If replicable on a large scale, this could provide short and long-term solution to LTC bed demand in Canada.

Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study.

PURPOSE: To determine factors associated with improvement in urinary incontinence (UI) for long-stay postacute, complex continuing care (CCC) patients. DESIGN: A retrospective cohort investigation of patients in a CCC setting using data obtained from the Canadian Institute for Health Information's Continuing Care Reporting System collected with interRAI Minimum Data Set 2.0. SETTING AND PARTICIPANTS: Individuals aged 18 years and older, were admitted to CCC hospitals in Ontario, Canada, between 2010 and 2018. METHODS: Multivariable logistic regression was used to determine the independent effects of predictors on UI improvement, for patients who were somewhat or completely incontinent on admission and therefore had the potential for improvement. RESULTS: The study cohort consisted of 18 584 patients, 74% (13 779) of which were somewhat or completely incontinent upon admission. Among those patients with potential for improvement, receiving bladder training, starting a new medication 90 days prior (odds ratio, OR: 1.54 [95% confidence interval, CI: 1.36-1.75]), and triggering the interRAI Urinary Incontinence Clinical Assessment Protocol to facilitate improvement (OR: 1.36 [95% CI: 1.08-1.71]) or to prevent decline (OR: 1.32 [95% CI: 1.13-1.53]) were the strongest predictors of improvement. Conversely, being totally dependent on others for transfer (OR: 0.62 [95% CI: 0.42-0.92]), is rarely or never understood (OR: 0.65 [95% CI: 0.50-0.85]), having a major comorbidity count of ≥3 (OR: 0.72 [95% CI: 0.59-0.88]), Parkinson's disease, OR: 0.77 (95% CI: 0.62-0.95), Alzheimer/other dementia, OR: 0.83 (95% CI: 0.74-0.93), and respiratory infections, OR: 0.57 (95% CI: 0.39-0.85) independently predicted less likelihood of improvement in UI. CONCLUSIONS AND IMPLICATIONS: Findings of this study suggest that improving physical function, including bed mobility, and providing bladder retraining have strong positive impacts on improvement in UI for postacute care patients. Evidence generated from this study provides useful care planning information for care providers in identifying patients and targeting the care that may lead to better success with the management of UI.

Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model.

OBJECTIVES: To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services. DESIGN: Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care. SETTING AND PARTICIPANTS: Adults aged 18 years and older, admitted to Complex Continuing Care hospitals in Ontario, Canada, between 2009 and 2015 (n = 78,913). METHODS: A multistate transition model was used to characterize the association between patient characteristics measured at admission and changes in urinary continence state transitions (continent, sometimes continent, and incontinent) between admission and follow-up. RESULTS: The cohort included 27,896 patients. At admission, 9583 (34.3%) patients belonged to the continent state, 6441 (23.09%) patients belonged to the sometimes incontinent state, and the remaining 11,872 (42.6%) patients belonged to the incontinent state. For patients who were continent at admission, the majority (62.7%) remained continent at follow-up. However, nearly a quarter (23.9%) transitioned to the sometimes continent state, and an additional 13.4% became incontinent at follow-up. Several factors were associated with continence state transitions, including cognitive impairment, rehabilitation potential, stroke, Parkinson's disease, Alzheimer's disease and related dementias, and hip fracture. CONCLUSIONS AND IMPLICATIONS: This study suggests that urinary incontinence is a prevalent problem for Complex Continuing Care hospital patients and multiple factors are associated with continence state transitions. Standardized assessment of urinary incontinence is helpful in this setting to identify patients in need of further assessment and patient-centered intervention and as a quality improvement metric to examine changes in continence from admission to discharge.

Online symptoms self-assessment during COVID-19 pandemic: an analysis of a COVID-19 portal responses from Canada.

COVID-19 case was first identified in Canada on January 25, 2020, on a Toronto resident who had travelled to Wuhan China, and not long after, the WHO declared the viral infection a pandemic. Ontario health West created an online self-assessment portal that allowed individuals in the health region and adjourning areas to report any COVID related symptoms. The purpose of this study was to evaluate the utility and usefulness of the Ontario Heath West online COVID-19 self-assessment portal. Record level data obtained from the Ontario Health West self-assessment portal was analyzed. Descriptive statistics using charts and graphs were used to characterize the distribution of responses to the portal. In-depth analysis using correlation, lead-lag analysis, and trend comparison with actual Government of Ontario COVID-19 cases for the region were also conducted. A total of 34,144 distinct responses were recorded on the portal between April 10 and July 29, 2020, with 1,250 (3.7%) responding positively to one of the emergency symptoms questions. Trend analysis showed a peak portal response in May 2020 with a smaller rise subsequently in July 2020, coinciding with the actual COVID-19 peak in the region. The five most reported symptoms on the portal were sore throat (17.2%), headache (12.9%), fatigue (12.3%), digestive problems (12.2%) and cough (9.1%). For four sub-regions, the trend of self-report on the portal positively lagged actual Public Health Ontario reported COVID-19 cases, while for one sub-region, the trend positively led the actual Public Health Ontario reported COVID-19 cases for the area. We found correlation between online COVID-19 self- assessment data and the confirmed COVID-19 cases in the Southwestern region of Ontario. Trends in the COVID-19 associated emergency symptoms reported on the portal also tracked confirmed COVID-19 cases in the community. Peak response to the portal coincided with the peak volume of confirmed cases in Ontario during the first wave of COVID-19 pandemic in Canada, suggesting some consistency between the experiences of portal users and patterns of COVID-19 illness in the community. The portal was a useful tool at the person-level because it provided guidance to individuals about how to access appropriate health services according to the symptoms that they reported and connected them with primary care, reducing unnecessary visit to health facilities for COVID-19 related care.

Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study

BACKGROUND: Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use. METHODS: In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35­70 years (n=156625) were recruited from 110803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys. FINDINGS: Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines.

Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study.

BACKGROUND: Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use. METHODS: In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys. FINDINGS: Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines. INTERPRETATION: Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes. FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).