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.
We conducted a survey of attitudes towards the sale of kidneys for transplantation within and without the medical community. Half of those polled received a case of a young man in India whose only chance for survival was to purchase a kidney, the other half a case of a Canadian man who was suffering side-effects from dialysis and had been on the transplant waiting list for three years. We found the percentage of responses allowing the patients to purchase a kidney was similar for the two cases (40 per cent in the Canadian case and 49 per cent in the Indian case). The medical groups had much lower rates of approval of this practice than the public. In all groups those allowing the practice showed similar concerns about regulation. This survey indicates public opinion to be contrary to public policy.
Objective To examine the association between maternal mRNA covid-19 vaccination during the first trimester of pregnancy and the prevalence of major congenital anomalies in offspring. Design Population based cohort study with sibling matched analysis. Setting Multiple health administrative databases, linked and analysed at ICES, an independent, non-profit research institute that collects and analyses healthcare and demographic data, Ontario, Canada, from 16 October 2021 to 1 May 2023. Population 174 296 singleton live births >20 weeks' gestation with an expected birth date between 16 October 2021 and 1 May 2023: 34 181 (20%) born to mothers who received one or two doses of an mRNA covid-19 vaccine in the first trimester and 34 951 (20%) born to mothers who did not receive a vaccine before or during pregnancy. The sibling matched analysis included 13 312 infants exposed to a covid-19 vaccine in the first trimester and 15 089 matched older siblings with the same mother, with an expected birth date after 16 October 2016 and no reported in utero exposure to a covid-19 vaccine. Main outcome measures Major congenital anomalies, overall and grouped by specific organ systems, diagnosed within 28 days of birth. Results Major congenital anomalies were present in 832 (24.3 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester compared with 927 (26.5 per 1000 live births) infants not exposed to a vaccine, resulting in an adjusted prevalence ratio of 0.89 (95% confidence interval (CI) 0.79 to 1.01). Major congenital anomalies were present in 283 (21.3 per 1000 live births) and 343 (22.7 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester and their older siblings not exposed to a vaccine, respectively (adjusted prevalence ratio 0.91, 95% CI 0.77 to 1.07). First trimester vaccination was not associated with an increase in major congenital anomalies grouped by specific organ system in the primary or sibling matched analyses. Results were similar across a range of subgroup and sensitivity analyses. Conclusions In this large population based cohort study and sibling matched analysis, mRNA covid-19 vaccination during the first trimester of pregnancy was not associated with an increase in major congenital anomalies in offspring, overall or grouped by organ system.
Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic.Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3-17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates.In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41-1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25-1.50) increase in risk for emergency department visit and hospitalization, respectively.Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization.
Abstract: There are considerable mortality data associated with renal transplantation in children; however, morbidity data, especially related to CV disease, are scarce. The objectives of this study were to determine incidence of non‐fatal and fatal CV events and all‐cause mortality in PRTx and evaluate risk factors for these conditions. Using a population‐based retrospective cohort design, 274 PRTx with or without a functioning graft was followed until death or date of last contact (median follow‐up 11.9 yr). Primary outcomes (time to first fatal or non‐fatal CV event and all‐cause mortality after first transplant) were ascertained from chart review and linkage with administrative databases of a universal health care system. During 3073 patient‐years, there were 46 deaths; 13 were because of CV disease. Twenty patients had CV events that did not result in death. Post‐transplant diabetes mellitus (10.5%) was associated with increased risk of death (HR: 2.79, 95% CI: 1.04–7.44) and CV events (HR: 3.90, 95% CI: 1.31–11.59). Low estimated glomerular filtration rate at one yr post‐transplant was also associated with increased risk of death. The rates of developing CV disease and dying prematurely are extraordinarily high in PRTx, underscoring the need for early and aggressive intervention to reduce the burden of suffering in this patient population.
Canada has 2 main streams of resettlement: government-assisted refugees and privately sponsored refugees, whereby citizens can privately sponsor refugees and provide resettlement services, including health care navigation. Our objective was to compare receipt of adequate prenatal care among privately sponsored and government-assisted refugees.This population-based study used linked health administrative and demographic databases. We included all resettled refugees classified as female who landed in Ontario, Canada, between April 2002 and May 2017, and who had a live birth or stillbirth conceived at least 365 days after their landing date. Our primary outcome - adequacy of prenatal care - was a composite that comprised receipt of a first-trimester prenatal visit, the number of prenatal care visits recommended by the Society of Obstetricians and Gynaecologists of Canada and a prenatal fetal anatomy ultrasound. We accounted for potential confounding with inverse probability of treatment weighting, using a propensity score.We included 2775 government-assisted and 2374 privately sponsored refugees. Compared with privately sponsored refugees (62.3% v. 69.3%), government-assisted refugees received adequate prenatal care less often, with a weighted relative risk of 0.93 (95% confidence interval 0.88-0.95).Among refugees resettled to Canada, a government-assisted resettlement model was associated with receiving less adequate prenatal care than a private sponsorship model. Government-assisted refugees may benefit from additional support in navigating health care beyond the first year after arrival.
Objective We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic. Methods This population-based repeated cross-sectional study of children and adolescents (3–17 years; N = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017–2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status. Results Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata. Conclusion During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning.
Objective To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. Method Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1–18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. Results In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P < 0.001)]. In the second cohort ( n = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up. Conclusions Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.
Adequate participant recruitment is critical for any qualitative research project. Our research team experienced numerous difficulties when attempting to recruit young adults with type 1 diabetes to discuss their transition from pediatric to adult-focused care. Using our experience as a case study, we identify the activities involved in four phases of participant recruitment: (1) development of a recruitment plan, (2) implementation, (3) participant engagement post-data collection, and (4) post-recruitment assessment. We present a new definition of participant recruitment which better captures the range of activities involved. We discuss aspects impacting recruitment in our case: the influence of other stakeholders, the dynamic nature of recruitment, recruitment of specific populations, and the challenges of recruiting within a healthcare environment. Finally, we identify and consider four factors that impact participant recruitment: communication, participant interest/value, participant trust in the research project, and participant availability and consider potential strategies for overcoming barriers related to each factor. In the end, our case underscores the centrality and potential fluidity of participant recruitment within qualitative research.
ResultsHospital births during the study period totaled 701 896, and 37 415 newborns (5.3%) had POE.Mothers were a mean (SD) age of 30.9 (5.3) years at current birth, 74.7% were Canadian-born, and 10.5% had pain-related hospital care 2 years before conception.The annual prevalence of POE decreased from 6.1% in 2014 to 4.5% in 2019 (P < .001).The highest rates of POE were among women aged 20 to 24 years (8.8% in 2014 to 7.1% in 2019), those living in rural areas (8.3% in 2014
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