CMAJ Open

This study combined public data and geospatial analysis to examine physicians language abilities and locations in Alberta, Canada, and produced an interactive map to allow patients and policymakers to view the data. We identified n=11,370 active physicians in the province of Alberta, of whom we further identified n=194 (1.7%) as University of Ottawa (uOttawa) graduates, n=955 (8.4%) as French-speaking, and n=4,965 (43.7%) as community-based family physicians. French-speaking physicians were concentrated in Census Division 6 (n=464, 48.6%) surrounding Calgary and Census Division 11 (n=356, 37.3%) surrounding Edmonton. Overall reported French-language ability was low, with just 955 (8.4%) of all active physicians reporting competency in French. uOttawa graduates (n=70, 36.1%) were much more likely to report French ability than graduates of other schools (n=885, 7.9%), women (n=457, 9.6%) were slightly more likely than men (n=497, 7.6%), and specialists (n=666, 10.4%) were more likely than family physicians (n=289, 5.8%).

ObjectivesTo determine the diagnostic yield of screening patients for SARS-CoV-2 who were admitted with a diagnosis unrelated to COVID-19, and identify risk factors for positive tests. DesignCohort from the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry Setting30 acute care hospitals across Canada ParticipantsPatients hospitalized for non-COVID-19 related diagnoses who were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 1, and December 29, 2020 Main outcomePositive nucleic acid amplification test (NAAT) for SARS-CoV-2 Outcome measureDiagnostic yield ResultsWe enrolled 15,690 consecutive eligible adults who were admitted to hospital without clinically suspected COVID-19. Among these patients, 122 tested positive for COVID-19, resulting in a diagnostic yield of 0.8% (95% CI 0.64% - 0.92%). Factors associated with a positive test included presence of a fever, being a healthcare worker, having a positive household contact or institutional exposure, and living in an area with higher 7-day average incident COVID-19 cases. ConclusionsUniversal screening of hospitalized patients for COVID-19 across two pandemic waves had a low diagnostic yield and should be informed by individual-level risk assessment in addition to regional COVID-19 prevalence. Trial registrationNCT04702945 SUMMARY BOXESSection 1: Universal screening of admitted patients for SARS-CoV-2 was implemented in many hospitals at the beginning of the pandemic. The Infections Diseases Society of America (IDSA) recommended avoiding universal screening of asymptomatic hospitalized patients in areas and times of low-COVID prevalence (defined as <2% prevalence) with very low certainty of evidence, based on studies of COVID-19 prevalence among asymptomatic individuals in the community. Section 2: This study supports IDSA recommendations to avoid universal screening for COVID-19 in times and areas of low COVID prevalence and identifies patient-level risk factors strongly associated with positive testing that should be considered for screening.

BackgroundHaving temporary immigration status affords limited rights, workplace protections, and access to services. There is not yet research data on impacts of the COVID-19 pandemic for people with temporary immigration status in Canada. MethodsWe use linked administrative data to describe SARS-CoV-2 testing, positive tests, and COVID-19 primary care service use in British Columbia from January 1, 2020, to July 31, 2021, stratified by immigration status (Citizen, Permanent Resident, Temporary Resident). We plot the rate of people tested and the rate of people confirmed positive for COVID-19 by week from April 19, 2020, to July 31, 2021, across immigration groups. Results4.9% of people with temporary immigration status had a positive test for SARS-CoV-2 over this period, compared to 4.0% among people with permanent residency and 2.1% among people who hold Canadian citizenship. This pattern is persistent by sex/gender, age group, neighborhood income quintile, health authority, and in both metropolitan and small urban settings. At the same time we observe lower access to testing and COVID-19 related primary care among people with temporary status. InterpretationPeople with temporary immigration status in BC experience higher SARS-CoV-2 test positivity; alarmingly, this was coupled with lower access to testing and primary care. Interwoven immigration, health and occupational policies place people with temporary status in circumstances of precarity and higher health risk. Extending permanent residency status to all immigrants residing in Canada and decoupling access to health care from immigration status could reduce precarity due to temporary immigration status.

BackgroundRural emergency departments (EDs) are critical to ensuring equitable access to acute care, yet face persistent systemic challenges. In Quebec, Canada, reforms to healthcare governance, funding and resource allocation, and service delivery have transformed rural ED operations. This study aimed to document characteristics, challenges, and improvement priorities for all rural EDs in the province. MethodsA participatory mixed-methods design was used. 26 rural EDs in Quebec were included. Data sources comprised administrative statistics, structured site surveys, individual stakeholder semi structured interviews, and a validation survey of identified local champions. Analyses comprised a triangulation of the quantitative and qualitative data using transversal thematic analysis to determine common issues. Potential solutions identified were validated through stakeholder questionnaires. The study was reported in accordance with the COREQ reporting guideline. ResultsMost respondents were women (64%) and professionals with more than 5 years of experience. Four main themes were identified: governance, healthcare organization, access to resources, and professional practice. Governance challenges included reduced local autonomy, administrative complexity, and budgeting models poorly adapted to rural realities. Participants emphasized the need for standardized but locally flexible administrative processes, regional emergency service managers, and rural-sensitive performance metrics. Organizational barriers included geographic isolation, limited access to primary care, and difficulties with interfacility transfers due to referral-center capacity and ambulance shortages. Resource constraints centered on shortages of human resources, diagnostic services and specialty coverage, especially anesthesia, obstetrics, and psychiatry. Professional practice was shaped by the need to maintain broad competencies in low-volume contexts, while contending with professional isolation and proximity to patients. Local champions prioritized expanding telemedicine, strengthening prehospital services, enhancing continuing education, and implementing tailored recruitment strategies. ConclusionThis study provides the first province-wide documentation of characteristics, challenges, and improvement priorities for all rural EDs. Findings highlight the need for systemic reforms that restore local decision-making authority, strengthen transfer and prehospital capacity, expand telehealth and specialty access, and support professional development. These results provide a foundation for evidence-based policies and actions to sustain equitable emergency care in rural regions.

BackgroundThe requirement for critical care in even a modest fraction of SARS-CoV-2 infected individuals made ICU resources an important societal chokepoint during the recent pandemic. We developed a simple regression-based point score in 2020 based on an objective of forecasting critical care occupancy in the Canadian province of Ontario based on mean age of cases, case numbers, and testing volume. Evolution of the pandemic (variants of concern, vaccination) led us to re-assess and re-calibrate our earlier work, with inclusion of information vaccination which became widespread in 2021. MethodsWe obtained complete provincial SARS-CoV-2 case, testing, and vaccination data for the period from March 2020 to September 2022, with data subdivided into 6 major "waves", following the approach applied by other Canadian investigators. Our initial model was fit only using the first two "wild type" SARS-CoV-2 waves; an updated model included wave 3 (N501Y+ variants). Our model was validated by comparing model projections to waves not used for model fitting; validation model fits were evaluated with Spearmans rho; counterfactuals without vaccination were modeled to impute fraction of critical care admissions prevented with vaccination. Costing was based on published economic estimates. ResultsOur initial model (fit to waves 1 and 2) was well calibrated (rho 0.85) but predictive validity was modest (rho 0.46). Predictive validity improved in models fit to the first 3 pandemic waves without vaccination (rho 0.60) or with vaccination (rho 0.68) (P for inclusion of vaccination 0.013 by Likelihood Ratio Test). Prevented fraction of ICU admissions attributable to vaccination was 144% (22017 admissions expected vs. 9020 observed); based on published estimates of ICU admission cost for SARS-CoV-2 the 12977 admissions averted $2.9 (CDN) billion in economic costs, in contrast to the $3 billion total cost of the vaccination program. ConclusionsSimple time series regression incorporating case and testing characteristics continues to be useful as a tool for forecasting critical care occupancy due to SARS-CoV-2 but early pandemic models need to be updated to capture the preventive effects of widespread vaccination. The economic benefit of vaccination for prevention of critical care resource consumption during the pandemic is substantial, achieving near cost neutrality with the provinces entire vaccination program.

IntroductionNational responses to the SARS-CoV-2 pandemic have been highly variable, which may explain some of the heterogeneity in the pandemics health and economic impacts across the world. We sought to explore the effectiveness of the Canadian pandemic response relative to responses in four peer countries with similar political, economic and health systems, and with close historical and cultural ties to Canada (the United States, United Kingdom, France, and Australia) from March 2020 to May 2022. MethodsWe used reported age-specific mortality data to generate estimates of pandemic mortality standardized to the Canadian population. Age-specific case fatality, hospitalization, and intensive care admission probabilities for the Canadian province of Ontario were applied to estimated deaths in order to calculate hospitalizations and intensive care admissions averted by the Canadian response. The monetary value of averted hospitalizations was estimated using cost estimates from the Canadian Institute for Health Information. Age-specific quality-adjusted life-years (QALY) lost due to fatality were estimated using published estimates. QALY were monetized using a net expected benefit approach. ResultsRelative to the United States, United Kingdom, and France, the Canadian pandemic response was estimated to have averted 94,492, 64,306 and 13,641 deaths respectively, with more than 480,000 hospitalizations averted, and 1 million QALY saved, relative to the United States. A United States pandemic response applied to Canada would have resulted in more than $40 billion in economic losses due to healthcare expenditures and lost QALY; losses relative to the United Kingdom and France would have been $21 billion and $5 billion respectively. By contrast, an Australian pandemic response would have averted over 28,000 additional deaths and averted nearly $9 billion in costs in Canada. ConclusionsCanada outperformed peer countries that aimed for mitigation, rather than elimination, of SARS-CoV-2 in the first two years of the pandemic, likely because of a more stringent public health response to disease transmission. This resulted in substantial numbers of lives saved and economic costs averted. However, comparison with Australia demonstrates that an elimination focus would have allowed Canada to save tens of thousands of lives, and would have saved substantial economic costs.

AO_SCPLOWBSTRACTC_SCPLOWO_ST_ABSObjectivesC_ST_ABSTo measure the population-based performance and impact of Ontario, Canadas modified-contingent prenatal screening system for the detection of trisomies 21 (T21) and 18 (T18). DesignA retrospective, descriptive cohort study examining routinely collected data from BORN Ontario, which captures linkable population data for prenatal and neonatal health encounters across a variety of settings (e.g., laboratories, birthing hospitals and midwifery practice groups). SettingA province-wide and publicly funded prenatal screening program in Ontario, Canada offering cfDNA screening for those at increased risk of having a pregnancy with T21 or T18. Participants373,682 singleton pregnancies with an estimated due date between September 1 2016 and March 31, 2019 who were offered publicly funded prenatal screening. Main outcome measuresPrenatal detection of T21 or T18, ascertained by cytogenetic results. Performance was assessed by calculating sensitivity, specificity, positive predictive value and negative predictive value against confirmatory diagnostic cytogenetic results and birth outcomes. The secondary objective was to determine the impact of contingent cfDNA screening by measuring uptake and the proportion of T21 screen-positive pregnancies undergoing subsequent cfDNA screening and invasive prenatal diagnostic testing (PND). Results69% of pregnancies in Ontario underwent prenatal screening for T21/T18. The modified-contingent screen sensitivity was 89.9% for T21 and 80.5% for T18. The modified-contingent screen-positive rate was 1.6% for T21 and 0.2% for T18. The cfDNA screening test failure rate was 2.2% (final result including multiple attempts). The PND rate among pregnancies screened was 2.4%. ConclusionsThis study is the largest evaluation of population-based performance of a publicly funded cfDNA prenatal screening system. We demonstrated a robust screening system with high sensitivity and low PND consistent with smaller validation studies

AbstractO_ST_ABSObjectivesC_ST_ABSCompare the average cost of an emergency department (ED) visit between three ED care models, namely management by an emergency physician (EP) alone (usual care), management by a primary contact physiotherapist (PT) and an EP (intervention), and management by a PT alone (sensitivity analysis). MethodsCost study (Canadian Public Payer perspective) based on data collected during a pragmatic randomized clinical trial (2018-2019) conducted in an urban Canadian academic ED (CHUL, Quebec City, Canada; n=78, 18-80 years old). Costs incurred for the management of persons presenting to the ED for a minor musculoskeletal disorder (MSKD) were calculated using Time-Driven Activity-Based Costing, in which time invested with a patient determines care costs. The main outcome measure was the average cost of an ED visit. Generalized linear models with Gamma distributions and log links were used to assess whether there were significant differences in average costs between the care models. ResultsMean ED visit cost was $267.08 (2019 $CAD, 95%CI: $212.75, $346.40) for PT and EP management, compared with $245.14 for EP management ($169.46, $336.72), resulting in a non- significant absolute difference of 21.94 CAD/patient ($-87.33, $132.63) between models (p=.60). Sensitivity analyses showed that the average cost of ED management by a PT was $194.38 ($161.50, $234.34), representing a non-significant average saving of 50.76 CAD/patient ($- 156.91, $37.54) compared to EP management. ConclusionThis study is a first step towards a better understanding of the costs incurred by the Canadian Public Payer for the management of persons presenting with MSKDs in the ED. Primary contact physiotherapists have the potential to complement care of MSKD ED patients without increasing healthcare costs.

BackgroundVirtual care for patients with COVID-19 allows providers to monitor COVID-19 positive patients with variable trajectories while reducing the risk of transmission to others and managing healthcare capacity in acute care facilities. ObjectiveTo develop and test the feasibility of a family medicine-led remote monitoring model of care (COVIDCare@Home program) to manage patients with COVID-19 in the community. MethodsThis multi-faceted, family medicine-led, interprofessional team-based remote monitoring program was developed at Womens College Hospital in Toronto, Ontario. A cross-sectional chart review of the first cohort of patients was conducted and learnings from the implementation of CovidCare@Home are described. ResultsDuring the study period, April 8 to May 11, 2020, there were 97 patients (average age 48.6, 62% female) with 424 recorded virtual visits with a median virtual length of stay of 8 days (IQR 5). 5.2% required escalation to an in-person visit with no patients requiring hospitalization. 16% of patients required support with mental and social health needs. InterpretationsA family medicine-led, team-based remote monitoring program can safely be used to manage outpatients diagnosed with COVID-19. Attention to mental and social health needs is critical for this population. Future efforts should consider how to design programs to best support populations disproportionately impacted by COVID-19, something which primary care is well-positioned to do. Further analysis will describe the effectiveness, impact, and satisfaction with the program among patients and providers.

VISUAL ABSTRACT CAN BE FOUND HERE ObjectivesIn the first full year of the COVID-19 pandemic (2020), South Asians living in the Greater Toronto Hamilton and Vancouver Areas experienced specific barriers to accessing SARS-CoV-2 testing and receiving reliable health information. However, between June 2021 and February 2022, the proportion of people having received at least 1 dose of a COVID-19 vaccine was higher among this group (96%) than among individuals who were not visible minorities (93%). A better understanding of successful approaches and the challenges experienced by those who remain unvaccinated among this highly vaccinated group may improve public health outreach in subsequent waves of the current pandemic or for future pandemic planning. Using qualitative methods, we sought to explore the perceptions of COVID-19 risk, vaccine access, uptake, and confidence among South Asians living in Canada. MethodsIn this qualitative study, we interviewed 25 participants between July 2021 and January 2022 in the Greater Toronto Hamilton and Greater Vancouver Areas (10 community members, 9 advocacy group leaders, 6 public health staff). We conducted initial and focused coding in duplicate and developed salient themes. Throughout this process, we held frequent discussions with members of the studys advisory group to guide data collection as it relates to community engagement, recruitment, and data analysis. ResultsAccess to and confidence in the COVID-19 vaccine was impacted by individual risk perceptions; sources of trusted information (ethnic and non-ethnic); impact of COVID-19 and the pandemic on individuals, families, and society; and experiences with COVID-19 mandates and policies (including temporal and generational differences). Approaches that include community-level awareness and tailored outreach as it relates to language and cultural context were considered successful. ConclusionUnderstanding factors and developing strategies that build vaccine confidence can guide our approach to increase vaccine acceptance in the current and future pandemics.

BackgroundWe compared the risk of, testing for, and death following COVID-19 infection across three settings (long-term care homes (LTCH), shelters, the rest of the population) in the Greater Toronto Area (GTA), Canada. MethodsWe sourced person-level data from COVID-19 surveillance and reporting systems in Ontario, and examined settings with population-specific denominators (LTCH residents, shelters, and the rest of the population). We calculated cumulatively, the diagnosed cases per capita, proportion tested for COVID-19, daily and cumulative positivity, and case fatality proportion. We estimated the age- and sex-adjusted relative rate ratios for test positivity and case fatality using quasi-Poisson regression. ResultsBetween 01/23/2020-05/25/2020, we observed a shift in the proportion of cases: from travel-related and into LTCH and shelters. Cumulatively, compared to the rest of the population, the number of diagnosed cases per 100,000 was 59-fold and 18-fold higher among LTCH and shelter residents, respectively. By 05/25/2020, 77.2% of LTCH residents compared to 2.4% of the rest of the population had been tested. After adjusting for age and sex, LTCH residents were 2.5 times (95% confidence interval (CI): 2.3-2.8) more likely to test positive. Case fatality was 26.3% (915/3485), 0.7% (3/402), and 3.6% (506/14133) among LTCH residents, shelter population, and others in the GTA, respectively. After adjusting for age and sex, case fatality was 1.4-fold (95%CI: 1.1-1.9) higher among LTCH residents than the rest of the population. InterpretationHeterogeneity across micro-epidemics among specific populations in specific settings may reflect underlying heterogeneity in transmission risks, necessitating setting-specific COVID-19 prevention and mitigation strategies.

BackgroundUse of masks and respirators for prevention of respiratory infectious disease transmission is not new, but has proven controversial, and even politically polarizing during the SARS-CoV-2 pandemic. In the Canadian province of Ontario, mask mandates were introduced by the 34 regional health authorities in an irregular fashion from June to September 2020, creating a quasi-experiment that can be used to evaluate impact of community mask mandates. Ontario SARS-CoV-2 case counts were strongly biased by testing focussed on long-term care facilities and healthcare workers. We developed a simple regression-based test-adjustment method that allowed us to adjust cases for undertesting by age and gender. We used this test- adjusted time series to evaluate mask mandate effectiveness. MethodsWe evaluated the effect of masking using count-based regression models that allowed adjustment for age, sex, public health region and time trends with either reported (unadjusted) cases, or testing-adjusted case counts, as dependent variables. Mask mandates were assumed to take effect in the week after their introduction. Model based estimates of effectiveness were used to estimate the fraction of SARS- CoV-2 cases, severe outcomes, and costs, averted by mask mandates. ResultsModels that used unadjusted cases as dependent variable identified protective effects of masking (effectiveness 15-42%), though effectiveness was variably statistically significant, depending on model choice. Mask effectiveness in models predicting test-adjusted case counts was substantially higher, ranging from 49% (44- 53%) to 73% (48-86%) depending on model choice. Effectiveness was greater in women than men (P = 0.016), and in urban health units as compared to rural units (P < 0.001). The prevented fraction associated with mask mandates was 46% (41-51%), averting approximately 290,000 clinical cases, averting 3008 deaths and loss of 29,038 QALY. Costs averted represented $CDN 610 million in economic wealth. ConclusionsLack of adjustment for SARS-CoV-2 undertesting in younger individuals and males generated biased estimates of infection risk and obscures the impact of public health preventive measures. After adjustment for under-testing, the effectiveness of mask mandates emerges as substantial, and robust regardless of model choice. Mask mandates saved substantial numbers of lives, and prevented economic costs, during the SARS-CoV-2 pandemic in Ontario, Canada.

BackgroundA hospital-level pandemic response involves anticipating local surge in healthcare needs. MethodsWe developed a mechanistic transmission model to simulate a range of scenarios of COVID-19 spread in the Greater Toronto Area. We estimated healthcare needs against 2019 daily admissions using healthcare administrative data, and applied outputs to hospital-specific data on catchment, capacity, and baseline non-COVID admissions to estimate potential surge by day 90 at two hospitals (St. Michaels Hospital [SMH] and St. Josephs Health Centre [SJHC]). We examined fast/large, default, and slow/small epidemics, wherein the default scenario (R0 2.4) resembled the early trajectory in the GTA. ResultsWithout further interventions, even a slow/small epidemic exceeded the citys daily ICU capacity for patients without COVID-19. In a pessimistic default scenario, for SMH and SJHC to remain below their non-ICU bed capacity, they would need to reduce non-COVID inpatient care by 70% and 58% respectively. SMH would need to create 86 new ICU beds, while SJHC would need to reduce its ICU beds for non-COVID care by 72%. Uncertainty in local epidemiological features was more influential than uncertainty in clinical severity. If physical distancing reduces contacts by 20%, maximizing the diagnostic capacity or syndromic diagnoses at the community-level could avoid a surge at each hospital. InterpretationAs distribution of the citys surge varies across hospitals over time, efforts are needed to plan and redistribute ICU care to where demand is expected. Hospital-level surge is based on community-level transmission, with community-level strategies key to mitigating each hospitals surge.

BackgroundThe increased use of telemedicine during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of telemedicine use prior to ED admissions and characterized the patients with prior telemedicine use and the physicians who provided these outpatient visits. MethodsWe conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization. ResultsThere were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%). InterpretationThe net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seems to be able to appropriately triage patients to the ED and may even prove beneficial for diverting patients away from the ED when an ED admission is not appropriate. The COVID-19 pandemic has led to the emergence of standard use of telemedicine in health care across the globe(1,2). In Ontario, Canada the proportion of ambulatory visits completed virtually has been maintained at slightly above 50% from 2020 to 2021 (3). Despite its widespread adoption, it is still unclear when virtual visits are clinically appropriate and how such wide use of telemedicine impacts patient outcomes and healthcare utilization metrics. Before the pandemic, there had been concerns that telemedicine may lead to an increased use of outpatient services with patients having both a virtual and an in-person visit for the same clinical issue(4,5). For example, pre-pandemic data (2007-2016) from Manitoba showed that telemedicine users had on average 1.3 times more ambulatory visits than non-users.(6) In addition, studies have produced mixed evidence with regard to the effect of telemedicine on urgent services such as emergency department (ED) admissions and hospitalizations (7). Many of the studies reported in the literature are based on data from site-specific programs and therefore have limited generalizability. Finally, policymakers and some physicians have become concerned that the high rates of telemedicine during COVID-19 have led to an increase in emergency department admissions because of poor access to in-person outpatient care (8). This concern is exacerbated when one considers rural and lower socioeconomic status patients who already had poor access to care before the pandemic(9). Combined with reports of lower uptake of telemedicine among these patients(10,11), it is not clear how the transition of care from in-person to virtual impacts ED use. The high adoption of telemedicine during the pandemic, in the context of a publicly funded healthcare system allowing us access to most visits across the entire population, offers a unique opportunity to examine the frequency of telemedicine use prior to ED admissions. Therefore, the goal of this study was to characterize the frequency and modality (in-person vs virtual) of outpatient care prior to ED admissions. We examined whether there was an overall increase in outpatient visits prior to ED admissions during a period of the pandemic when access to telemedicine was available compared to a seasonality matched period before the pandemic where access to telemedicine was quite limited. We also aimed to characterize the patients who had a telemedicine visit prior to an ED admission vs. those who had an in-person visit and the physicians who saw patients with virtual only visits prior to their ED admission compared to those who saw patients virtually or in-person prior to their ED admission.

As telehealth is being integrated into a regularly functioning system, policy makers have been adding some restrictions related to its use (e.g. modalities and pre-existing in-person relationship rules). We explored how the new policies impacted the levels of use across telehealth modalities and if the impact varied across sociodemographic and chronic condition groups of patients. This is a population-based repeated cross-sectional study examining all outpatient visits in Ontario, Canada on a weekly basis from the week of January 1st, 2018 until the week of December 25th, 2023. We used linked health administrative databases of health services provided to all Ontario residents who are insured through the Ontario Health Insurance Plan (OHIP). We examined the total number of visits and the rates of in-person and telehealth visits per 1000 persons per week. Across Ontario, there were 115 046 536 telehealth visits during the study time period (26.4% of all ambulatory care). There was a 6.7% reduction in telehealth and a 10% reduction in the number of physicians using telehealth at the beginning of December 2022 when the new policies were introduced. This was in the absence of a reduction of total ambulatory visits. The impact varied across medical specialties, patient age groups, rurality and chronic conditions, but seemingly not across sex or income quintiles. The use of video increased slightly over the study period with 1 in 4 telehealth visits occurring over video. While the policy changes led to an overall reduction in telehealth use, the total ambulatory visits did not change, suggesting a shift of care from virtual to in-person. The adoption of video increased, but future studies should focus on exploring whether there are clear benefits of using video over telephone, as certain groups of patients may be impacted more than others. Author SummaryAs healthcare systems returned to normal functioning after the pandemic, rules around the use of telehealth (use of telephone and video to provide care) changed. For example, in Ontario, Canada, physicians were paid on par for video visits as in-person visits, but telephone visits were paid at 85% of the rate. In addition, the government introduced requirements related to whether a patient has been seen in-person by a physician within the last two years prior to a telehealth visit. Our study explored the impact of these changes using physician billing data. Overall, there was a 6.7% reduction in telehealth and a 10% reduction in the number of physicians using telehealth when the new policies were introduced in Dec, 2022. The impact varied across medical specialties, patient age groups, rurality and chronic conditions, but seemingly not across sex or income quintiles. Overall outpatient visits were not impacted, suggesting that care shifted back to in-person. The majority of telehealth still occurred over telephone, despite a slight increase in the use of video after the policies were introduced.

COVID-19 presented a crisis for long-term care homes (LTCHs) and retirement homes (RHs). This study explored the pandemic-related challenges LTCHs and RHs faced and the strategies they used to mitigate them. Ninety-one key informant interviews were conducted with LTCH and RH leadership across 47 homes (33 LTCHs, 14 RHs) in Ontario, Canada from February 2021 to July 2022. Findings confirmed evidence for three main challenges. First, leaders were challenged to implement infection prevention and control protocols and measures. Second, they needed supports to facilitate COVID-19 vaccine access and to promote vaccine confidence. Third, LTCH/RH staff experienced significant well-being challenges in the face of COVID-19 pressures. Findings also reveal a plethora of strategies implemented by homes, with ranging reports of perceived success. Homes needs evolved rapidly as the COVID-19 pandemic progressed. The use of a co-creation, responsive and tailored approach to address evolving barriers and meaningfully support homes during emergencies is recommended. Key pointsO_LICOVID-19 challenges in homes persisted over one year into the pandemic C_LIO_LIWe describe the IPAC, vaccine and wellness challenges faced by LTCH and RH C_LIO_LIWe used these data to design a congregate care home support program to navigate COVID-19 challenges C_LI

The pandemic caused by SARS-CoV-2 has proven challenging clinically, and at the population level, due to heterogeneity in both transmissibility and severity. Recent case incidence in Ontario, Canada (autumn 2020) has outstripped incidence in seen during the first (spring) pandemic wave; but has been associated with a lower incidence of intensive care unit (ICU) admissions and deaths. We hypothesized that differential ICU burden might be explained by increased testing volumes, as well as the shift in mean case age from older to younger. We constructed a negative binomial regression model using only three covariates, at a 2-week lag: log10(weekly cases); log10(weekly deaths); and mean weekly case age. This model reproduced observed ICU admission volumes, and demonstrated good preliminary predictive validity. Furthermore, when admissions were used in combination with ICU length of stay, our modeled estimates demonstrated excellent convergent validity with ICU occupancy data reported by the Canadian Institute for Health Information. Our approach needs external validation in other settings and at larger and smaller geographic scales, but appears to be a useful short-term forecasting tool for ICU resource demand; we also demonstrate that the virulence of SARS-CoV-2 infection has not meaningfully changed in Ontario between the first and second waves, but the demographics of those infected, and the fraction of cases identified, have.

BackgroundThe COVID-19 pandemic placed immense strain on Canadas healthcare system and disproportionately affected individuals with poorer baseline health. Healthcare-associated infections (HAIs) increase risk for both patients and healthcare workers and are often more severe due to advanced age and comorbidities. While efforts have aimed to reduce in-hospital transmission, the individual- and community-level consequences of HAIs require further study. We aimed to assess whether healthcare-associated COVID-19 cases had higher odds of death compared to hospitalized community-acquired cases, and to evaluate the directionality of transmission between hospitals and the community. MethodsWe analyzed COVID-19 surveillance data from Ontarios Case Contact and Management System and the COVaxON vaccine registry (March 17, 2020, to September 4, 2022). Latent class analysis was used to classify hospitalized cases by likelihood of healthcare-associated infection. Mortality odds by category were estimated using binomial logistic regression. Directionality between hospital outbreaks and community cases was assessed using a modified Granger causality approach. FindingsCompared to patients with low likelihood of healthcare-associated infection, those moderately likely to have acquired COVID-19 in hospital had elevated odds of death (OR: 1.26, 95% CI: 1.14-1.40); no significant increase was seen in the high-likelihood group (OR: 1.05, 95% CI: 0.96-1.15). Community cases did not predict hospital outbreaks (p=0.5749), but hospital outbreaks predicted community case growth (p<0.0001). InterpretationHospital-acquired COVID-19 is associated with excess mortality and may drive community transmission. Preventing in-hospital transmission is critical to protecting patients and controlling broader epidemic spread. FundingSupported by a Canadian Institutes for Health Research project grant, #518192.

During the COVID-19 pandemic the World Health Organization updated guidelines for travel measure implementation to recommend consideration of a regions specific epidemiological, health system, and socioeconomic context. As such, travel measure implementation decisions require region-specific data, analysis, and models to support risk assessment frameworks. From May 2020 to May 2021, the Canadian province of Newfoundland and Labrador (NL) implemented travel measures that required self-isolation and testing of individuals returning from out-of-province travel. We found that during the pandemic travel to NL decreased by 82%. Our best model was 135 times more likely to explain reported travel-related cases arriving in NL than a model where travel volume and infection data did not consider the Canadian jurisdiction of origin. To test an approach used in other studies, we formulated a model without considering the travel-related case data and found that this model performed very poorly. We conclude that importation models need to be supported with data describing the daily number of travel-related cases arriving in Canadian jurisdictions and daily travel volumes originating from each country and each Canadian province and territory. While there was some reporting of this information during the COVID-19 pandemic, these data were not consistently reported or easily accessible.

Background: The SARS-CoV-2 disease 2019 (COVID-19) pandemic has spread across the world with varying impact on health systems and outcomes. We assessed how the type and timing of public-health interventions impacted the course of the outbreak in Alberta and the other Canadian provinces. Methods: We used publicly-available data to summarize rates of laboratory data and mortality in relation to measures implemented to contain the outbreak and testing strategy. We estimated the transmission potential of SARS-CoV-2 before the state of emergency declaration for each province (R0) and at the study end date (Rt). Results: The first cases were confirmed in Ontario (January 25) and British Columbia (January 28). All provinces implemented the same health-policy measures between March 12 and March 30. Alberta had a higher percentage of the population tested (3.8%) and a lower mortality rate (3/100,000) than Ontario (2.6%; 11/100,000) or Quebec (3.1%; 31/100,000). British Columbia tested fewer people (1.7%) and had similar mortality as Alberta. Data on provincial testing strategies were insufficient to inform further analyses. Mortality rates increased with increasing rates of lab-confirmed cases in Ontario and Quebec, but not in Alberta. Ro was similar across all provinces, but varied widely from 2.6 (95% confidence intervals 1.9-3.4) to 6.4 (4.3-8.5), depending on the assumed time interval between onset of symptoms in a primary and a secondary case (serial interval). The outbreak is currently under control in Alberta, British Columbia and Nova Scotia (Rt <1). Interpretation: COVID-19-related health outcomes varied by province despite rapid implementation of similar health-policy interventions across Canada. Insufficient information about provincial testing strategies and a lack of primary data on serial interval are major limitations of existing data on the Canadian COVID-19 outbreak.