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ObjectivesOccupational gender segregation is a contributing factor to gender pay inequity in medicine but has not been thoroughly characterised. We assessed the historical relationship between surgeon sex, type of work and value of procedural payments. We hypothesised that female surgeons perform lower-paying procedures as a group, and that this could be seen both with broad historical overview and with focused analysis of major operative procedures in a specific year.DesignWe conducted repeated cross-sectional studies using public payment data from the Canadian Institute for Health Information. We calculated average payment per service by sex and service category and used linear regression to assess the association between proportion of female surgeons performing a procedure and payment value per procedure for 41 major procedures in 2019–2020.ParticipantsSurgeons in 10 Canadian jurisdictions from 1996 to 1997 (5459) to 2019–2020 (8069).ResultsThe proportion of female surgeons increased over the study period from 10.5% (n=575) in 1996–1997 to 28.7% (n=2314) in 2019–2020. The sex gap in the average payment per service narrowed but persisted. A greater proportion of women’s earnings came from non-procedural work in consultation and visits (43% for women vs 36% for men in 2019–2020) while a greater proportion of men’s earnings was from procedural work in major surgery (23% for women vs 38% for men in 2019–2020). There was an inverse relationship between proportion of women performing a procedure and payment value such that for one percent increase in female proportion, the procedural payment was CAD$1.77 lower.ConclusionsOur findings suggest that women receive fewer procedural payments than men and tend to perform lower paying procedures. Reforms to referral systems and billing codes can help address root causes for the gender pay gap in surgery.

Ischemic heart disease (IHD) is one of the leading causes of death worldwide. While extreme summer surface air temperatures are thought to be a risk factor for IHD, it is unclear whether large-scale climate patterns also influence this risk. This multi-national population-based study investigated the association between summer Pacific and Atlantic sea surface temperature (SST) variability and annual acute myocardial infarction (AMI) or IHD event rates among older adults residing in North America and the United Kingdom. Overall, a shift from cool to warm phase of the El Niño Southern Oscillation (ENSO) was associated with reduced AMI admissions in western Canada (adjusted rate ratio [RR] 0.89; 95% CI, 0.80–0.99), where this climate pattern predominatly forces below-normal cloud cover and precipitation during summertime, and increased AMI deaths in western United States (RR 1.09; 95% CI, 1.04–1.15), where it forces increased cloud cover and precipitation. Whereas, the Atlantic Multidecadal Oscillation (AMO) during a strong positive phase was associated with reduced AMI admissions in eastern Canada (RR 0.93; 95% CI, 0.87–0.98) and increased IHD mortality during summer months in the United Kingdom (RR 1.08; 95% CI, 1.03–1.14). These findings suggest that SST variability can be used to predict changes in cardiovascular event rates in regions that are susceptible.

Diverse strategies are needed to reduce frailty. This study evaluated the effects of two behavioural interventions targeting outdoor walking on reducing the level of frailty among community-dwelling older adults with mobility limitations. Data from two participant cohorts of the Getting Older Adults Outdoors (GO-OUT) study were analyzed. After baseline evaluations, 190 participants were invited to a one-day educational workshop and were then randomized to either a 10-week supervised outdoor walk group (n = 98) or a 10-week telephone weekly reminders group (n = 92). Frailty was assessed using Fried's frailty index at 0, 3, and 5.5 months. Mixed-effects linear and ordinal regression models were used to evaluate change in frailty score and phenotype over time after accounting for age, sex, study site, participation on own or with a partner, and cohort. At baseline, participant mean age was 74.5 ± 7.1 years; 73% were female, 7% were frail, and 59% were pre-frail. Total frailty scores decreased, on average, by 0.13 points (b = -0.13, 95% CI: -0.26 to -0.01; p = .036) across all participants from 0 to 3 months (immediately post-intervention). Participants were 55% less likely to progress to more severe frailty phenotypes at 3 months compared to baseline (OR=0.45; 95% CI: 0.25 to 0.81; p = .008). No significant between-group differences or long-term effects were observed. A short-term reduction in frailty was observed in older adults with mobility limitations following participation in behavioural interventions aimed at improving outdoor walking; neither intervention was superior. Supervised outdoor walk group and telephone weekly reminder interventions to increase outdoor walking may have the potential to mitigate frailty in older adults with mobility limitations.

The Getting Older Adults Outdoors (GO-OUT) randomized trial showed that a 10-week outdoor walk group (OWG) program was not superior to 10 weekly phone reminders in increasing physical and mental health; however, OWG attendance varied. This study examined whether dose-response relationships existed between OWG attendance and improvement in physical and mental health among older adults with mobility limitations. We analyzed data from 76 OWG participants with pre- and post-intervention scores on at least one of seven measures of health outcomes (walking endurance, comfortable and fast walking speed, balance, lower extremity strength, walking self-efficacy, and emotional well-being). Participants were classified as attending 0-9, 10-15, and 16-20 OWG sessions based on attendance tertiles. We adjusted for participant sex and study site in regression analyses. Among the 76 participants, mean age was 74.9 ± 6.6 years and 72% were female. Compared to those attending 0-9 OWG sessions, participants attending 16-20 sessions exhibited a 56.3-meter greater improvement in walking endurance (95% CI: 17.3, 95.4, p = 0.005); 0.15-meter/second greater improvement in comfortable walking speed (95% CI: 0.01, 0.29, p = 0.034); and 0.18-meter/second greater improvement in fast walking speed (95% CI: 0.03, 0.34, p = 0.020). Higher attendance was associated with greater odds of improvement in comfortable walking speed (OR = 7.1; 95% CI: 1.1, 57.8, p = 0.047) and fast walking speed (OR = 10.1, 95% CI: 1.8, 72.0, p = 0.014). No significant dose-response relationships for the remaining outcomes were observed. Higher attendance in a park-based, supervised, task-oriented and progressive OWG program is associated with greater improvement in walking endurance and walking speed among older adults with mobility limitations. Attendance likely impacted walking capacity and not balance, lower extremity strength, walking self-efficacy or emotional well-being due to task-specificity of training. This study highlights the importance of attendance when designing and implementing OWG programs to enhance walking endurance and speed among older adults.

Related Article This is a corrected version. See correction statement in: https://mental.jmir.org/2020/9/e24131/ Background: A student mental health crisis is increasingly acknowledged and will only intensify with the COVID-19 crisis. Given accessibility of methods with demonstrated efficacy in reducing depression and anxiety (eg, mindfulness meditation and cognitive behavioral therapy [CBT]) and limitations imposed by geographic obstructions and localized expertise, web-based alternatives have become vehicles for scaled-up delivery of benefits at modest cost. Mindfulness Virtual Community (MVC), a web-based program informed by CBT constructs and featuring online videos, discussion forums, and videoconferencing, was developed to target depression, anxiety, and experiences of excess stress among university students. Objective: The aim of this study was to assess the effectiveness of an 8-week web-based mindfulness and CBT program in reducing symptoms of depression, anxiety, and stress (primary outcomes) and increasing mindfulness (secondary outcome) within a randomized controlled trial (RCT) with undergraduate students at a large Canadian university. Methods: An RCT was designed to assess undergraduate students (n=160) who were randomly allocated to a web-based guided mindfulness–CBT condition (n=80) or to a waitlist control (WLC) condition (n=80). The 8-week intervention consisted of a web-based platform comprising (1) 12 video-based modules with psychoeducation on students’ preidentified life challenges and applied mindfulness practice; (2) anonymous peer-to-peer discussion forums; and (3) anonymous, group-based, professionally guided 20-minute live videoconferences. The outcomes (depression, anxiety, stress, and mindfulness) were measured via an online survey at baseline and at 8 weeks postintervention using the Patient Health Questionnaire-9 (PHQ9), the Beck Anxiety Inventory (BAI), the Perceived Stress Scale (PSS), and the Five Facets Mindfulness Questionnaire Short Form (FFMQ-SF). Analyses employed generalized estimation equation methods with AR(1) covariance structures and were adjusted for possible covariates (gender, age, country of birth, ethnicity, English as first language, paid work, unpaid work, relationship status, physical exercise, self-rated health, and access to private mental health counseling). Results: Of the 159 students who provided T1 data, 32 were males and 125 were females with a mean age of 22.55 years. Participants in the MVC (n=79) and WLC (n=80) groups were similar in sociodemographic characteristics at T1 with the exception of gender and weekly hours of unpaid volunteer work. At postintervention follow-up, according to the adjusted comparisons, there were statistically significant between-group reductions in depression scores (β=–2.21, P=.01) and anxiety scores (β=–4.82, P=.006), and a significant increase in mindfulness scores (β=4.84, P=.02) compared with the WLC group. There were no statistically significant differences in perceived stress for MVC (β=.64, P=.48) compared with WLC. Conclusions: With the MVC intervention, there were significantly reduced depression and anxiety symptoms but no significant effect on perceived stress. Online mindfulness interventions can be effective in addressing common mental health conditions among postsecondary populations on a large scale, simultaneously reducing the current burden on traditional counseling services. Trial Registration: ISRCTN Registry ISRCTN12249616; http://www.isrctn.com/ISRCTN12249616

Clinical information collected in electronic health records (EHRs) is becoming an essential source to emulate randomized experiments. Since patients do not interact with the healthcare system at random, the longitudinal information in large observational databases must account for irregular visits. Moreover, we need to also account for subject-specific unmeasured confounders which may act as a common cause for treatment assignment mechanism (e.g. glucose-lowering medications) while also influencing the outcome (e.g. Hemoglobin A1c). We used the calibration of longitudinal weights to improve the finite sample properties and to account for subject-specific unmeasured confounders. A Monte Carlo simulation study is conducted to evaluate the performance of calibrated inverse probability estimators using time-dependent treatment assignment and irregular visits with subject-specific unmeasured confounders. The simulation study showed that the longitudinal weights with calibrated restrictions improved the finite sample bias when compared to the stabilized weights. The application of the calibrated weights is demonstrated using the exposure of glucose lowering medications and the longitudinal outcome of Hemoglobin A1c. Our results support the effectiveness of glucose lowering medications in reducing Hemoglobin A1c among type II diabetes patients with elevated glycemic index ( ≥ 8.5 % ) using stabilized and calibrated weights.

Background Federal deregulation of opioid agonist therapies are an attractive policy option to improve access to opioid use disorder care and achieve widespread beneficial impacts on growing opioid-related harms. There have been few evaluations of such policy interventions and understanding effects can help policy planning across jurisdictions. Methods Using health administrative data from eight of ten Canadian provinces, this study evaluated the impacts of Health Canada’s decision in May 2018 to rescind the requirement for Canadian health professionals to obtain an exemption from the Canadian Drugs and Substance Act to prescribe methadone for opioid use disorder. Over the study period of June 2017 to May 2019, we used descriptive statistics to capture overall trends in the number of agonist therapy prescribers across provinces and we used interrupted time series analysis to determine the effect of this decision on the trajectories of the agonist therapy prescribing workforces. Results There were important baseline differences in the numbers of agonist therapy prescribers. The province with the highest concentration of prescribers had 7.5 more prescribers per 100,000 residents compared to the province with the lowest. All provinces showed encouraging growth in the number of prescribers through the study period, though the fastest growing province grew 4.5 times more than the slowest. Interrupted time series analyses demonstrated a range of effects of the federal policy intervention on the provinces, from clearly positive changes to possibly negative effects. Conclusions Federal drug regulation policy change interacted in complex ways with provincial health professional regulation and healthcare delivery, kaleidoscoping the effects of federal policy intervention. For Canada and other health systems such as the US, federal policy must account for significant subnational variation in OUD epidemiology and drug regulation to maximize intended beneficial effects and mitigate the risks of negative effects.

To determine whether more patients presented with Attention-deficit/hyperactivity disorder (ADHD)-related visits and/or sought care from family physicians more frequently during the COVID-19 pandemic. Electronic medical records from the University of Toronto Practice-Based Research Network were used to characterize changes in family physician visits and prescriptions for ADHD medications. Annual patient prevalence and visit rates pre-pandemic (2017-2019) were used to calculate the expected rates in 2020 and 2021. The expected and observed rates were compared to identify any pandemic-related changes. The number of patients presenting for ADHD-related visits during the pandemic was consistent with pre-pandemic trends. However, observed ADHD-related visits in 2021 were 1.32 times higher than expected (95% CI: 1.05-1.75), suggesting that patients visited family physicians more frequently than before the pandemic. Demand for primary care services related to ADHD has continued to increase during the pandemic, with increased health service use among those accessing care.

The design of suburban communities encourages car dependency and discourages walking, characteristics that have been implicated in the rise of obesity. Walkability measures have been developed to capture these features of urban built environments. Our objective was to examine the individual and combined associations of residential density and the presence of walkable destinations, two of the most commonly used and potentially modifiable components of walkability measures, with transportation, overweight, obesity, and diabetes. We examined associations between a previously published walkability measure and transportation behaviors and health outcomes in Toronto, Canada, a city of 2.6 million people in 2011. Data sources included the Canada census, a transportation survey, a national health survey and a validated administrative diabetes database. We depicted interactions between residential density and the availability of walkable destinations graphically and examined them statistically using general linear modeling. Individuals living in more walkable areas were more than twice as likely to walk, bicycle or use public transit and were significantly less likely to drive or own a vehicle compared with those living in less walkable areas. Individuals in less walkable areas were up to one-third more likely to be obese or to have diabetes. Residential density and the availability of walkable destinations were each significantly associated with transportation and health outcomes. The combination of high levels of both measures was associated with the highest levels of walking or bicycling (p<0.0001) and public transit use (p<0.0026) and the lowest levels of automobile trips (p<0.0001), and diabetes prevalence (p<0.0001). We conclude that both residential density and the availability of walkable destinations are good measures of urban walkability and can be recommended for use by policy-makers, planners and public health officials. In our setting, the combination of both factors provided additional explanatory power.

The COVID-19 pandemic required a rapid transition to virtual care as a key strategy to maintain healthcare access while minimizing virus transmission risks. However, the impact of this shift on hospitalizations and emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs) remains unclear. This study aims to assess the relationship between the modality of outpatient care for ACSCs and their outcomes in Ontario, Canada. In this population-based retrospective cohort study, we analyzed hospitalization and ED visit data for ACSCs, including diabetes, epilepsy, congestive heart failure, hypertension, and angina, during the pandemic (April 2020 to April 2023) and post-pandemic (May 2023 to August 2023) periods. Monthly trends in hospitalizations and ED visits were evaluated using Generalized Additive Models and Generalized Additive Mixed Models, accounting for the effects of virtual and in-person care within 30 days and 60 days preceding each event. Despite a notable decrease in virtual visits and a corresponding rise in in-person visits, overall hospitalizations and ED visits for ACSCs remained relatively stable. Our analysis found no significant association between care modality and changes in hospitalizations and ED visits, suggesting that virtual care, particularly during the early pandemic, effectively supported chronic disease management and contributed to the stability of acute care needs. In conclusion, virtual care proved to be a sustainable component of ACSC management during and after the COVID-19 pandemic, complementing in-person care.