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Job polarization refers to the shrinking share of employment in middle-skill, routine occupations experienced over the past 35 years. Jobless recoveries refers to the slow rebound in aggregate employment following recent recessions despite recoveries in aggregate output. We show how these two phenomena are related. First, essentially all employment loss in routine occupations occurs in economic downturns. Second, jobless recoveries in the aggregate can be accounted for by jobless recoveries in the routine occupations that are disappearing.

Family physicians play a key role in the care of older adults, yet the impact of additional geriatric training or focused practice remains unclear. We compared performance on established clinical practice measures among family physicians with/without evidence of elderly-focused practice or training. We used linked administrative data to conduct a population-based, propensity score-matched cohort study. Participants included family physicians in Ontario, Canada with rostered patients in 2019. Using logistic regression, we established propensity scores to match physicians with a focused alternative funding plan and/or a Certificate of Added Competence in 'Care of the Elderly' at a 1:4 ratio to a control group without focused practices or added competence certificates. We compared 11 practice-based measures endorsed by Canadian clinicians and researchers, adjusting for physician factors, medical practice characteristics, and primary care activities. We identified 232 family physicians with elderly-focused practices or training and 928 comparable controls. While differences in study group clinical practices were not statistically significant for most processes, they were in three areas. More physicians with elderly-focused practice or training conducted testing aligned with the most recent Canadian Consensus on Dementia and were more likely to prescribe potentially inappropriate medications and antipsychotics to older attached patients. We observed limited to no differences in clinical practice measures between family physicians with 'Care of the Elderly' focused practice or certification to those without. The lack of differences may reflect true performance, the effect of uniform constraints of primary care practice, or inherent limitations of objective performance measurement.

We construct longitudinal data from U.S. census records to study the economics of the Dust Bowl migration of the 1930s. Most of our findings contradict long-standing perceptions. While migration rates were high relative to elsewhere in the United States, they were similar to migration rates from the region in the 1920s. Relative to other occupations, farmers were the least likely to move. Furthermore, migrants from the Dust Bowl were not exceptionally likely to move to California. Finally, there was negligible migrant selectivity, and migration was not associated with long-lasting negative labor market outcomes; indeed, for farmers, the gains from migration were positive.

We established consensus on practice-based metrics that characterize quality of care for older primary care patients and can be examined using secondary health administrative data. We conducted a two-round RAND/UCLA Appropriateness Method (RAM) study and recruited 10 Canadian clinicians and researchers with expertise relevant to the primary care of elderly patients. Informed by a literature review, the first RAM round evaluated the appropriateness and importance of candidate quality measures in an online questionnaire. Technical definitions were developed for each endorsed indicator to specify how the indicator could be operationalized using health administrative data. In a virtual synchronous meeting, the expert panel offered feedback on the technical specifications for the endorsed indicators. Panelists then completed a second (final) questionnaire to rate each indicator and corresponding technical definition on the same criteria (appropriateness and importance). We used statistical integration to combine technical expert panelists’ judgements and content analysis of open-ended survey responses. Our literature search and internal screening resulted in 61 practice-based quality indicators for rating. We developed technical definitions for indicators endorsed in the first questionnaire (n = 55). Following the virtual synchronous meeting and second questionnaire, we achieved consensus on 12 practice-based quality measures across four Priority Topics in Care of the Elderly. The endorsed indicators provide a framework to characterize practice- and population-level encounters of family physicians delivering care to older patients and will offer insights into the outcomes of their care provision. This study presented a case of soliciting expert feedback to develop measurable practice-based quality indicators that can be examined using administrative data to understand quality of care within population-based data holdings. Future work will refine and operationalize the technical definitions established through this process to examine primary care provision for older adults in a particular context (Ontario, Canada).

ObjectivesFrailty is a multidimensional syndrome of loss of reserves in energy, physical ability, cognition and general health. Primary care is key in preventing and managing frailty, mindful of the social dimensions that contribute to its risk, prognosis and appropriate patient support. We studied associations between frailty levels and both chronic conditions and socioeconomic status (SES).DesignCross-sectional cohort studySettingA practice-based research network (PBRN) in Ontario, Canada, providing primary care to 38 000 patients. The PBRN hosts a regularly updated database containing deidentified, longitudinal, primary care practice data.ParticipantsPatients aged 65 years or older, with a recent encounter, rostered to family physicians at the PBRN.InterventionPhysicians assigned a frailty score to patients using the 9-point Clinical Frailty Scale. We linked frailty scores to chronic conditions and neighbourhood-level SES to examine associations between these three domains.ResultsAmong 2043 patients assessed, the prevalence of low (scoring 1–3), medium (scoring 4–6) and high (scoring 7–9) frailty was 55.8%, 40.3%, and 3.8%, respectively. The prevalence of five or more chronic diseases was 11% among low-frailty, 26% among medium-frailty and 44% among high-frailty groups (χ2=137.92, df 2, p<0.001). More disabling conditions appeared in the top 50% of conditions in the highest-frailty group compared with the low and medium groups. Increasing frailty was significantly associated with lower neighbourhood income (χ2=61.42, df 8, p<0.001) and higher neighbourhood material deprivation (χ2=55.24, df 8, p<0.001).ConclusionThis study demonstrates the triple disadvantage of frailty, disease burden and socioeconomic disadvantage. Frailty care needs a health equity approach: we demonstrate the utility and feasibility of collecting patient-level data within primary care. Such data can relate social risk factors, frailty and chronic disease towards flagging patients with the greatest need and creating targeted interventions.

We investigate the consequences of demographic change for business cycle analysis. We find that changes in the age composition of the labor force account for a significant fraction of the variation in cyclical volatility observed in the G7. Since World War II, these countries have experienced dramatic demographic changes, although details regarding timing and nature differ across countries. We exploit this variation to show that the workforce age composition has a large and significant effect on cyclical volatility. We relate our results to the recent decline in US macroeconomic volatility, finding that demographic change accounts for approximately one-fifth to one-third of this moderation.

Background The COVID-19 pandemic is a significant public health emergency that impacts all sectors of healthcare. The negative health outcomes for the COVID-19 infection have been most severe in the frail elderly dwelling in Canadian long-term care (LTC) homes. Methods An online cross-sectional survey of Ontario LTC Clinicians working in LTC homes in Ontario Canada was conducted to provide the clinician perspective on the preparedness and engagement of the LTC sector during the COVID-19 pandemic. The survey questionnaire was developed in collaboration with the Ontario Long-Term Care Clinicians organization (OLTCC) and was distributed between March 30, 2020 to May 25, 2020. All registered members of the OLTCC and Nurse-led LTC Outreach Teams were invited to participate. The primary outcomes were: 1) the descriptive report of the screening measures implemented, communication and information received, and the preparation of the respondent’s LTC home to a potential COVID-19 outbreak; and 2) the level of agreement, as reported using a five-point Likert scale), to COVID-19 preparedness statements for the respondent’s LTC home was also assessed. Results The overall response rate was 54% (160/294). LTC homes implemented a wide range of important interventions (e.g. instituting established respiratory isolation protocols, active screening of new LTC admissions, increasing education on infection control processes, encouraging sick staff to take time off, etc). Ample communications pertinent to the pandemic were received from provincial LTC organizations, the government and public health officials. However, the feasibility of implementing public health recommendations, as well as the engagement of the LTC sector in pandemic planning were identified as areas of concern. Medical director status was associated with an increased knowledge of local implementation of interventions to mitigate COVID-19, as well as endorsing increased access to reliable COVID-19 information and resources to manage a potential COVID-19 outbreak in their LTC home. Conclusions This study highlights the communication and implementation of recommendations in the Ontario LTC sector, despite some concerns regarding feasibility. Importantly, LTC clinician respondents clearly indicated that better engagement with LTC leaders is needed to plan a coordinated pandemic response.

Over the business cycle young workers experience much greater volatility of hours worked than prime-aged workers. This can arise from age differences in labor supply or labor demand characteristics. To distinguish between these, we document that, for young workers, both the cyclical volatilities of hours and wages are greater than those of the prime-aged. We argue that a general class of models featuring only age-specific labor supply differences cannot reconcile these facts. We then show that a simple model featuring labor demand differences can. (JEL E32, J13, J22, J23, J31)

Background Patients who maintain longitudinal provider-patient relationships experience better overall health outcomes. However, most older adults in Canada lose contact with their family physician when they enter long-term care (LTC) as new providers assume responsibility for their care. There is relatively little known about the contextual factors, processes, knowledge, and health professions education antecedents that promote the benefits of relational, management, and informational care continuity during LTC transitions. Methods Using a rigorous scoping review method, we searched multiple databases systematically to identify and scrutinize peer-reviewed articles pertaining to continuity of care during LTC transitions in Canada. Guided by Transitions Theory, two independent reviewers screened citations and extracted data. A descriptive analytical method was employed to categorize content into themes. Results Eight articles met the inclusion criteria. Our findings confirm that instances of relational continuity are very few during LTC transitions, suggesting barriers associated with practice models and the influence of physician characteristics. Notably, the review also highlights that the involvement of interprofessional team members, patients, and their partners-in-care in transition planning could improve informational and management care continuity for patients as they move into LTC. Conclusion Patient and family involvement, provider training, and practice and funding arrangements are all critical to improving relational, management, and informational care continuity during LTC transition. We recommend more studies to understand processes and policies to optimize informational continuity as a panacea for the often-disrupted relational continuity.

Background Family physicians serve an important role in the care of older adults, and have variable levels of training and comfort navigating this complex patient population. The Care of the Elderly (COE) Certificate of Added Competence offered by The College of Family Physicians of Canada recognizes family physicians with advanced expertise in older adult healthcare. We explored how COE training and certification impacts primary care delivery to older patients, including factors that impact group practice. Methods We conducted a secondary analysis of multiple case study data to explore similarities and differences within and across cases. We defined cases as a practice or collective of family physicians working within a defined group of patients in an interconnected community. We analyzed semi-structured interview transcripts ( n  = 48) from six practice groups of family physicians across Canada using conventional (unconstrained, inductive) content analysis. Results We identified similarities and differences in how COE family physicians function within their group practice and the broader healthcare system. In some cases, COE certifications increased patients’ access to geriatric resources by reducing travel and wait times. Some physicians observed minimal changes in their role or group practice after earning the COE designation, including continuing to largely function as a generalist. While family physicians tended to highly value their COE CAC, this designation was differentially recognized by others. Conclusions Our findings highlight the impacts and limitations of COE training and certification, including an opportunity for COE family physicians to fill knowledge and practice gaps. As the number of older adults in Canada continues to grow and increasingly rely on primary care services, COE family physicians are uniquely positioned to strengthen the health system’s capacity to deliver specialized geriatric care.