Aaron Jones

Background: People living with dementia frequently present to emergency departments (EDs) and are at increased risk of hospitalization, institutionalization, and other adverse outcomes. Geriatric Emergency Management (GEM) programs are designed to improve emergency care for older adults, but their effectiveness among people living with dementia remains uncertain. We evaluated the association between attendance at an ED with an active GEM program and days alive and at home among older adults living with dementia. Methods: We conducted a population‐based retrospective cohort of Ontario residents aged 65 years or older with identified dementia who had an index ED visit between April 1, 2021, and March 31, 2024. The exposure was attendance at an ED with an active GEM program. Results: The cohort included 145,874 individuals, including 110,288 who presented to EDs with GEM programs and 35,586 who presented to EDs without GEM programs. The median age of the population was 81 years and 58.5% of participants were female. After propensity score overlap weighting and adjustment for facility characteristics, individuals who visited GEM EDs spent 7.5 (95% CI, 3.1–12.0) more days alive and at home during the following year than those who visited non‐GEM EDs. Approximately half of this difference was attributable to fewer days spent in long‐term care homes. Visits to GEM EDs were also associated with fewer subsequent ED visits, although index ED length of stay and hospital admission rates were higher. Conclusions and Relevance: Among older adults living with dementia, care in EDs with GEM programs was associated with more days alive at home over the following year. These findings support continued investment in GEM programs to promote aging at home and to delay institutionalization among people living with dementia.

Summary: Anti‐cluster of differentiation 38 (Anti‐CD38) monoclonal antibodies such as daratumumab are widely used in multiple myeloma (MM), yet the timing and magnitude of infectious risk remain incompletely defined. We performed an individual patient‐level meta‐analysis of six randomized trials ( N = 2989) comparing daratumumab‐ versus non‐daratumumab–containing regimens in newly diagnosed and relapsed/refractory MM, assessing infectious events over 2 years. Daratumumab‐treated patients had higher rates of any‐grade (79% vs. 61%) and grade ≥3 infections (29% vs. 20%) than controls, with risk peaking in the first 3 months (42% vs. 36%, p = 0.001) before plateauing. After adjustment, daratumumab was independently associated with grade ≥1 (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.10–1.57), respiratory (OR 1.38, 95% CI 1.11–1.71) and grade ≥3 (OR 1.47, 95% CI 1.08–2.00) infection by 3 months. Daratumumab‐treated patients had a higher rate of infection over 2 years (adjusted incidence rate ratio 1.60, 95% CI 1.47–1.73) and more frequently experienced recurrent infections (33% vs. 22% with multiple any‐grade infections; 11% vs. 7% with multiple grade ≥3 infections). Preventive strategies were underused, with <20% of patients with severe respiratory infections receiving immunoglobulin replacement. These findings identify an early window of infectious vulnerability with daratumumab and support temporally targeted prevention and monitoring strategies in contemporary MM care.

Background: The association between loneliness and incident use of benzodiazepines and opioids, and sociodemographic factors associated with their use, is unknown. Methods: Using the Canadian Longitudinal Study on Aging’s comprehensive cohort, we conducted a longitudinal study to understand how loneliness was associated with incident use of benzodiazepines and opioids, separately, using multivariable modified logistic regression models. We evaluated sociodemographic factors associated with benzodiazepine and opioid use among lonely participants. Results: We included 29 976 participants, of whom 10.8% were lonely (all the time or occasionally) at baseline. Lonely participants were older [mean age 64.4, standard deviation (SD) 10.5 vs. mean age 62.8, SD 10.2] and more likely to be female (57.9% vs. 50.1%) and live alone (45.2% vs. 19.9%) than participants who were not lonely. Lonely participants had a higher rate of incident use of benzodiazepines [73 (2.8%) vs. 305 (1.3%); adjusted odds ratio (aOR) 1.94, 95% confidence interval (95% CI) 1.47–2.57] and opioids [60 (2.2%) vs. 283 (1.2%); aOR 1.43, 95% CI 1.05–1.93] compared to those who were not lonely. Loneliness remained significantly associated with use of benzodiazepines, but not opioids, after adjusting for mood and anxiety disorders. Lonely females and non-Whites were more likely to be initiated on benzodiazepines, whereas lonely immigrants were less likely to be initiated on benzodiazepines. Conclusions: Loneliness was associated with incident use of benzodiazepines and opioids. Multimodal interventions to deprescribe these medications in lonely individuals and decrease symptoms of loneliness could mitigate their attendant health effects.

Background: Retention in HIV care is associated with higher rates of antiretroviral treatment adherence and viral suppression, as well as lower risk of AIDS-related morbidity and mortality. However, the multidimensional nature of retention complicates measurement standardisation, limiting comparability and global evaluation. Objectives: This study explored how HIV stakeholders define and assess retention, aiming to develop a patient-centred and conceptually robust understanding to inform research and practice. Methods: We conducted a qualitative study using interpretive description methodology, an applied qualitative approach designed to generate practice-relevant knowledge in health research. We purposively sampled 20 stakeholders representing diverse areas of expertise and geographic regions across World Bank country income classifications. We conducted and video-recorded in-depth semistructured interviews and subsequently transcribed them. Using constant comparative analysis, we identified recurring, convergent and contradictory patterns. Results: The analysis identified five overarching themes. The first two, exploratory themes, included Patient-Centred Understanding of Retention in HIV Care, which captured how stakeholders conceptualised retention in their respective contexts and Operationalisation of Retention Measures, which explored the key components used to measure retention. The next two explanatory themes, included Purpose-Driven Definitions of Retention, which described how retention measures were selected based on their intended use, and Building Capacity through Shared Understanding and Integrated Action, which emphasised retention as a cyclical, interconnected process dependent on collaboration between patients and health systems. The final, prescriptive theme, Advancements Shaping Retention, reflected stakeholders’ shared vision of improving retention through innovations in HIV treatment and technology. Conclusions: The findings suggest that stakeholders operationalise retention measures in line with specific objectives and individual health goals, while remaining attentive to contextual realities. Retention measures should remain flexible and patient-centred, rather than relying on a single rigid standard.

Background and Objectives: Older adults in Canada are experiencing increasing demand for housing, but limited evidence exists on how wealth status relates to the transition to seniors’ housing. We investigated the association between wealth status and transitions to seniors’ housing. Research Design and Methods: We conducted a longitudinal study using the Canadian Longitudinal Study on Aging data. The primary outcome was the transition to seniors’ housing from participants’ own homes, assessed between baseline and follow-up 1, and between follow-up 1 and follow-up 2. The wealth status was the primary exposure measured by “total savings and investments.” We used a multivariable generalized estimating equation model adjusted for confounders. Results: We included 17,837 participants at baseline and 19,756 at follow-up 1, aged 65 and older. Higher wealth (100,000 to <1 million CAD) was associated with 40% lower odds of transitioning to seniors’ housing (aOR = 0.60, 95% CI: 0.46–0.78) than lower wealth status (50,000 CAD). Being older, living alone, being a home care recipient, mild ADL impairments, poor general health status, and eyesight were associated with higher odds of transitioning. Wealth was significantly associated with transition to seniors’ housing in Alberta and Quebec, but not in British Columbia, Ontario, Atlantic, or the Prairie provinces. Discussion and Implications: The association between wealth and transitions to seniors’ housing suggests that, overall, in Canada and across the provinces, financial resources play an important role in determining transition to seniors’ housing. These findings highlight the need for targeted policies to reduce inequalities across jurisdictions.

Background: Continuity of care (COC) measurements that reflect relational continuity have been used as quality indicators, yet their applicability near the end of life may be limited. Modified continuity indices—UPC-Team (Usual Provider of Care) and BB-Team (Bice-Boxerman)—were developed to reflect escalating care needs and capture associations with patient-centered outcomes. Objectives: To measure associations between the modified COC indices, UPC-Team, and BB-Team during the last year of life and end-of-life (EOL) health care outcomes. Methods: Retrospective cohort study of adults who died between January 1, 2018, and December 31, 2022, with advanced chronic obstructive pulmonary disease and/or heart failure prevalent ≥2 years before death, using health administrative data from Ontario, Canada. Multivariate regressions measured associations between the indices and days spent in community during the last 30 and 14 days of life, and place of death. Results: Among 175,323 included individuals (median age at death=80; 55.4% male), the median number of community days was 23 and 10 in the last 30 and 14 days of life; 56.5% died in a health care institution. Higher UPC-Team and BB-Team scores were associated with increased odds of institutional deaths and fewer community days. Conclusions: Higher continuity scores were associated with increased odds of institutional death and fewer days spent in the community, suggesting limited utility of these modified indices in predicting favorable EOL health care outcomes. Findings highlight the need for future research to incorporate all aspects of continuity (ie, relational, informational, and management) to better capture care coordination in this context.

Background: Sustained retention in care supports continuous access to antiretroviral therapy, routine clinical monitoring, and long-term viral suppression. Objective: To compare the effectiveness of interventions for improving retention in care among people living with HIV (PLHIV). Design: Systematic review and network meta-analysis Data sources: PubMed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Library from 1995 to December 2024. Eligibility criteria: Randomised controlled trials (RCTs) evaluating interventions to improve retention in care, viral load suppression, or quality of life (QoL) among PLHIV, compared with standard of care (SoC) or other interventions. Data extraction and synthesis: Pairs of reviewers independently screened studies, extracted data, and assessed risk of bias using ROBUST-RCT. We conducted a fixed-effect frequentist network meta-analysis and rated interventions categories relative to SoC based on effect estimates effects and the certainty of evidence.. Dichotomous outcomes were summarized as odds ratios (ORs) with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) with 95% CI. Results: Eighty-four trials enrolling 107 137 PLHIV evaluated 13 intervention categories. For retention in care, five interventions supported by moderate or high certainty evidence proved superior to SoC: multi-month dispensing (OR 2.02, 95% CI 1.32 to 3.09), task shifting (OR 1.94, 95% CI 1.42 to 2.66), differentiated service delivery (OR 1.47, 95% CI 1.22 to 1.76), behavioural counselling (OR 1.36, 95% CI 1.21 to 1.54), and supportive interventions (OR 1.31, 95% CI 1.11 to 1.55). For viral load suppression, two interventions supported by moderate or high certainty evidence proved superior to SoC: task shifting (OR 2.07, 95% CI 1.25 to 3.43) and behavioural counselling (OR 1.34, 95% CI 1.11 to 1.67). Across outcomes, no intervention demonstrated convincing superiority over other active interventions. Conclusions: Among 13 intervention categories, only a subset provided moderate or high-certainty evidence of superiority to the standard of care, and no superiority to other interventions. Persistent evidence gaps for key populations, diverse settings, and long-term outcomes support the need for context-sensitive and patient-centred interventions. Registration: PROSPERO CRD42024589177 Strengths and limitations of this study: ➢ This systematic review followed Cochrane methods and was reported in accordance with PRISMA-NMA guidelines. ➢ The network meta-analysis integrated direct and indirect evidence to compare multiple intervention categories within a single framework. ➢ Risk of bias and certainty of evidence were assessed using ROBUST-RCT and the GRADE approach for network meta-analysis, respectively. ➢ Some networks were sparse, and limited representation of key populations and long-term follow-up constrained the strength and generalisability of inferences.

Background: Family physicians (FP) are critical in providing outpatient end-of-life (EOL) care, yet most continuity measures do not consider temporal changes in visits. The relative variance index (RVI), which measures visit interval variation, has not been applied to the EOL context. Aim: To measure the association between outpatient FP visit regularity & acute care use in the last month of life. Design: Retrospective cohort study using linked population-level health administrative data. FP visit regularity was measured using the RVI, calculated from outpatient visits during the last two years of life (excluding the last month). Outcomes included hospitalizations, emergency department (ED) visits in the last month of life & acute care setting deaths. Setting: Adults with cardiorespiratory conditions who died in Ontario, Canada, between 2017 & 2019. Results: Patients' (N = 151 030) median age at 2-years before death was 80, 55% were male, & had a median of 9 FP outpatient visits in the last two years of life. Higher FP RVI scores were associated with increased hospitalizations (IRR [95% CI]: 1.07 [1.05,1.10]), ED visits (1.06 [1.03, 1.08]) & acute care deaths (OR [95% CI]: 1.30 [1.26, 1.35]). Sensitivity analyses identified that RVI scores varied across different look-back periods, while sensitivity model performances remained stable when adjusting for specialist visit regularity. Conclusions: Higher outpatient FP visit regularity was associated with increased EOL acute care use, despite low visit regularity during the last two years of life. However, the RVI's sensitivity to observation period lengths limits its utility as an EOL care-quality indicator.

Objectives: To develop and describe the performance of two modified relational continuity of care indices for adults with organ failure nearing the end of life, addressing limitations of existing indices that penalise multispecialty physician care. Design: Population-based retrospective study. Setting: Linked routinely collected health administrative databases in Ontario, Canada. Participants: Adults aged ≥19 years who died between 1 January 2018 and 31 December 2022, with kidney failure on dialysis, advanced chronic obstructive pulmonary disease and/or heart failure. Primary and secondary outcome measures: We adapted the Usual Provider of Care (UPC) and Bice-Boxerman Continuity of Care (BB) indices to avoid penalising multispecialty physician care, resulting in the UPC-Team and BB-Team indices. Indices were calculated for the last 2 years of life (truncating the last month) using outpatient physician visits. Correlation coefficients were produced between the unmodified indices, the modified indices and outpatient healthcare utilisation. Results: The cohort included 199 035 individuals, with a median age of 79 years (P25, P75: 70, 86); 55.5% were male. The median modified continuity scores were higher than the unmodified scores (UPC=0.44 (0.32, 0.61), UPC-Team=0.79 (0.67, 0.89); BB=0.24 (0.15, 0.40), BB-Team=0.75 (0.52, 0.95)). The modified indices shared weaker correlations with outpatient healthcare use (ie, number of visits or specialists involved), compared with the unmodified indices. Conclusions: The UPC-Team and BB-Team indices do not penalise patients for receiving multispecialty physician care, compared with the unmodified UPC and BB indices. The modified indices demonstrated more consistency in measuring continuity across patients with varying degrees of medical complexity and less correlation with outpatient healthcare use. Use of these indices is suggested to capture different aspects of relational continuity in the context of multispecialty care nearing the end of life.

Background: Antipsychotic medications remain widely used in nursing homes (NHs) despite guidelines discouraging potentially inappropriate use. While home‐level variation is known, less is understood at the unit and organization levels, or across other psychotropic and non‐psychotropic drugs. We examined prescribing variation across NHs in Ontario, Canada. We examined prescribing variation for psychotropic and non‐psychotropic drugs across NH units, homes, and organizations in Ontario, Canada. Methods: We conducted a retrospective cohort study of NH residents using EMR data from April 1, 2022, to March 31, 2023. Outcomes included whether residents were prescribed any antipsychotic, antidepressant, statins, cardiovascular disease (CVD) medications, and trazodone for at least 1 day during the follow‐up period. Multi‐level logistic regression models adjusted for resident characteristics and included random intercepts for units, homes, and organizations. Results: Among 16,896 NH residents across 179 homes and five organizations, 39% were prescribed antipsychotics, 65.5% antidepressants, 33% statins, 65% CVD medications, and 38% trazodone. Substantial variation was observed across all medications. For antipsychotics, the home‐level median odds ratio (MOR) was 1.65 (95% CrI: 1.52–1.78) and unit‐level MOR was 1.24 (95% CrI: 1.10–1.33). Trazodone exhibited the highest variation (home‐level MOR: 2.06, 95% CrI 1.75–2.37; unit‐level MOR: 1.87, 95% CrI 1.76–1.97). No significant variation was found at the organization level. Resident characteristics, like aggression and dementia, were associated with prescribing but did not explain unit and home‐level differences. Conclusions: Prescribing variation extends beyond antipsychotics to other common pharmacotherapies. Unit‐level variation reveals additional unexplained variation not captured in previous home‐level studies, providing new targets for research and quality improvement interventions. Future research should explore potential unit‐ and home‐level contributors, such as staffing, practice culture, clinician decision‐making, and policies.