Astrid Guttmann

Background: Timely follow-up is crucial for youth whose first mental health contact is through a hospital; virtual care could facilitate this. Objective: This study aimed to examine the association between the significant expansion of virtual care in Ontario, Canada, and follow-up mental health care rates for these youths. Methods: We conducted a population-based repeated cross-sectional study using linked health administrative databases. We identified first-contact emergency department (ED) visits or hospital admissions for self-harm, mood disorders, or psychosis from March 1, 2009, to February 29, 2024, among Ontario youth (aged 10-24 years). Virtual care was expanded in March 2020; we examined 2 expansion stages (temporary and permanent). Autoregressive integrated moving average analyses estimated level and slope changes (vs before virtual care) in age- and sex-standardized monthly rates of 7-day mental health follow-up. Subgroup analyses examined rurality and socioeconomic status. Results: We identified 42,208 first-contact ED visits and 17,701 first-contact hospital admissions. Pre–virtual care mean follow-up rates were 17.64 (SD 2.97) per 100 first-contact ED visits and 21.90 (SD 5.05) per 100 first-contact hospital admissions. Temporary expansion was associated with immediate increases in follow-up that declined (level changes: 4.81, 95% CI 2.82-6.81 for ED visits and 7.51, 95% CI 4.41-10.60 for hospital admissions; slope changes: −0.31, 95% CI −0.42 to −0.21 for ED visits and −0.32, 95% CI −0.48 to −0.15 for hospital admissions). Permanent expansion was associated only with an immediate decrease in ED visit follow-up (level change: −3.81, 95% CI −6.70 to −0.92) that was significant in rural (−1.06, 95% CI −1.93 to −0.184) but not urban (0.44, 95% CI −0.179 to 1.06) areas; results were otherwise similar between subgroups. Conclusions: Virtual care was not associated with sustained changes or equity improvements in mental health follow-up for high-acuity youth, representing a missed opportunity to extend physician reach and address barriers. Further research and quality improvement are needed.

Importance: Timely follow-up after pediatric hospitalization is critical to support safe discharge, yet many children face barriers to in-person visits. Virtual care may facilitate follow-up; however, its association with follow-up trends remains unknown. Objective: To examine whether a system-wide virtual care remuneration policy, characterized by virtual care physician billing codes, was associated with changes in 7-day postdischarge follow-up rates overall and by hospitalization type and equity factors. Design, Setting, and Participants: This population-based, repeated cross-sectional study used administrative data on all children aged 18 years or younger with provincial health insurance in Ontario, Canada, who were discharged home after medical or surgical hospitalization between March 1, 2011, and June 30, 2024. Exposures: The primary exposure was the implementation of the virtual care remuneration policy (instituted December 1, 2022); effects were stratified by hospitalization type, rurality, and socioeconomic status. Main Outcomes and Measures: The primary outcome was the monthly rate of physician follow-up within 7 days of hospital discharge. The absolute difference in observed vs estimated follow-up visits per 1000 discharges was estimated using an interrupted time series analysis with autoregressive integrated moving average model. Results: The study included 643 156 hospital discharges across 469 066 children (mean [SD] age, 6.3 [5.7] years; 55.1% male). Before the virtual care policy, 42.0% of children received follow-up within 7 days of discharge vs 40.9% thereafter (follow-up provided virtually in 0.2% of postdischarge visits before the virtual care policy vs 11.0% after implementation). After policy implementation, follow-up remained lowest among rural (29.8%) and the most materially deprived populations (39.0%). Accounting for seasonality and autocorrelation, no significant change in slope (0.36; 95% CI, −0.15 to 0.87) or level (−2.70; 95% CI, −7.09 to 1.69) of follow-up rates were observed after policy implementation. Observed follow-up rates did not differ from those estimated (1 fewer visit per 1000 discharges). No clinically meaningful change in slope or level of follow-up rates were observed by hospitalization type, rurality, or socioeconomic status. Conclusions and Relevance: In this cross-sectional study of Ontario children discharged from the hospital, a virtual care remuneration policy was not associated with an increase in timely follow-up after pediatric hospitalization, nor was it associated with narrowing of geographic and socioeconomic disparities. Virtual care billing policies alone may be insufficient to enhance postdischarge follow-up and may reinforce existing inequities.

BACKGROUND Timely follow-up is crucial for youth whose first mental health contact is through a hospital; virtual care could facilitate this. OBJECTIVE This study aimed to examine the association between the significant expansion of virtual care in Ontario, Canada, and follow-up mental health care rates for these youths. METHODS We conducted a population-based repeated cross-sectional study using linked health administrative databases. We identified first-contact emergency department (ED) visits or hospital admissions for self-harm, mood disorders, or psychosis from March 1, 2009, to February 29, 2024, among Ontario youth (aged 10-24 years). Virtual care was expanded in March 2020; we examined 2 expansion stages (temporary and permanent). Autoregressive integrated moving average analyses estimated level and slope changes (vs before virtual care) in age- and sex-standardized monthly rates of 7-day mental health follow-up. Subgroup analyses examined rurality and socioeconomic status. RESULTS We identified 42,208 first-contact ED visits and 17,701 first-contact hospital admissions. Pre–virtual care mean follow-up rates were 17.64 (SD 2.97) per 100 first-contact ED visits and 21.90 (SD 5.05) per 100 first-contact hospital admissions. Temporary expansion was associated with immediate increases in follow-up that declined (level changes: 4.81, 95% CI 2.82-6.81 for ED visits and 7.51, 95% CI 4.41-10.60 for hospital admissions; slope changes: −0.31, 95% CI −0.42 to −0.21 for ED visits and −0.32, 95% CI −0.48 to −0.15 for hospital admissions). Permanent expansion was associated only with an immediate decrease in ED visit follow-up (level change: −3.81, 95% CI −6.70 to −0.92) that was significant in rural (−1.06, 95% CI −1.93 to −0.184) but not urban (0.44, 95% CI −0.179 to 1.06) areas; results were otherwise similar between subgroups. CONCLUSIONS Virtual care was not associated with sustained changes or equity improvements in mental health follow-up for high-acuity youth, representing a missed opportunity to extend physician reach and address barriers. Further research and quality improvement are needed. CLINICALTRIAL

Importance: Health care resource constraints across North America are leading to decreased access to primary care, particularly for newcomers. In Canada, several pathways to permanent residency shape early navigation to the publicly funded health care system. Objective: To explore access to primary care by analyzing the percentage of all minor illness visits seen in an emergency department (ED) in recently arrived refugee and immigrant children compared with their Ontario-born peers. Design, Setting, and Participants: This population-based cohort study took place in Ontario, Canada, and included immigrant children who arrived between 2008 and 2017 and Ontario-born children. Participants were aged 0 to 14 years and followed up for 4 years after index date (ie, 1 year after health care eligibility). Data were analyzed between November 2023 and December 2025. Exposure: Government-assisted refugees (GARs), privately sponsored refugees (PSRs), successful asylum-seekers (referred to as protected persons [PPs] in Canada), nonrefugee immigrant (NRIs), each matched 1:4 to Ontario-born children by age, sex, and urban area. Main Outcomes and Measures: The percentage of minor illness ED visits (ie, primary care plus ED visits for equivalent reasons) in the first and second 2-year periods after eligibility was calculated for each child with at least 1 minor illness visit. The difference in mean percentage was modeled using linear regression and compared each immigrant group to Ontario-born children adjusting for morbidity, material resources quintile, and primary care affiliation. Results: Overall, 458 597 children were included (mean [SD] age, 8.0 [4.3] years; 221 237 females [48%]; 237 360 males [52%]; GARs, 10 211 [2.23%]; PSRs, 7810 [1.70%]; PPs, 11 540 [2.52%]; NRIs, 83 537 [18.22%]; Ontario-born matches, 345 499 [75.34%]). In the first 2 years, immigrant groups had significantly lower adjusted differences in the mean percentage of minor illnesses seen in the ED compared with their Ontario-born matches (GARs: −5.11% [95% CI, −5.63% to −4.57%]; PSRs: −5.24% [95% CI, −5.80% to −4.67%]; PPs: −3.37% [95% CI, −3.86% to −2.87%]; NRIs: −4.24% [95% CI, −4.40% to −4.09%]). In the second 2 years, differences were attenuated but remained significantly lower. Conclusions and Relevance: In this cohort study, refugee and nonrefugee immigrant children in their early resettlement period were less likely to use the ED than Ontario-born children for minor illnesses, suggesting adequate access to primary care.

Introduction: First Nations communities in Canada are disproportionately impacted by prenatal opioid exposure (POE) and neonatal abstinence syndrome (NAS). In response, we developed a research partnership with 13 First Nations communities in Ontario. Phase I of the research project, initiated in 2018, included the development of mixed-methods reports on the impact of POE for each community. This protocol outlines the evaluation of phase II, during which nine communities individually co-designed and implemented community-specific knowledge mobilisation (KMb) plans informed by findings from phase I. The evaluation aims to assess advisory working group engagement, KMb implementation and perceived community-level impacts. Methods and analysis: This mixed-methods evaluation integrates survey and qualitative data to assess First Nations-led KMb products and activities. The Public and Patient Engagement Evaluation Tool, a validated survey instrument, will be administered to advisory group members and analysed descriptively. Focus groups and interviews will be conducted to explore advisory working group members’ experiences and analysed using phenomenological methods. Qualitative findings will be mapped to the Engage with Impact framework to assess outcomes across engagement domains. Ethics and dissemination: Ethics approval has been granted by Vancouver Island University. All community contacts and advisory working group members will provide informed consent prior to data collection. Phase II activities are governed by formal community agreements. In alignment with First Nations Principles of OCAP (Ownership, Control, Access and Possession), First Nations community partners retain ownership of their KMb products and are actively involved in the design, implementation and dissemination of the project evaluation. Results will be shared through peer-reviewed publications, community reports and knowledge-sharing events.

Objective: We sought to measure whether receipt of an enhanced 18-month well-baby visit with use of a developmental screening tool versus a routine 18-month well-baby visit (which typically involves developmental surveillance without screening) is associated with time to identification of developmental delays. Method: We conducted a cohort study of children (17–22 months) in Ontario who received an 18-month well-baby visit (March 2020‒March 2022), followed to September 2022 using linked health administrative datasets. Visits were categorized as enhanced (n = 83,554) or routine (n = 15,723). The outcome was the identification of a developmental delay within 6 months (early) and more than 6 months after (late) the 18-month visit. Piecewise Cox proportional hazards models estimated hazard ratios (aHR) adjusted for child, maternal, and physician factors, comparing developmental delay diagnosis by visit type. Results: Children who received an enhanced visit were slightly older, had a lower representation in the most deprived group, and a higher percentage of patients with pediatricians as their usual provider of care. After adjustment, children with enhanced compared with routine visits were more likely to have developmental delays detected in the early period (aHR 1.19 95% CI 1.11‒1.28) but not in the late period following the well-baby visit. Conclusion: Enhanced visits are associated with earlier identification of developmental delays compared with routine visits in the 6 months following the 18-month well-baby visit. Enhanced developmental monitoring using screening tools may facilitate earlier recognition of developmental concerns.

Introduction Opioids are widely used during pregnancy and can lead to health complications for pregnant people, parents and their children. Yet, little is known about the long- and short-term effects of perinatal opioid exposures on health outcomes in Canada. Evidence is needed to inform optimal support for maternal and child health following perinatal opioid exposures. Aim We aim to develop the Canadian Perinatal Opioid Project, a pan-Canadian federated health data system to capture perinatal opioid exposures across multiple provinces, along with subsequent maternal and child health outcomes. Methods and analysis This health data system uses population-based administrative health records from Alberta, British Columbia, Manitoba, Ontario and Saskatchewan, each with two population-based cohorts: (1) all pregnancies among people aged 12–49 years, 2013–2023 and (2) liveborn infants from these pregnancies. Pregnant people will be followed for 1 year after the end of pregnancy; live births will be followed for 8 years. Data will be obtained from outpatient prescription opioid records, mother-infant linked hospitalisation records, emergency department visits, outpatient physician visits, birth registries and vital statistics. This work is being conducted in collaboration with Indigenous and non-Indigenous people with lived/living experience of perinatal opioid use and knowledge users. Analysis We will use descriptive statistics to describe incidence and cohort characteristics and Poisson regression to assess annual trends. Patient-level analysis will occur in each province, and province-level aggregated results will be meta-analysed. Ethics and dissemination Ethics approval was granted by research ethics boards at the University of British Columbia (H24-03406), University of Calgary (REB24-1721), University of Manitoba (HS26640), University of Toronto (46764) and University of Saskatchewan (5348). We will develop knowledge dissemination plans and products with people with lived/living experience of perinatal opioid use and knowledge users. Health data indicators will be featured in an open-access online dashboard. We expect to share methods and research findings through peer-reviewed publications in high-impact journals, presentations at national and international conferences, presentations to community members and knowledge users, and research summaries for the general population.

Rationale: Home mechanical ventilation (HMV) is an advanced medical therapy offered to children with medical complexity. Despite the growing pediatric HMV population in North America, there are limited studies describing healthcare use and predictors of highest costs using robust health administrative data. Objectives: To describe patterns of healthcare use and costs in children receiving HMV over a 14-year period in Ontario, Canada. Methods: We conducted a retrospective population-based cohort study (April 1, 2003, to March 31, 2017) of children aged 0–18 years receiving HMV via invasive mechanical ventilation or noninvasive ventilation. Paired t tests compared healthcare system use and costs 2 years before and 2 years after HMV approval. We developed linear models to analyze variables associated with children in the top quartile of health service use and costs. Results: We identified 835 children receiving HMV. In the 2 years after HMV approval compared with the 2 years prior, children had decreased hospitalization days (median, 9 [interquartile range, 3–30] vs. 29 [6–99]; P < 0.0001) and intensive care unit admission days (6.6 [1.9–18.0] vs. 17.1 [3.3–70.9]; P < 0.0001) but had increased homecare service approvals (195 [24–522] vs. 40 [12–225]; P < 0.0001) and outpatient pulmonology visits (3 [1–4] vs. 2 [1–3]; P < 0.0001). Total healthcare costs were higher in the 2 years after HMV approval (mean, CAD$164,892 [standard deviation, CAD$214,187] vs. CAD$128,941 [CAD$194,199]; P < 0.0001). However, all-cause hospital admission costs were reduced (CAD$66,546 [CAD$142,401] vs. CAD$81,578 [CAD$164,672]; P < 0.0001). The highest total 2-year costs were associated with invasive mechanical ventilation (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.24–5.31; reference noninvasive ventilation), number of medical devices at home (OR, 1.63; 95% CI, 1.35–1.96; reference no technology), and increased healthcare costs in the year before HMV initiation (OR, 2.23; 95% CI, 1.84–2.69). Conclusions: Children progressing to the need for HMV represent a worsening in their respiratory status that will undoubtedly increase healthcare use and costs. We found that the initiation of HMV in these children can reduce inpatient healthcare use and costs but can still increase overall healthcare expenditures, especially in the outpatient setting.

Objective: To examine the association between maternal mRNA covid-19 vaccination during the first trimester of pregnancy and the prevalence of major congenital anomalies in offspring. Design: Population based cohort study with sibling matched analysis. Setting: Multiple health administrative databases, linked and analysed at ICES, an independent, non-profit research institute that collects and analyses healthcare and demographic data, Ontario, Canada, from 16 October 2021 to 1 May 2023. Population: 174 296 singleton live births >20 weeks' gestation with an expected birth date between 16 October 2021 and 1 May 2023: 34 181 (20%) born to mothers who received one or two doses of an mRNA covid-19 vaccine in the first trimester and 34 951 (20%) born to mothers who did not receive a vaccine before or during pregnancy. The sibling matched analysis included 13 312 infants exposed to a covid-19 vaccine in the first trimester and 15 089 matched older siblings with the same mother, with an expected birth date after 16 October 2016 and no reported in utero exposure to a covid-19 vaccine. Main outcome measures: Major congenital anomalies, overall and grouped by specific organ systems, diagnosed within 28 days of birth. Results: Major congenital anomalies were present in 832 (24.3 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester compared with 927 (26.5 per 1000 live births) infants not exposed to a vaccine, resulting in an adjusted prevalence ratio of 0.89 (95% confidence interval (CI) 0.79 to 1.01). Major congenital anomalies were present in 283 (21.3 per 1000 live births) and 343 (22.7 per 1000 live births) infants exposed to an mRNA covid-19 vaccine in the first trimester and their older siblings not exposed to a vaccine, respectively (adjusted prevalence ratio 0.91, 95% CI 0.77 to 1.07). First trimester vaccination was not associated with an increase in major congenital anomalies grouped by specific organ system in the primary or sibling matched analyses. Results were similar across a range of subgroup and sensitivity analyses. Conclusions: In this large population based cohort study and sibling matched analysis, mRNA covid-19 vaccination during the first trimester of pregnancy was not associated with an increase in major congenital anomalies in offspring, overall or grouped by organ system.

Objective To assess reported community engagement in the design and conduct of health equity-focused articles published in high-impact journals. Design Scoping review follows guidance from the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Data sources We selected the three highest-ranked journals from the ‘Medicine—General and Internal’ category including the Journal of the American Medical Association (JAMA), The Lancet and The New England Journal of Medicine (NEJM) along with all journals under their family of subspecialty journals (JAMA Network, The Lancet Group and the NEJM Group). Ovid MEDLINE was searched between 1 January 2021 to 22 September 2022. Eligibility criteria We included health equity-focused articles and assessed for the reporting of community engagement at each stage of the research process. Data extraction and synthesis Two independent reviewers extracted data from articles that met the inclusionary criteria. Inter-rater reliability was assessed using Cohen’s kappa to measure the agreement between two independent reviewers. Disagreements were adjudicated by a third independent reviewer. Results 7616 articles were screened, 626 (8.2%) met our inclusion criteria: 457 (3.8%) were published by the JAMA Network; 167 (2.4%) by The Lancet Group; and 2 (0.2%) by the NEJM group. Most articles were from USA (68.4%) and focused on adult populations (57.7%). The majority of the articles focused on the topic of race/ethnicity (n=176, 28.1%), socioeconomic status (n=114, 18.2%) or multiple equity topics (n=111, 17.7%). The use of community engagement approaches was reported in 97 (15.5%) articles, of which 13 articles (13.4%) reported engagement at all stages. The most common form of reported engagement was in the acknowledgement or additional contribution section (n=86, 88.7%). Conclusions Community engagement is infrequently reported in health equity-focused research published in high-impact medical journals.