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1.  Systematic review and assessment of validated case definitions for depression in administrative data 
BMC Psychiatry  2014;14(1):289.
Administrative data are increasingly used to conduct research on depression and inform health services and health policy. Depression surveillance using administrative data is an alternative to surveys, which can be more resource-intensive. The objectives of this study were to: (1) systematically review the literature on validated case definitions to identify depression using International Classification of Disease and Related Health Problems (ICD) codes in administrative data and (2) identify individuals with and without depression in administrative data and develop an enhanced case definition to identify persons with depression in ICD-coded hospital data.
(1) Systematic review: We identified validation studies using ICD codes to indicate depression in administrative data up to January 2013. (2) Validation: All depression case definitions from the literature and an additional three ICD-9-CM and three ICD-10 enhanced definitions were tested in an inpatient database. The diagnostic accuracy of all case definitions was calculated [sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV)].
(1) Systematic review: Of 2,014 abstracts identified, 36 underwent full-text review and three met eligibility criteria. These depression studies used ICD-9 and ICD-10 case definitions. (2) Validation: 4,008 randomly selected medical charts were reviewed to assess the performance of new and previously published depression-related ICD case definitions. All newly tested case definitions resulted in Sp >99%, PPV >89% and NPV >91%. Sensitivities were low (28-35%), but higher than for case definitions identified in the literature (1.1-29.6%).
Validating ICD-coded data for depression is important due to variation in coding practices across jurisdictions. The most suitable case definitions for detecting depression in administrative data vary depending on the context. For surveillance purposes, the most inclusive ICD-9 & ICD-10 case definitions resulted in PPVs of 89.7% and 89.5%, respectively. In cases where diagnostic certainty is required, the least inclusive ICD-9 and −10 case definitions are recommended, resulting in PPVs of 92.0% and 91.1%. All proposed case definitions resulted in suboptimal levels of sensitivity (ranging from 28.9%-35.6%). The addition of outpatient data (such as pharmacy records) for depression surveillance is recommended and should result in improved measures of validity.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0289-5) contains supplementary material, which is available to authorized users.
PMCID: PMC4201696  PMID: 25322690
Depression; Validation; Systematic review; Administrative data; International Classification of Diseases
2.  Comparison of sampling methods for hard-to-reach francophone populations: yield and adequacy of advertisement and respondent-driven sampling 
Open Medicine  2014;8(4):e120-e129.
Francophones who live outside the primarily French-speaking province of Quebec, Canada, risk being excluded from research by lack of a sampling frame. We examined the adequacy of random sampling, advertising, and respondent-driven sampling for recruitment of francophones for survey research.
We recruited francophones residing in the city of Calgary, Alberta, through advertising and respondentdriven sampling. These 2 samples were then compared with a random subsample of Calgary francophones derived from the 2006 Canadian Community Health Survey (CCHS). We assessed the effectiveness of advertising and respondent-driven sampling in relation to the CCHS sample by comparing demographic characteristics and selected items from the CCHS (specifically self-reported general health status, perceived weight, and having a family doctor).
We recruited 120 francophones through advertising and 145 through respondent-driven sampling; the random sample from the CCHS consisted of 259 records. The samples derived from advertising and respondentdriven sampling differed from the CCHS in terms of age (mean ages 41.0, 37.6, and 42.5 years, respectively), sex (proportion of males 26.1%, 40.6%, and 56.6%, respectively), education (college or higher 86.7% , 77.9% , and 59.1%, respectively), place of birth (immigrants accounting for 45.8%, 55.2%, and 3.7%, respectively), and not having a regular medical doctor (16.7%, 34.5%, and 16.6%, respectively). Differences were not tested statistically because of limitations on the analysis of CCHS data imposed by Statistics Canada.
The samples generated exclusively through advertising and respondent-driven sampling were not representative of the gold standard sample from the CCHS. Use of such biased samples for research studies could generate misleading results.
PMCID: PMC4242789  PMID: 25426180
3.  Mining rich health data from Canadian physician claims: features and face validity 
BMC Research Notes  2014;7(1):682.
Physician claims data are one of the largest sources of coded health information unique to Canada. There is skepticism from data users about the quality of this data. This study investigated features of diagnostic codes used in the Alberta physician claims database.
Alberta physician claims from January 1 to March 31, 2011 are analyzed. Claims contain coded diagnoses using the International Classification of Diseases, 9th revision (ICD-9), procedures, physician specialty and service-fee type. Descriptive statistics examined the diversity and frequency of unique ICD-9 diagnostic codes used and the level of code extension (e.g. 3- or 4-digit coding).
A total of 7,441,005 claims by 6,601 physicians were analyzed. The average number of claims per physician was 1,079, with ranges between 1,330 for family medicine, 690 for internal medicine, 722 for surgery, 516 for pediatrics and 409 for neurology. Family physicians used an average of 121 diagnostic codes, internal medicine physicians 32, surgery 36, pediatrics 46 and neurology 27. Overall, 43.5% of claims had a more detailed diagnosis (ICD code with >3 digits). Physicians on a fee-for-service plan submitted 1,184 claims and used 88 unique diagnosis codes on average compared to 438 claims and 44 unique diagnosis codes from physicians on an alternative payment plan (APP).
Face validity of diagnosis coded in physician claims is substantially high and the features of diagnosis codes seem to reasonably reflect the clinical specialty. Physicians submit a diverse array of ICD 9 diagnostic codes and nearly half of the ICD-9 diagnostic codes examined were more detailed than required (i.e. ICD code with >3 digits). Finally, guidelines and policies should be explored to assess the submission of shadow billings for physicians on APPs.
PMCID: PMC4193126  PMID: 25270407
Administrative data; International classification of diseases; Quality; Validity
4.  The Alberta Heart Failure Etiology and Analysis Research Team (HEART) study 
Nationally, symptomatic heart failure affects 1.5-2% of Canadians, incurs $3 billion in hospital costs annually and the global burden is expected to double in the next 1–2 decades. The current one-year mortality rate after diagnosis of heart failure remains high at >25%. Consequently, new therapeutic strategies need to be developed for this debilitating condition.
The objective of the Alberta HEART program ( is to develop novel diagnostic, therapeutic and prognostic approaches to patients with heart failure with preserved ejection fraction. We hypothesize that novel imaging techniques and biomarkers will aid in describing heart failure with preserved ejection fraction. Furthermore, the development of new diagnostic criteria will allow us to: 1) better define risk factors associated with heart failure with preserved ejection fraction; 2) elucidate clinical, cellular and molecular mechanisms involved with the development and progression of heart failure with preserved ejection fraction; 3) design and test new therapeutic strategies for patients with heart failure with preserved ejection fraction. Additionally, Alberta HEART provides training and education for enhancing translational medicine, knowledge translation and clinical practice in heart failure. This is a prospective observational cohort study of patients with, or at risk for, heart failure. Patients will have sequential testing including quality of life and clinical outcomes over 12 months. After that time, study participants will be passively followed via linkage to external administrative databases. Clinical outcomes of interest include death, hospitalization, emergency department visits, physician resource use and/or heart transplant. Patients will be followed for a total of 5 years.
Alberta HEART has the primary objective to define new diagnostic criteria for patients with heart failure with preserved ejection fraction. New criteria will allow for targeted therapies, diagnostic tests and further understanding of the patients, both at-risk for and with heart failure.
Trial registration NCT02052804.
PMCID: PMC4222863  PMID: 25063541
Heart failure; Preserved ejection fraction; Heart failure risk factors; Heart failure diagnosis
5.  Likelihood of coronary angiography among First Nations patients with acute myocardial infarction 
Morbidity due to cardiovascular disease is high among First Nations people. The extent to which this may be related to the likelihood of coronary angiography is unclear. We examined the likelihood of coronary angiography after acute myocardial infarction (MI) among First Nations and non–First Nations patients.
Our study included adults with incident acute MI between 1997 and 2008 in Alberta. We determined the likelihood of angiography among First Nations and non–First Nations patients, adjusted for important confounders, using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database.
Of the 46 764 people with acute MI, 1043 (2.2%) were First Nations. First Nations patients were less likely to receive angiography within 1 day after acute MI (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI] 0.62–0.87). Among First Nations and non–First Nations patients who underwent angiography (64.9%), there was no difference in the likelihood of percutaneous coronary intervention (PCI) (adjusted hazard ratio [HR] 0.92, 95% CI 0.83–1.02) or coronary artery bypass grafting (CABG) (adjusted HR 1.03, 95% CI 0.85–1.25). First Nations people had worse survival if they received medical management alone (adjusted HR 1.38, 95% CI 1.07–1.77) or if they underwent PCI (adjusted HR 1.38, 95% CI 1.06–1.80), whereas survival was similar among First Nations and non–First Nations patients who received CABG.
First Nations people were less likely to undergo angiography after acute MI and experienced worse long-term survival compared with non–First Nations people. Efforts to improve access to angiography for First Nations people may improve outcomes.
PMCID: PMC4081235  PMID: 24847149
6.  Coding of obesity in administrative hospital discharge abstract data: accuracy and impact for future research studies 
Obesity is a pervasive problem and a popular subject of academic assessment. The ability to take advantage of existing data, such as administrative databases, to study obesity is appealing. The objective of our study was to assess the validity of obesity coding in an administrative database and compare the association between obesity and outcomes in an administrative database versus registry.
This study was conducted using a coronary catheterization registry and an administrative database (Discharge Abstract Database (DAD)). A Body Mass Index (BMI) ≥30 kg/m2 within the registry defined obesity. In the DAD obesity was defined by diagnosis codes E65 – E68 (ICD-10). The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an obesity diagnosis in the DAD was determined using obesity diagnosis in the registry as the referent. The association between obesity and outcomes was assessed.
The study population of 17380 subjects was largely male (68.8%) with a mean BMI of 27.0 kg/m2. Obesity prevalence was lower in the DAD than registry (2.4% vs. 20.3%). A diagnosis of obesity in the DAD had a sensitivity 7.75%, specificity 98.98%, NPV 80.84% and PPV 65.94%. Obesity was associated with decreased risk of death or re-hospitalization, though non-significantly within the DAD. Obesity was significantly associated with an increased risk of cardiac procedure in both databases.
Overall, obesity was poorly coded in the DAD. However, when coded, it was coded accurately. Administrative databases are not an optimal datasource for obesity prevalence and incidence surveillance but could be used to define obese cohorts for follow-up.
PMCID: PMC3996078  PMID: 24524687
Obesity; Coding; Administrative data; Clinical databases; ICD-10
7.  Outcomes following percutaneous coronary intervention and coronary artery bypass grafting surgery in Chinese, South Asian and white patients with acute myocardial infarction: administrative data analysis 
Little is known on whether there are ethnic differences in outcomes following percutaneous coronary intervention (PCI) and coronary artery bypass grafting surgery (CABG) after acute myocardial infarction (AMI). We compared 30-day and long-term mortality, recurrent AMI, and congestive heart failure in South Asian, Chinese and White patients with AMI who underwent PCI and CABG.
Hospital administrative data in British Columbia (BC), Canada were linked to the BC Cardiac Registry to identify all patients with AMI who underwent PCI (n = 4729) or CABG (n = 1687) (1999–2003). Ethnicity was determined from validated surname algorithms. Logistic regression for 30-day mortality and Cox proportional-hazards models were adjusted for age, sex, socio-economic status, severity of coronary disease, comorbid conditions, time from AMI to a revascularization procedure and distance to the nearest hospital.
Following PCI, Chinese had higher short-term mortality (Odds Ratio (OR): 2.36, 95% CI: 1.12-5.00; p = 0.02), and South Asians had a higher risk for recurrent AMI (OR: 1.34, 95% CI: 1.08-1.67, p = 0.007) and heart failure (OR 1.81, 95% CI: 1.00-3.29, p = 0.05) compared to White patients. Risk of heart failure was higher in South Asian patients who underwent CABG compared to White patients (OR (95% CI) = 2.06 (0.92-4.61), p = 0.08). There were no significant differences in mortality following CABG between groups.
Chinese and South Asian patients with AMI and PCI or CABG had worse outcomes compared to their White counterparts. Further studies are needed to confirm these findings and investigate potential underlying causes.
PMCID: PMC3890497  PMID: 24369071
PCI; CABG; Ethnicity; AMI; Outcomes
8.  Surveillance of ischemic heart disease should include physician billing claims: population-based evidence from administrative health data across seven Canadian provinces 
Canadian provinces and territories routinely collect health information for administrative purposes. This study used Canadian medical and hospital administrative data for population-based surveillance of diagnosed ischemic heart disease (IHD).
Hospital discharge abstracts and physician billing claims data from seven provinces were analyzed to estimate prevalence and incidence of IHD using three validated algorithms: a) one hospital discharge abstract with an IHD diagnosis or procedure code (1H); b) 1H or at least three physician claims within a one-year period (1H3P) and c) 1H or at least two physician claims within a one-year period (1H2P). Crude and age-standardized prevalence and incidence rates were calculated for Canadian adults aged 20 +.
IHD prevalence and incidence varied by province, were consistently higher among males than females, and increased with age. Prevalence and incidence were lower using the 1H method compared to using the 1H2P or 1H3P methods in all provinces studied for all age groups. For instance, in 2006/07, crude prevalence by province ranged from 3.4%-5.5% (1H), from 4.9%-7.7% (1H3P) and from 6.0%-9.2% (1H2P). Similarly, crude incidence by province ranged from 3.7-5.9 per 1,000 (1H), from 5.0-6.9 per 1,000 (1H3P) and from 6.1-7.9 per 1,000 (1H2P).
Study findings show that incidence and prevalence of diagnosed IHD will be underestimated by as much as 50% using inpatient data alone. The addition of physician claims data are needed to better assess the burden of IHD in Canada.
PMCID: PMC3871006  PMID: 24138129
Ischemic heart disease; Incidence; Prevalence; Hospital administrative data; Canada
9.  Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study) 
BMJ Open  2013;3(10):e003716.
To assess if the Agency for Healthcare Research and Quality  patient safety indictors (PSIs) could be used for case findings in the International Classification of Disease 10th revision (ICD-10) hospital discharge abstract data.
We identified and randomly selected 490 patients with a foreign body left during a procedure (PSI 5—foreign body), selected infections (IV site) due to medical care (PSI 7—infection), postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT; PSI 12—PE/DVT), postoperative sepsis (PSI 13—sepsis)and accidental puncture or laceration (PSI 15—laceration) among patients discharged from three adult acute care hospitals in Calgary, Canada in 2007 and 2008. Their charts were reviewed for determining the presence of PSIs and used as the reference standard, positive predictive value (PPV) statistics were calculated to determine the proportion of positives in the administrative data representing ‘true positives’.
The PPV for PSI 5—foreign body was 62.5% (95% CI 35.4% to 84.8%), PSI 7—infection was 79.1% (67.4% to 88.1%), PSI 12—PE/DVT was 89.5% (66.9% to 98.7%), PSI 13—sepsis was 12.5% (1.6% to 38.4%) and PSI 15—laceration was 86.4% (75.0% to 94.0%) after excluding those who presented to the hospital with the condition.
Several PSIs had high PPV in the ICD administrative data and are thus powerful tools for true positive case finding. The tools could be used to identify potential cases from the large volume of admissions for verification through chart reviews. In contrast, their sensitivity has not been well characterised and users of PSIs should be cautious if using them for ‘quality of care reporting’ presenting the rate of PSIs because under-coded data would generate falsely low PSI rates.
PMCID: PMC3796280  PMID: 24114372
10.  Patterns of engagement with the health care system and risk of subsequent hospitalization amongst patients with diabetes 
Re-hospitalization is common among patients with diabetes, and may be related to aspects of health care use. We sought to determine the association between patterns of health care engagement and risk of subsequent hospitalization within one year of discharge for patients with diabetes.
We identified adults with incident diabetes in Alberta, Canada, who had at least one hospitalization following their diabetes diagnosis between January 1, 2004 and March 31, 2011. We used Cox regression to estimate the association between factors related to health care engagement (prior emergency department use, primary care visits, and discharge disposition (i.e. whether the patient left against medical advice)) and the risk of subsequent all-cause hospitalization within one year.
Of the 33811 adults with diabetes and at least one hospitalization, 11095 (32.8%) experienced a subsequent all-cause hospitalization within a mean (standard deviation) follow-up time of 0.68 (0.3) years. Compared to patients with no emergency department visits, there was a 4 percent increased risk of a subsequent hospitalization for every emergency department visit occurring prior to the index hospitalization (adjusted Hazard Ratio [HR]: 1.04; 95% CI: 1.03–1.05). Limited and increased use of primary care was also associated with increased risk of a subsequent hospitalization. Compared to patients with 1–4 visits, patients with no visits to a primary care physician (adjusted HR: 1.11; 95% CI: 0.99–1.25) and those with 5–9 visits (adjusted HR: 1.06; 95% CI: 1.00–1.12) were more likely to experience a subsequent hospitalization. Finally, compared to patients discharged home, those leaving against medical advice were more likely to have a subsequent hospitalization (adjusted HR: 1.74; 95% CI: 1.50–2.02) and almost 3 times more likely to have a diabetes-specific subsequent event (adjusted HR: 2.86; 95% CI: 1.82–4.49).
Patterns of health care use and the circumstances surrounding hospital discharge are associated with an increased risk of subsequent hospitalization among patients with diabetes. Whether these patterns are related to the health care systems ability to manage complex patients within a primary care setting, or to access to primary care services, remains to be determined.
PMCID: PMC3851786  PMID: 24103159
Diabetes; Administrative data; Hospitalization
11.  Development and validation of an administrative case definition for inflammatory bowel diseases 
A population-based database of inflammatory bowel disease (IBD) patients is invaluable to explore and monitor the epidemiology and outcome of the disease. In this context, an accurate and validated population-based case definition for IBD becomes critical for researchers and health care providers.
IBD and non-IBD individuals were identified through an endoscopy database in a western Canadian health region (Calgary Health Region, Calgary, Alberta). Subsequently, using a novel algorithm, a series of case definitions were developed to capture IBD cases in the administrative databases. In the second stage of the study, the criteria were validated in the Capital Health Region (Edmonton, Alberta).
A total of 150 IBD case definitions were developed using 1399 IBD patients and 15,439 controls in the development phase. In the validation phase, 318,382 endoscopic procedures were searched and 5201 IBD patients were identified. After consideration of sensitivity, specificity and temporal stability of each validated case definition, a diagnosis of IBD was assigned to individuals who experienced at least two hospitalizations or had four physician claims, or two medical contacts in the Ambulatory Care Classification System database with an IBD diagnostic code within a two-year period (specificity 99.8%; sensitivity 83.4%; positive predictive value 97.4%; negative predictive value 98.5%). An alternative case definition was developed for regions without access to the Ambulatory Care Classification System database. A novel scoring system was developed that detected Crohn disease and ulcerative colitis patients with a specificity of >99% and a sensitivity of 99.1% and 86.3%, respectively.
Through a robust methodology, a reproducible set of criteria to capture IBD patients through administrative databases was developed. The methodology may be used to develop similar administrative definitions for chronic diseases.
PMCID: PMC3472911  PMID: 23061064
Administrative database; Crohn disease; Epidemiology; Inflammatory bowel diseases; Population-based data; Ulcerative colitis
12.  Recommendations for optimal ICD codes to study neurologic conditions 
Neurology  2012;79(10):1049-1055.
Administrative health data are frequently used for large population-based studies. However, the validity of these data for identifying neurologic conditions is uncertain.
This article systematically reviews the literature to assess the validity of administrative data for identifying patients with neurologic conditions. Two reviewers independently assessed for eligibility all abstracts and full-text articles identified through a systematic search of Medline and Embase. Study data were abstracted on a standardized abstraction form to identify ICD code–based case definitions and corresponding sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs).
Thirty full-text articles met the eligibility criteria. These included 8 studies for Alzheimer disease/dementia (sensitivity: 8–86.5, specificity: 56.3–100, PPV: 60–97.9, NPV: 68.0–98.9), 2 for brain tumor (sensitivity: 54.0–100, specificity: 97.0–99.0, PPV: 91.0–98.0), 4 for epilepsy (sensitivity: 98.8, specificity: 69.6, PPV: 62.0–100, NPV: 89.5–99.1), 4 for motor neuron disease (sensitivity: 78.9–93.0, specificity: 99.0–99.9, PPV: 38.0–90.0, NPV: 99), 2 for multiple sclerosis (sensitivity: 85–92.4, specificity: 55.9–92.6, PPV: 74.5–92.7, NPV: 70.8–91.9), 4 for Parkinson disease/parkinsonism (sensitivity: 18.7–100, specificity: 0–99.9, PPV: 38.6–81.0, NPV: 46.0), 3 for spinal cord injury (sensitivity: 0.9–90.6, specificity: 31.9–100, PPV: 27.3–100), and 3 for traumatic brain injury (sensitivity: 45.9–78.0 specificity: 97.8, PPV: 23.7–98.0, NPV: 99.2). No studies met eligibility criteria for cerebral palsy, dystonia, Huntington disease, hydrocephalus, muscular dystrophy, spina bifida, or Tourette syndrome.
To ensure the accurate interpretation of population-based studies with use of administrative health data, the accuracy of case definitions for neurologic conditions needs to be taken into consideration.
PMCID: PMC3430709  PMID: 22914826
13.  Risk factors, quality of care and prognosis in South Asian, East Asian and White patients with stroke 
BMC Neurology  2013;13:74.
Stroke has emerged as a significant and escalating health problem for Asian populations. We compared risk factors, quality of care and risk of death or recurrent stroke in South Asian, East Asian and White patients with acute ischemic and hemorrhagic stroke.
Retrospective analysis was performed on consecutive patients with ischemic stroke or intracerebral hemorrhage admitted to 12 stroke centers in Ontario, Canada (July 2003-March 2008) and included in the Registry of the Canadian Stroke Network database. The database was linked to population-based administrative databases to determine one-year risk of death or recurrent stroke.
The study included 253 South Asian, 513 East Asian and 8231 White patients. East Asian patients were more likely to present with intracerebral hemorrhage (30%) compared to South Asian (17%) or White patients (15%) (p<0.001). Time from stroke to hospital arrival was similarly poor with delays >2 hours for more than two thirds of patients in all ethnic groups. Processes of stroke care, including thrombolysis, diagnostic imaging, antithrombotic medications, and rehabilitation services were similar among ethnic groups. Risk of death or recurrent stroke at one year after ischemic stroke was similar for patients who were White (27.6%), East Asian (24.7%, aHR 0.97, 95% CI 0.78-1.21 vs. White), or South Asian (21.9%, aHR 0.91, 95% CI 0.67-1.24 vs. White). Although risk of death or recurrent stroke at one year after intracerebral hemorrhage was higher in East Asian (35.5%) and White patients (47.9%) compared to South Asian patients (30.2%) (p=0.002), these differences disappeared after adjustment for age, sex, stroke severity and comorbid conditions (aHR 0.89 [0.67-1.19] for East Asian vs White and 0.99 [0.54-1.81] for South Asian vs. White).
After stratification by stroke type, stroke care and outcomes are similar across ethnic groups in Ontario. Enhanced health promotion is needed to reduce delays to hospital for all ethnic groups.
PMCID: PMC3726470  PMID: 23829874
14.  Health Literacy in Rural Areas of China: Hypertension Knowledge Survey 
We conducted this study to determine levels and correlates of hypertension knowledge among rural Chinese adults, and to assess the association between knowledge levels and salty food consumption among hypertensive and non-hypertensive populations. This face-to-face cross sectional survey included 665 hypertensive and 854 non-hypertensive respondents in the rural areas of Heilongjiang province, China. Hypertension knowledge was assessed through a 10-item test; respondents received 10 points for each correct answer. Among respondents, the average hypertension knowledge score was 26 out of a maximum of 100 points for hypertensive and 20 for non-hypertensive respondents. Hypertension knowledge was associated with marital status, education, health status, periodically reading books, newspapers or other materials, history of blood pressure measurement, and attending hypertension educational sessions. Hypertension knowledge is extremely low in rural areas of China. Hypertension education programs should focus on marginal populations, such as individuals who are not married or illiterate to enhance their knowledge levels. Focusing on educational and literacy levels in conjunction with health education is important given illiteracy is still a prominent issue for the Chinese rural population.
PMCID: PMC3709308  PMID: 23507738
hypertension; knowledge; rural Chinese adult; hypertension education program
15.  Association between perceived unmet health care needs and risk of adverse health outcomes among patients with chronic medical conditions 
Open Medicine  2013;7(1):e21-e30.
Adults with chronic medical conditions are more likely to report unmet health care needs. Whether unmet health care needs are associated with an increased risk of adverse health outcomes is unclear.
Adults with at least one self-reported chronic condition (arthritis, chronic obstructive pulmonary disease, diabetes mellitus, heart disease, hypertension, mood disorder, stroke) from the 2001 and 2003 cycles of the Canadian Community Health Survey were linked to national hospitalization data. Participants were followed from the date of their survey until March 31, 2005, for the primary outcomes of all-cause and cause-specific admission to hospital. Secondary outcomes included length of stay, 30-day and 1-year all-cause readmission to hospital, and in-hospital death. Negative binomial regression models were used to estimate the association between unmet health care needs, admission to hospital, and length of stay, with adjustment for socio-demographic variables, health behaviours, and health status. Logistic regression was used to estimate the association between unmet needs, readmission, and in-hospital death. Further analyses were conducted by type of unmet need.
Of the 51 932 adults with self-reported chronic disease, 15.5% reported an unmet health care need. Participants with unmet health care needs had a risk of all-cause admission to hospital similar to that of patients with no unmet needs (adjusted rate ratio [RR] 1.04, 95% confidence interval [CI] 0.94–1.15). When stratified by type of need, participants who reported issues of limited resource availability had a slightly higher risk of hospital admission (RR 1.18, 95% CI 1.09–1.28). There was no association between unmet needs and length of stay, readmission, or in-hospital death.
Overall, unmet health care needs were not associated with an increased risk of admission to hospital among those with chronic conditions. However, certain types of unmet needs may be associated with higher or lower risk. Whether unmet needs are associated with other measures of resource use remains to be determined.
PMCID: PMC3654502  PMID: 23687534
16.  Language barriers 
Canadian Family Physician  2012;58(12):e709-e716.
To assess use of regular medical doctors (RMDs), as well as awareness and use of telephone health lines or telehealth services, by official language minorities (OLMs) in Canada.
Analysis of data from the 2006 postcensal survey on the vitality of OLMs.
In total, 7691 English speakers in Quebec and 12 376 French speakers outside Quebec, grouped into those who experienced language barriers and those with no language barriers.
Main outcome measures
Health services utilization (HSU) by the presence of language barriers; HSU measures included having an RMD, use of an RMD’s services, and awareness of and use of telephone health lines or telehealth services. Multivariable models examined the associations between HSU and language barriers.
After adjusting for age and sex, English speakers residing in Quebec with limited proficiency in French were less likely to have RMDs (adjusted odds ratio [AOR] 0.66, 95% CI 0.50 to 0.87) and to use the services of their RMDs (AOR 0.65, 95% CI 0.50 to 0.86), but were more likely to be aware of the existence of (AOR 1.50, 95% CI 1.16 to 1.93) and to use (AOR 1.43, 95% CI 0.97 to 2.11) telephone health lines or telehealth services. This pattern of having and using RMDs and telehealth services was not observed for French speakers residing outside of Quebec.
Overall we found variation in HSU among the language barrier populations, with lower use observed in Quebec. Age older than 45 years, male sex, being married or in common-law relationships, and higher income were associated with having RMDs for OLMs.
PMCID: PMC3520678  PMID: 23242902
17.  The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence 
The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.
The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.
Materials and methods
Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.
Results and discussion
The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian's framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.
PMCID: PMC3197985  PMID: 21659445
Clinical informatics; quality of healthcare; systematic review; machine learning; health data standards; vocabulary; ontology; scientific information and health data policy; consumer health/patient education information; information retrieval; NLP; public health informatics; clinical trials; electronic medical records; primary care; systematic review
18.  Experiences of French Speaking Immigrants and Non-immigrants Accessing Health Care Services in a Large Canadian City 
French speakers residing in predominantly English-speaking communities have been linked to difficulties accessing health care. This study examined health care access experiences of immigrants and non-immigrants who self-identify as Francophone or French speakers in a mainly English speaking province of Canada. We used semi-structured interviews to gather opinions of recent users of physician and hospital services (N = 26). Language barriers and difficulties finding family doctors were experienced by both French speaking immigrants and non-immigrants alike. This was exacerbated by a general preference for health services in French and less interest in using language interpreters during a medical consultation. Some participants experienced emotional distress, were discontent with care received, often delayed seeking care due to language barriers. Recent immigrants identified lack of insurance coverage for drugs, transportation difficulties and limited knowledge of the healthcare system as major detractors to achieving health. This study provided the groundwork for future research on health issues of official language minorities in Canada.
PMCID: PMC3509478  PMID: 23202772
immigrants; French language; health care access; family doctor; qualitative descriptive; official language minorities
19.  The Model for End-stage Liver Disease accurately predicts 90-day liver transplant wait-list mortality in Atlantic Canada 
To determine the generalizability of the predictions for 90-day mortality generated by Model for End-stage Liver Disease (MELD) and the serum sodium augmented MELD (MELDNa) to Atlantic Canadian adults with end-stage liver disease awaiting liver transplantation (LT).
The predictive accuracy of the MELD and the MELDNa was evaluated by measurement of the discrimination and calibration of the respective models’ estimates for the occurrence of 90-day mortality in a consecutive cohort of LT candidates accrued over a five-year period. Accuracy of discrimination was measured by the area under the ROC curves. Calibration accuracy was evaluated by comparing the observed and model-estimated incidences of 90-day wait-list failure for the total cohort and within quantiles of risk.
The area under the ROC curve for the MELD was 0.887 (95% CI 0.705 to 0.978) – consistent with very good accuracy of discrimination. The area under the ROC curve for the MELDNa was 0.848 (95% CI 0.681 to 0.965). The observed incidence of 90-day wait-list mortality in the validation cohort was 7.9%, which was not significantly different from the MELD estimate of 6.6% (95% CI 4.9% to 8.4%; P=0.177) or the MELDNa estimate of 5.8% (95% CI 3.5% to 8.0%; P=0.065). Global goodness-of-fit testing found no evidence of significant lack of fit for either model (Hosmer-Lemeshow χ2 [df=3] for MELD 2.941, P=0.401; for MELDNa 2.895, P=0.414).
Both the MELD and the MELDNa accurately predicted the occurrence of 90-day wait-list mortality in the study cohort and, therefore, are generalizable to Atlantic Canadians with end-stage liver disease awaiting LT.
PMCID: PMC3174075  PMID: 21876856
End-stage liver disease; Liver transplantation; Mortality; Statistical models; Validation study; Wait list
20.  Implementation of ICD-10 in Canada: how has it impacted coded hospital discharge data? 
The purpose of this study was to assess whether or not the change in coding classification had an impact on diagnosis and comorbidity coding in hospital discharge data across Canadian provinces.
This study examined eight years (fiscal years 1998 to 2005) of hospital records from the Hospital Person-Oriented Information database (HPOI) derived from the Canadian national Discharge Abstract Database. The average number of coded diagnoses per hospital visit was examined from 1998 to 2005 for provinces that switched from International Classifications of Disease 9th version (ICD-9-CM) to ICD-10-CA during this period. The average numbers of type 2 and 3 diagnoses were also described. The prevalence of the Charlson comorbidities and distribution of the Charlson score one year before and one year after ICD-10 implementation for each of the 9 provinces was examined. The prevalence of at least one of the seventeen Charlson comorbidities one year before and one year after ICD-10 implementation were described by hospital characteristics (teaching/non-teaching, urban/rural, volume of patients).
Nine Canadian provinces switched from ICD-9-CM to ICD-I0-CA over a 6 year period starting in 2001. The average number of diagnoses coded per hospital visit for all code types over the study period was 2.58. After implementation of ICD-10-CA a decrease in the number of diagnoses coded was found in four provinces whereas the number of diagnoses coded in the other five provinces remained similar. The prevalence of at least one of the seventeen Charlson conditions remained relatively stable after ICD-10 was implemented, as did the distribution of the Charlson score. When stratified by hospital characteristics, the prevalence of at least one Charlson condition decreased after ICD-10-CA implementation, particularly for low volume hospitals.
In conclusion, implementation of ICD-10-CA in Canadian provinces did not substantially change coding practices, but there was some coding variation in the average number of diagnoses per hospital visit across provinces.
PMCID: PMC3411494  PMID: 22682405
International classification of disease version 10; Administrative data; Hospital records; Canada; Coding; Hospital discharge data
21.  A systematic review of interventions to increase breast and cervical cancer screening uptake among Asian women 
BMC Public Health  2012;12:413.
The Asian population is one of the fastest growing ethnic minority groups in western countries. However, cancer screening uptake is consistently lower in this group than in the native-born populations. As a first step towards developing an effective cancer screening intervention program targeting Asian women, we conducted a comprehensive systematic review, without geographic, language or date limitations, to update current knowledge on the effectiveness of existing intervention strategies to enhance breast and cervical screening uptake in Asian women.
This study systematically reviewed studies published as of January 2010 to synthesize knowledge about effectiveness of cancer screening interventions targeting Asian women. Fifteen multidisciplinary peer-reviewed and grey literature databases were searched to identify relevant studies.
The results of our systematic review were reported in accordance with the PRISMA Statement. Of 37 selected intervention studies, only 18 studies included valid outcome measures (i.e. self-reported or recorded receipt of mammograms or Pap smear). 11 of the 18 intervention studies with valid outcome measures used multiple intervention strategies to target individuals in a specific Asian ethnic group. This observed pattern of intervention design supports the hypothesis that employing a combination of multiple strategies is more likely to be successful than single interventions. The effectiveness of community-based or workplace-based group education programs increases when additional supports, such as assistance in scheduling/attending screening and mobile screening services are provided. Combining cultural awareness training for health care professionals with outreach workers who can help healthcare professionals overcome language and cultural barriers is likely to improve cancer screening uptake. Media campaigns and mailed culturally sensitive print materials alone may be ineffective in increasing screening uptake. Intervention effectiveness appears to vary with ethnic population, methods of program delivery, and study setting.
Despite some limitations, our review has demonstrated that the effectiveness of existing interventions to promote breast and cervical cancer screening uptake in Asian women may hinge on a variety of factors, such as type of intervention and study population characteristics. While some studies demonstrated the effectiveness of certain intervention programs, the cost effectiveness and long-term sustainability of these programs remain questionable. When adopting an intervention program, it is important to consider the impacts of social-and cultural factors specific to the Asian population on cancer screening uptake. Future research is needed to develop new interventions and tools, and adopt vigorous study design and evaluation methodologies to increase cancer screening among Asian women to promote population health and health equity.
PMCID: PMC3488494  PMID: 22676147
22.  Postoperative complications following colectomy for ulcerative colitis: A validation study 
BMC Gastroenterology  2012;12:39.
Ulcerative colitis (UC) patients failing medical management require colectomy. This study compares risk estimates for predictors of postoperative complication derived from administrative data against that of chart review and evaluates the accuracy of administrative coding for this population.
Hospital administrative databases were used to identify adults with UC undergoing colectomy from 1996–2007. Medical charts were reviewed and regression analyses comparing chart versus administrative data were performed to assess the effect of age, emergent operation, and Charlson comorbidities on the occurrence of postoperative complications. Sensitivity, specificity, and positive/negative predictive values of administrative coding for identifying the study population, Charlson comorbidities, and postoperative complications were assessed.
Compared to chart review, administrative data estimated a higher magnitude of effect for emergent admission (OR 2.52 [95% CI: 1.80–3.52] versus 1.49 [1.06–2.09]) and Charlson comorbidities (OR 2.91 [1.86–4.56] versus 1.50 [1.05–2.15]) as predictors of postoperative complications. Administrative data correctly identified UC and colectomy in 85.9% of cases. The administrative database was 37% sensitive in identifying patients with ≥ 1Charlson comorbidity. Restricting analysis to active comorbidities increased the sensitivity to 63%. The sensitivity of identifying patients with at least one postoperative complication was 68%; restricting analysis to more severe complications improved the sensitivity to 84%.
Administrative data identified the same risk factors for postoperative complications as chart review, but overestimated the magnitude of risk. This discrepancy may be explained by coding inaccuracies that selectively identifying the most serious complications and comorbidities.
PMCID: PMC3432603  PMID: 22943760
23.  Association between chronic conditions and perceived unmet health care needs 
Open Medicine  2012;6(2):e48-e58.
Although effective treatments exist, many Canadians with chronic medical conditions do not receive the full care they require, possibly as a consequence of limited accessibility or availability. A commonly used indicator of inadequate access to or availability of care is the perception of unmet health care needs. The objective of this study was therefore to determine the association between chronic conditions and perceived unmet health care needs.
We extracted data for adult respondents from the combined 2001, 2003 and 2005 cross-sectional cycles of the Canadian Community Health Survey. Multivariate logistic regression was used to estimate the association between 7 high-prevalence and high-impact chronic conditions (arthritis, chronic obstructive pulmonary disease/emphysema, diabetes, heart disease, hypertension, mood disorder and stroke) and perceived unmet health care needs in the prior 12 months, adjusting for sociodemographic variables, health behaviours, health status and survey cycle.
Of the 360 105 adult respondents, 12.2% reported an unmet health care need. Compared with those without chronic conditions, respondents with at least one condition were more likely to report an unmet need (adjusted odds ratio [OR] 1.51, 95% confidence interval [CI] 1.45–1.59). Those with mood disorders were almost twice as likely to report an unmet need (OR 1.94, 95% CI 1.78–2.12), while those with diabetes or hypertension were less likely to report an unmet need (diabetes OR 0.85, 95% CI 0.76–0.94; hypertension OR 0.96, 95% CI 0.89–1.04). Furthermore, the likelihood of an unmet need increased with the number of chronic conditions (OR 1.71, 95% CI 1.56–1.88 for 3 or more conditions). Respondents with chronic conditions were more likely than those without to report an unmet need related to resource availability (OR 1.14, 95% CI 1.06–1.22).
Adults with chronic medical conditions are more likely to report an unmet health care need, and the likelihood increases with an increasing number of conditions. Whether these unmet needs are associated with worse outcomes, and whether interventions targeted to address these needs may improve outcomes for Canadians with chronic disease, remain to be determined.
PMCID: PMC3659214  PMID: 23696769
24.  Appropriateness of the use of intravenous immune globulin before and after the introduction of a utilization control program 
Open Medicine  2012;6(1):e28-e34.
Intravenous immune globulin (IVIG) is an expensive and sometimes scarce blood product that carries some risk. It may often be used inappropriately. We evaluated the appropriateness of IVIG use before and after the introduction of an utilization control program to reduce inappropriate use.
We used the RAND/UCLA Appropriateness Method to measure the appropriateness of IVIG use in the province of British Columbia (BC) in 2001 and 2003, before and after the introduction of a utilization control program designed to reduce inappropriate use. For comparison, we measured the appropriateness of use during the same periods in the province of Alberta, which had no control program.
Of 2256 instances of IVIG use, 54.1% were deemed to be appropriate, 17.4% were of uncertain benefit, and 28.5% were deemed inappropriate. The frequency of inappropriate use in BC after the introduction of the utilization control program did not differ significantly from the frequency before the program or the frequency in Alberta.
Almost half of IVIG use in BC and Alberta was judged to be inappropriate or of uncertain benefit, and the frequency of inappropriate use did not decrease after implementation of a utilization control program in BC. More effective utilization controls are necessary to prevent wasted resources and unnecessary risk to patients.
PMCID: PMC3329117  PMID: 22567080
25.  Diagnosed hypertension in Canada: incidence, prevalence and associated mortality 
Hypertension is a leading risk factor for cardiovascular diseases. Our objectives were to examine the prevalence and incidence of diagnosed hypertension in Canada and compare mortality among people with and without diagnosed hypertension.
We obtained data from linked health administrative databases from each province and territory for adults aged 20 years and older. We used a validated case definition to identify people with hypertension diagnosed between 1998/99 and 2007/08. We excluded pregnant women from the analysis.
This retrospective population-based study included more than 26 million people. In 2007/08, about 6 million adults (23.0%) were living with diagnosed hypertension and about 418 000 had a new diagnosis. The age-standardized prevalence increased significantly from 12.5% in 1998/99 to 19.6% in 2007/08, and the incidence decreased from 2.7 to 2.4 per 100. Among people aged 60 years and older, the prevalence was higher among women than among men, as was the incidence among people aged 75 years and older. The prevalence and incidence were highest in the Atlantic region. For all age groups, all-cause mortality was higher among adults with diagnosed hypertension than among those without diagnosed hypertension.
The overall prevalence of diagnosed hypertension in Canada from 1998 to 2008 was high and increasing, whereas the incidence declined during the same period. These findings highlight the need to continue monitoring the effectiveness of efforts for managing hypertension and to enhance public health programs aimed at preventing hypertension.
PMCID: PMC3255225  PMID: 22105752

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