An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011

Prevalence and management of osteoarthritis in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network

BACKGROUND

Osteoarthritis is a common chronic condition that affects many older Canadians and is a considerable cause of disability. Our objective was to describe the epidemiology of osteoarthritis in patients aged 30 years and older using electronic medical records (EMRs) in a Canadian primary care population.

METHODS

In this retrospective cohort study, we analyzed the EMRs of 207 610 patients over 30 years of age (extracted on December 31, 2012) who had at least one clinic visit during the preceding 2 years. We calculated the age-sex standardized prevalence of diagnosed osteoarthritis and its association with comorbidities and covariates available in the Canadian Primary Care Sentinel Surveillance Network database.

RESULTS

The estimated prevalence of diagnosed osteoarthritis was 14.2% (15.6% among women, 12.4% among men). The diagnosis of osteoarthritis was associated with several comorbidities: hypertension (prevalence ratio [PR] 1.17, 95% confidence interval [CI] 1.15-1.18), depression (PR 1.26, 95% CI 1.22-1.3), chronic obstructive pulmonary disease (COPD) (PR 1.16, 95% CI 1.11-1.21) and epilepsy (PR 1.27, 95% CI 1.13-1.43). In addition, 56.6% of patients had received a prescription for a range of nonsteroidal anti-inflammatory drugs, 45% of which were topical. Opioid medications were prescribed to 33% of patients for pain management.

CONCLUSION

Osteoarthritis is a common disease in middle-aged and older Canadians. It is more common in women than in men and is associated with comorbid conditions. Most patients with osteoarthritis received pharmacotherapy for inflammation and pain management. As the Canadian population ages, osteoarthritis will become an increasing burden for individuals and the health care system.

Who receives rehabilitation in canadian long-term care facilities? A cross-sectional study

PURPOSE

To describe the proportion of residents receiving occupational therapy (OT) and physical therapy (PT) and the factors associated with receiving PT in long-term care (LTC) facilities across five provinces and one territory in Canada.

METHODS

Using a population-based, retrospective analysis of cross-sectional data, the proportion of LTC facility residents in each province or territory receiving three different amounts (time and frequency) of PT, OT, or both before July 1, 2013, was calculated according to the Resource Utilization Groups-III rehabilitation classifications. Twenty-three variables from the Resident Assessment Instrument 2.0, such as age and cognition, were examined as correlates; those significant at p<0.01 were included in a multivariate logistic regression.

RESULTS

Between 63.7% and 88.6% of residents did not receive any PT or OT; 0.8%-12.6% received both PT and OT; 5.8%-29.5% received an unspecified amount of PT; 1.9%-7.0% received 45 minutes or more of PT 3 days or more per week; and fewer than 1% received 150 minutes or more of PT on 5 or more days per week. Province, age, cognitive status, depression, clinical status, fracture, multiple sclerosis, and self-rated potential for improvement were associated with PT irrespective of time intensity.

CONCLUSIONS

The proportion of LTC residents receiving rehabilitation services varies across Canada and appears to be associated with physical impairments and the potential for improvement; older residents with cognitive impairment or mood disorders are less likely to receive rehabilitation services. Future recommendations should consider what is driving the patterns of service use, determine whether the resources available are appropriate, and address the most appropriate goals for residents in LTC.

Use of the interRAI CHESS scale to predict mortality among persons with neurological conditions in three care settings

Background

Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions.

Methods

Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories.

Results

CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings.

Conclusions

CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.

Prevalence and epidemiology of diabetes in Canadian primary care practices: a report from the Canadian Primary Care Sentinel Surveillance Network

OBJECTIVE

The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is a large, validated national primary care Electronic Medical Records (EMR)-based database. Our objective was to describe the epidemiology of diabetes in this Canadian sample.

METHODS

We analyzed the records of 272 469 patients10 years of age and older, with at least 1 primary care clinical encounter between January 1, 2011, and December 31, 2012. We calculated the age-gender standardized prevalence of diabetes. We compared health care utilization and comorbidities for 7 selected chronic conditions in patients with and without diabetes. We also examined patterns of medication usage.

RESULTS

The estimated population prevalence of diabetes was 7.6%. Specifically, we studied 25 425 people with diabetes who had at least 1 primary care encounter in 2 years. On average, patients with diabetes had 1.42 times as many practice encounters as patients without diabetes (95% CI 1.42 to 1.43, p<0.0001). Patients with diabetes had 1.29 times as many other comorbid conditions as those without diabetes (95% CI 1.27 to 1.31, p<0.0001). We found that 85.2% of patients taking hypoglycemic medications were taking metformin, and 51.8% were taking 2 or more classes of medications.

CONCLUSIONS

This study is the first national Canadian report describing the epidemiology of diabetes using primary care EMR-based data. We found significantly higher rates of primary care use, and greater numbers of comorbidities in patients with diabetes. Most patients were on first-line hypoglycemic medications. Data routinely recorded in EMRs can be used for surveillance of chronic diseases such as diabetes in Canada. These results can enable comparisons with other national EMR-based datasets.

Examining Do-Not-Resuscitate Orders Among Newly Admitted Residents of Long-term Care Facilities

Do-not-resuscitate (DNR) orders are an important part of advance directives. To date, little is known about DNR orders in Ontario’s long-term care (LTC) facilities. The Canadian Institute for Health Information (CIHI) stated that in between 2011 and 2012, there were more than 32,000 discharges from Ontario’s LTC facilities, 44% of which resulted from death. This study examined DNR orders in LTC homes in Ontario. The sample includes all LTC residents receiving care between 2010 and 2012. Data provided by the CIHI were collected using the Canadian version of the Resident Assessment Instrument. The data included administrative assessments on health of 112,746 residents. The average age of LTC residents in this study was 84.5 years, and about 70% were female residents. Results showed that residents admitted from home were less likely to have a DNR order on file during assessment and three months later. Residents whose families were responsible for care were more likely to have DNR orders when admitted, but this effect was not found at three-month follow-up. Residents who were in end-stage diseases were more likely to have completed DNR orders upon admission to LTC facilities. The presence of a health condition (eg frailty, depression, heart condition, pulmonary or psychiatric condition) increased the likelihood of residents having DNR orders when admitted to LTC facilities. Residents whose conditions were deteriorating were more likely to have completed DNR orders before the three-month follow-up. In conclusion, this study represents an important step in identifying issues related to DNR orders in LTC facilities. The factors that influence whether residents have DNR orders on file upon admission depend on the presence of family members, whether the residents are designated as end-of-life cases (six months or less), older age, and health. Discussions about resuscitation are an important part of care plans.

Prevalence of neurological conditions across the continuum of care based on interRAI assessments

Background

Although multiple studies have estimated the prevalence of neurological conditions in the general Canadian population, limited research exists regarding the proportion affected with these conditions in non-acute health care settings in Canada. Data from standardized clinical assessments based on the interRAI suite of instruments were used to estimate the prevalence of eight neurological conditions across the continuum of care including Alzheimer’s disease, Parkinson’s disease, epilepsy, traumatic brain injury, multiple sclerosis, cerebral palsy, Huntington’s disease, and amyotrophic lateral sclerosis.

Methods

Cohorts of individuals receiving care in nursing homes (N=103,820), home care (N=91,021), complex continuing care (N=10,581), and psychiatric hospitals (N=23,119) in Canada were drawn based on their most recent interRAI assessment within each sector for a six-month period in 2010. These data were linked to the Discharge Abstract Database and National Ambulatory Care Reporting System data sets to develop five different case definition scenarios for estimating prevalence.

Results

The conditions with the highest estimated prevalences in these care settings in Canada were Alzheimer’s disease and related dementias, Parkinson’s disease, epilepsy, and traumatic brain injury. However, there were notable cross-sector differences in the prevalence of each condition, and regional variations. Prevalence estimates based on acute hospital administrative data alone were substantially lower for all conditions evaluated.

Conclusions

The proportion of persons with neurological conditions in non-acute health care settings in Canada is substantially higher than is generally reported for the general population. It is essential for these care settings to have the expertise and resources to respond effectively to the strengths, preferences, and needs of the growing population of persons with neurological conditions. The use of hospital or emergency department records alone is likely to substantially underestimate the true prevalence of neurological conditions across the continuum of care. However, interRAI assessment records provide a helpful source of information for obtaining these estimates in nursing home, home care, and mental health settings.

Validity of the RAI-MDS for ascertaining diabetes and comorbid conditions in long-term care facility residents

BACKGROUND

This study assessed the validity of the Resident Assessment Instrument Minimum Data Set (RAI-MDS) Version 2.0 for diagnoses of diabetes and comorbid conditions in residents of long-term care facilities (LTCFs).

METHODS

Hospital inpatient, outpatient physician billing, RAI-MDS, and population registry data for 1997 to 2011 from Saskatchewan, Canada were used to ascertain cases of diabetes and 12 comorbid conditions. Prevalence estimates were calculated for both RAI-MDS and administrative health data. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated using population-based administrative health data as the validation data source. Cohen's κ was used to estimate agreement between the two data sources.

RESULTS

23,217 LTCF residents were in the diabetes case ascertainment cohort. Diabetes prevalence was 25.3% in administrative health data and 21.9% in RAI-MDS data. Overall sensitivity of a RAI-MDS diabetes diagnoses was 0.79 (95% CI: 0.79, 0.80) and the PPV was 0.92 (95% CI: 0.91, 0.92), when compared to administrative health data. Sensitivity of the RAI-MDS for ascertaining comorbid conditions ranged from 0.21 for osteoporosis to 0.92 for multiple sclerosis; specificity was high for most conditions.

CONCLUSIONS

RAI-MDS clinical assessment data are sensitive to ascertain diabetes cases in LTCF populations when compared to administrative health data. For many comorbid conditions, RAI-MDS data have low validity when compared to administrative data. Risk-adjustment measures based on these comorbidities might not produce consistent results for RAI-MDS and administrative health data, which could affect the conclusions of studies about health outcomes and quality of care across facilities.

Examining non-suicidal self-injury among adolescents with mental health needs, in Ontario, Canada

The objectives of this study were to examine the prevalence of non-suicidal self-injury (NSSI) among adolescents with mental health needs and specific factors associated with NSSI among adolescents aged 14 to 18 years who received mental health services in adult mental health facilities in Ontario, Canada. Data on 2,013 adolescents were obtained from the Ontario Mental Health Reporting System using the Resident Assessment Instrument-Mental Health (RAI-MH) and were analyzed using logistic regression. Approximately, 20.2% (407 adolescents) of the sample engaged in NSSI within the last 12 months. Results from multivariate logistic regression indicate that females were 2.19 times more likely to engage in NSSI than males. Intentional misuse of prescription medication emerged as the most important factor associated with NSSI. Other factors found to be associated with NSSI included multiple psychiatric admissions, sexual abuse, use of alcohol, mood disorders (e.g., depression), adjustment disorders, personality disorders and symptoms of depression. The article discusses the implications of the findings, with suggestions for future research.